Work with Health Cloud for Payers

Learning Objectives

After completing this unit, you’ll be able to:

Identify Health Cloud end users for payers.
Describe end users’ jobs to be done.

A Health Plan for Retirement

Health Cloud for payers makes work easier for all kinds of users. In this unit, you explore how Health Cloud meets their needs across the entire health plan journey.

At the center of any health plan is the member. So first, let’s meet Milly Lee, a 64-year-old professional. She’s currently enrolled in group insurance with Cumulus Health Plans through her employer. Milly intends to retire next year and is researching health care options online.

[alt text: Milly Lee, a member of Cumulus Health Plans.]

Milly and her husband, Charles, are understandably anxious about entering this new, uncertain phase of their lives. Beyond the uncertainty of their insurance options, they also face new medical complications that reduce their overall quality of life. Milly is experiencing recurring hip pain, which prevents her from enjoying her favorite outdoor activities. And Charles was recently diagnosed with diabetes, which he’s currently struggling to manage on his own.

More than anything, they hope to find a health plan that can help them navigate their golden years with a sense of ease and security.

Here’s a walkthrough of this member journey and how Cumulus uses Health Cloud and other Salesforce tools to connect them with quality and affordable care.

Commercial Sales

Commercial Sales helps health plans deliver a modern rate, quote, and shopping experience. It provides tailored solutions for all lines of health insurance, including individual, family, group, Medicare, and ancillary plans like vision and dental.

To deliver a complete shop-and-enroll experience for prospective members, Cumulus uses a number of Salesforce tools alongside Health Cloud, including Experience Cloud, Salesforce Industries (SFI), and Marketing Cloud.

To reach out to current members approaching retirement age, the team at Cumulus creates personalized journeys powered by Marketing Cloud. In Milly’s case, she receives a Happy Birthday email on her 64th birthday with a link to Cumulus Medicare offerings.

Later that year, as her retirement date approaches, a telesales agent at Cumulus reaches out to Milly directly. After discussing Milly’s preferences, the agent helps her schedule a virtual scope of appointment with an independent broker.

The broker, Jake Williams, is credentialed as a qualified selling partner through the Cumulus Distribution Management solution.

[alt text: Jake Williams, the independent broker credentialed with Cumulus.]

Jake receives an appointment request in his digital portal, where he can see all of Milly’s history and engagement. He then walks her through a purchasing flow, which is prepopulated with information from her profile. Together, they confirm Milly’s conditions and medication to ensure the best-fit plan. Jake then takes Milly through her personalized medical plan recommendations.

[alt text: Product offerings for Medicare Advantage.]

They select the preferred plan and review the final quote together.

After confirming the quote, Milly soon receives an official enrollment quote in her member portal inbox. She provides payment details and electronically signs the application. Milly is now enrolled and ready to take advantage of her new plan.

From there, Milly enters an onboarding campaign where a personalization engine delivers needed resources to her at the right time.

Provider Network Management

Just as Cumulus manages and empowers brokers with a distribution management system, it also sets up a provider network system to manage all key stages of the payer-provider relationship.

Provider Network Management enables organizations to find and manage their provider partners, including recruitment, credentialing, contracting, appointment, onboarding, and servicing providers with a network.

At the center of the solution is the health care provider—the individual or organization licensed to provide the actual health care diagnosis and treatment services to members. A provider may be an individual professional such as a doctor or a large health facility organization such as a hospital. When treating insured patients, health care providers receive their payments for services from health plans.

Let’s meet Dr. Joanne Bass, an orthopedic surgeon who runs a private practice.

[alt text: Dr. Joanne Bass, the orthopedic surgeon who runs a private practice.]

Using CRM Analytics in concert with Health Cloud, the marketing and recruiting team at Cumulus identifies Dr. Bass as a high-value prospect. Dr. Bass is particularly valuable as she fills in important geographic and speciality gaps in its existing provider network. To express interest, Cumulus sends a personalized email that invites Dr. Bass to fill out a provider registration form.

Dr. Bass fills the form and completes the application on Cumulus’s dedicated provider portal.

[alt text: The Provider Portal welcome page.]

From there, the credentialing specialist at Cumulus takes the reins using Health Cloud and Flow Orchestration tools to verify Dr. Bass’s professional qualifications.

Once the credentialing stage is complete, it’s time to discuss and negotiate the plan’s terms. This stage consists of hashing out agreements about prior authorizations, reimbursements, claims processes, rates, and more. Robust digital contracting tools and workflows plus predesigned templates, versioning, approvals, and e-signature integrations make everything fast and efficient.

After signing the contract, Dr. Bass initiates her onboarding experience with guided workflows and automation from Health Cloud, which smooths her path. Over time, she and the office staff stay connected to Cumulus through ongoing outreach campaigns, portals, and personalized provider service.

Utilization Management

Utilization Management enables Cumulus Health Plans to perform core utilization review functions, such as prior authorization and service requests, so Cumulus can better manage its member’s cost of care. This process helps both members and providers to ensure the right care is delivered at the right time.

It’s time to return to Milly and see how Utilization Management works when she seeks treatment for her nagging hip pain.

[alt text: Milly favoring her hip, wincing in pain as she tries to hike a trail.]

Over the last couple of years, the pain has prevented Milly from enjoying her favorite outdoor activities. One of her friends who was suffering from a similar hip condition just had a successful surgery. Milly gets curious and decides to look into a hip operation for herself.

She searches the Cumulus provider network and sets up an appointment to meet Dr. Bass, the orthopedic surgeon. After a consultation, Dr. Bass concludes that Milly should hold off on surgery at this stage and try physical therapy.

Using the provider portal, Dr. Bass’s office manager confirms Milly’s benefits and submits a prior authorization request for physical therapy visits.

[alt text: The Prior Authorization Required step in a guided process.]

After the office manager enters additional information about the request, authorization for physical therapy visits is automatically approved. Dr. Bass downloads the authorization summary and schedules Milly’s physical therapy treatment without delay.

When Milly seeks a second opinion outside of her network, tools such as Intelligent Document Automation and Intelligent Form Reader automate all stages of the process.

If a service request can’t be automatically approved, Health Cloud routes it to the clinical team for review. Everything the reviewer needs to assess the request is right there in a single view. In Milly’s case, Dr. Bass had documented that surgery wasn’t a medical necessity because Milly hadn’t tried a conservative treatment yet.

Ultimately, Milly opts for physical therapy and responds extremely well. After just a couple of months, her hip is feeling much better, and she’s back to enjoying an active life. Actually, she’s relieved she didn’t need surgery in the end.

Care Management

Increasingly, members expect health plans to go beyond determining service authorizations and more actively participate in the orchestration of their care.

Care Management enables health plans to establish a care plan for a member's specific condition or risk factors. This includes developing and monitoring health goals and care plans, monitoring health states, member outreach, scheduling, claims review, and program eligibility.

It’s time to check back in with Charles Lee, Milly's husband.

[alt text: Charles Lee, Milly’s husband.]

Charles is a recent retiree who also has a Medicare plan with Cumulus. He’s working to better control his diabetes. Based on risk stratification metrics, Charles recently moved from low risk to high risk.

Health Cloud assigns Charles to Cara Candle, a care manager who specializes in managing high-risk diabetic members.

[alt text: Cara Candle, the care manager at Cumulus.]

Before meeting with Charles for a screening, Cara reviews the relevant details from his member record. Thanks to Member 360, she can access all information about Charles in a single view. From the member timeline, she sees that Charles has never been enrolled in a formal care program.

Cara consults with Charles and he provides consent to enroll. Next, she takes an assessment and personalizes the care plan according to his needs and characteristics. The assessment is held in Salesforce and provides a dynamic framework to ask relevant, targeted questions, and identify any barriers to a successful treatment.

Based on the results, Cara creates a care plan for Charles. She can review and update the plan as needed. After that, Charles receives personalized automated member outreach, which delivers education and reminders at the right time. If he doesn’t respond, Cara receives a notification and can follow up.

Charles takes full advantage of the care plan, regularly visiting his member portal to learn all about his care, benefits, and sources for diabetes information and data. His wife, Milly, is assigned insulin intake education, just in case Charles can’t inject himself. They can always use the member chat feature to ask questions and get real-time answers.

Soon, Charles shows major progress and completes the program. But the support doesn’t end there. He receives personalized reminders on his birthday and during flu season. Plus, every 3 months, he takes an interactive quiz that reinforces key lessons. This continuous engagement helps keep Charles healthy and reduces the chances of reenrollment.

Charles and Milly, reaching the top of a steep hill, smiling and embracing.

Thanks to Health Cloud, Milly and Charles can live a much more active and fulfilling life, and their future looks bright and healthy.

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