Geographic Expansion and New Insurance Products

Client Description

The client, a leading New England health insurer, is a local carrier with a national reputation for quality and care management. The client offers a variety of commercial products in addition to Medicare and Medicaid products, and covers one million members across three states.

Challenge

The client had been looking for expansion opportunities to support the corporate strategic goals of membership growth and revenue enhancement. The entrance into a new market enabled the insurer to gain access to a large market where a limited number of competitors had a presence. The new market was entered as a joint venture with a provider network with a shared vision to create a new health insurance company based on cost and quality. In addition, the project supports the corporate goal of enhancing the member experience and satisfaction by expanding the existing provider network to another border state.

The new expansion area was a joint venture between the client and another entity. All of the systems needed to segregate this data to be reportable as a separate legal entity.

Ninestone’s Approach

The client engaged Ninestone to manage all aspects of the software development lifecycle, from business requirements analysis to final implementation. Ninestone was selected because of our long-standing relationship with the client, our ability to lead projects using their rigorous project management approach as well as our experience with a number of the software applications that were part of the implementation.

Ninestone broke down multiple related work threads and prioritized and planned the phased implementation over several go live dates to coincide with the business cycle and process. As with any entrance into a new market, the state insurance division had their own time lines for approval of rates and products that the client could offer in the new state. The work Ninestone managed had to mesh with the business planning and approval process so that the systems being built supported the approved product suite. The product planning and submission work was delayed and the approval process was slow which impacted the ability to get fully defined requirements in a timely manner to support the committed go live date of the products. The go live was agreed to before the business planning was completed. This created a need from the outset to be creative and manage many iterative work streams to get the critical path items lined up with limited time left to complete the work. The work threads included the set-up of the new products and state regulatory requirements, five self-insured employer group custom benefit plan designs,and the integration of an HRA/HSA vendor and two carve out pharmacy vendors to round out the full implementation.

The scope of overall work included business requirements across thirty platforms and approximately ten outside vendors managed through multiple release cycles. The Ninestone program manager worked directly with representatives from the client, multiple vendors, and the business areas to understand and communicate requirements and discuss alternatives when necessary.

An infrastructure work thread included the telecom and infrastructure team to set up the new office space and coordinate with real estate for the build out.

Technology

There were a number of technologies involved in this complex implementation: health plan administration systems, internal and external reporting, web portals, application configuration, claims, clinical systems, EDI, IVR, telecom, many vendor integrations, and new state regulatory reporting requirements. There were other internal projects occurring in parallel which required a great deal of coordination and collaboration across all of the platforms during the entire process.

Results

The client met its January 1, 2016 objectives of quoting products for this new market as well as the implementation for the self-insured employer groups and vendor implementations. There were items that were staged throughout early 2016 and the deployments continued until all in-scope work had been completed. There were some challenges and gaps identified due to the limited time available from product design to development and go live, so a structured approach was put in place by the program manager with the project management and technical team to monitor report and triage some additional work.