Transparency in Coverage Final Rule and Other Regulatory Highlights Health Plans Need To Know

Transparency in Coverage Final Rule

On October 29th, the Transparency in Coverage Final Rule was released and will be published in the Federal Register. We reviewed the Proposed Rule which impacts health plans, which would require health plans to provide personalized out-of-pocket cost information for all covered healthcare items and services.  This information that a health plan must post to its website includes in-network negotiated rates and out-of-network historical payment amounts using a very specific format at regular intervals. So basically, negotiated rates would be transparent to the world. Insurers that incentivize consumers by encouraging them to shop for services from lower cost and higher value providers will be allowed to use the shared savings in the MLR calculations.

The timeline of the Final Rule begins in 2022 and we will review the 500-plus page document in the next few days and begin to develop the HealthEdge Compliance Requirements and Position Statements.

  • 2022 -Plans must post in-network negotiated provider rates, out-of-network coverage rates, and in-network drug pricing in a machine-readable format
  • 2023- Plans must offer an online shopping tool or similar platform that includes an out-of-pocket cost estimate and negotiated prices for 500 of the “most shoppable” services
  • 2024- The online shopping tool is extended to all services

The Final Rule also allows the plan to include in the numerator of the MLR any shared savings payments the issuer has made to an enrollee as a result of the enrollee choosing to obtain health care from a lower-cost, higher-value provider, beginning in the 2020 MLR reporting year.

In addition, because of the provider world’s current state, specifically hospitals, some clients are concerned about the Hospital Price Transparency final rule that becomes effective January 1, 2021. Hospitals will have to put the prices of their most common services on their website.

ONC and CMS interoperability rules

The Patient Access API and Provider Directory API will be enforced in mid-2021.

Right now, plans are likely focused on the current member portal technology that they have and how to leverage that for the patient access and provider directory APIs—the data will be similar, but the access points will be different. Many plans are also wondering about authentication and authorization management, meaning how a plan can ensure that they are only releasing information to the correct third party under the member’s consent.

A much heavier lift for health plans will be the payer-to-payer data exchange that will be enforced in 2022. At this point, it is unlikely that plans are looking to achieve the ingestion of payer-to-payer data. They are focused on the extraction and sending of the information. The ingestion is the more complex, requiring a look at how the information will benefit the member’s care by creating a continuum that can be used to guide the member’s care decisions.

HealthEdge is currently looking at the known data requirements in CMS recommended companion guides —CARIN Alliance Blue Button® Framework and Common Payer Consumer Data Set (CPCDS) and others.  We are assessing changes to the API and monitoring future requirements to ensure all data available from our technology is in the appropriate formats for their use.  We have plans to address the business use cases for the use of the received data in early 2021.

We are in the CMS world at the moment, and these requirements will impact Impacts Medicare Advantage (MA), Medicaid, CHIP, and Qualified Health Plan (QHP) issuers on the Federally-Facilitated Exchanges (FFEs).

Information Blocking

Going hand-in-hand with interoperability, the Information Blocking final rule goes into effect on November 2, 2020. This rule prohibits health providers, technology vendors, health information exchanges, and health information networks from practices that inhibit the exchange, use, or access to electronic health information (EHI). There are some exceptions that the federal government has put into place.

Although payers may not fit neatly into any of these categories, they do hold information that interoperability is trying to put into members’ hands. We will continue to monitor updates and the potential impact this rule could have on payers.

Additional news

In other news, discussions are ongoing between the National Committee on Vital and Health Statistics’ (NCVHS) and the Department of Health and Human Services on adopting a newer version of the X12N HIPAA EDI Transactions. At some point in the next few years, we can anticipate moving all of our EDI transactions to a newer version of the X12 rolls.

The final item is the CMS Annual Enrollment Period. On November 2 and November 3, CMS will conduct its CMS-generated rollover processing, a big deal for health plans. Some health plans may hit some bumps in the road and need our immediate attention and we are ready to support our customers.

Never Load In A Fee Schedule Again

For claims and pricing teams, managing fee schedules can be a massive headache.

With Medicare undergoing major quarterly updates as well as policy adjustments and retroactive changes coming in regularly, fee schedules require constant maintenance. Add in Medicaid policies and rates, perhaps across different states, and the lift begins to grow exponentially. And when there are new codes and policies coming about rapidly, such as we saw this spring with changes around the handling of COVID-19 testing and treatment, it can be nearly impossible to keep the information up to date.

Researching these updates and then manually loading fee schedules into a system requires time that many payers could devote elsewhere. Furthermore, ensuring that all information is accurate, and current, is a time-consuming process that is vulnerable to human error and leaves plans at risk of non-compliance or delivering over- and underpayments to providers.

In the ever-evolving health care landscape, health plans need a way to automate these processes. They need technology solutions backed by a policy team that handles the heavy lifting, takes care of the research, and manages and loads in fee schedules automatically, with rates and policies modified, tested, and operational on or before the effective dates. With cloud-based delivery, health plans do not need to lift a finger. This lowers costs, increases operational efficiency, and mitigates risk from a compliance standpoint.

This is an important issue not just for claims pricing teams, but for multiple areas of health plans. In HealthEdge’s recent independent Voice of The Market Survey, a study of 245 IT executives at leading health plans, the top challenge these individuals cited with their organization’s core administrative processing system, was low claims accuracy and auto-adjudication rates.

But not all health plans are the same, and every insurer has different contracts and unique billing requirements. Payers need the flexibility to configure their system to meet their specific business needs. They need a technology that can easily apply certain policies updates that match their business structure. With fee schedules loaded in and configured in a way that matches their business, health plans no longer need to worry about policy changes impacting their day-to-day business operations.

With less maintenance on the system and additional flexibility to make real-time updates, resources can be re-directed to more productive and innovative tasks. Empowered by the right technology, health plans will have improved accuracy, reduced waste, and adaptability in a changing marketplace.

The Opportunity In Interoperability

I know regulations can seem overwhelming, but if you look beyond checking the boxes to ensure compliance, there is so much opportunity. I always try to remind the health plans I work with that regulations result from constituents going to their legislator with a problem that needs to be fixed, eventually resulting in a mandate. Beyond compliance, addressing these mandates can have positive results for the health plans and its members.

Think of interoperability, for example. It may seem overwhelming, but the concept of serving tailored, customized information to an individual is not far-fetched. If someone turns on their TV or opens a streaming service, the consumer sees a menu of options and suggested programming or channels of interest based on previous activity. With interoperability, individuals can apply that same concept to healthcare.

Traditionally, members have had to collect data from various sources—member portals, lab results, claims statements, and more— and try to figure out what it all means, and what to do next! Interoperability will pull that information together and make recommendations based on that information.

The driver behind interoperability is that patients, or members, want to know more about their own health. Interoperability provides information and analytics that could help individuals connect the dots and take away guessing when it comes to their healthcare. Interoperability empowers individuals to address their concerns, ask questions, identify additional steps, and lifestyle changes they can take to improve their well-being and have the full picture of their health.

For members, interoperability is about getting access to the right information. For health plans, interoperability is about collecting and sharing that information.

To make interoperability successful, health plans need the right technology and, almost more importantly, sound business processes, resulting in good data. Anyone can learn how to do FHIR-enabled APIs. But understanding how a claim should come in, how it should process in the system, and how it produces the information needed to be consumed by the APIs is very important. Payers should focus on the claims administration system and ensure they’re collecting the right data consistently so that they can provide the right message to the patient, other payers, and providers.

For CFOs, Knowledge Is Power

Health plans face financial decisions every day that impact their bottom line. What terms will make a new provider contract more beneficial? How should a new payment policy be implemented for Medicare Advantage or Commercial business? To answer these questions well, payers need solutions that enable them to overcome the limitations of their existing technology and leverage real-time insights for business decisions and negotiations.

But some health plans run on multiple core claims systems that use several disparate pricing, editing, and payment integrity point solutions to try to pay claims accurately. Claims administrators spend hours looking at data from disparate sources and compiling information.

Historically, claims analytics can be disjointed. A payer may need to export claims from multiple sources, then process them in multiple batches using a separate solution to get the analytical data they need. This back-and-forth process produces old information that cannot be relied on for accurate analysis. It causes delays for everyone involved, and if decision-makers do not have quality information in a timely manner, there is less confidence for those in medical management and contracting when they make crucial decisions for a health plan’s financial success.

It is time for health plans to invest in integrated systems that allow data, and therefore analytics, to land in one centralized place. There is an opportunity to simplify the entire payment ecosystem and seamlessly connect to multiple claims systems and third-party solutions. Rather than connecting individually with different systems for Medicare and Medicaid pricing or specialty systems like genetic testing, the data should be available in a single location.

To gain a competitive edge in the evolving health care market, health plan CFOs need access to real-time data and the ability to view and analyze all claims as they are processed. Imagine that you could look at scenarios quickly with accurate data and evaluate “what if” modeling to discover better ways to do business. This information can transform a business, delivering immense value — like predicting the potential savings from structuring a contract differently.

Financial decisionmakers need a modeling tool that can take claims from one provider and run those claims through another provider’s contract to see how they would have priced differently. Imagine heading to the negotiation table armed with this data. A simple payment term could hold up an agreement – on the surface, one might assume this would deliver a big financial hit, but what if the data said otherwise? What if the data showed that there would not be a significant impact? Then the payer and provider could quickly agree to a contract that satisfies all parties without a contentious debate.

With the right technology and business intelligence tools, payers can model and forecast different pricing scenarios. They can make customizations and edits to see how different pricing rules calculate down to the cent. Reliable, real-time, integrated analytics unlock new possibilities and enable complete business transformation.

CIOs Must Understand The Business They Support

The alignment of business and technology, especially in this industry, is becoming increasingly important. To be successful, technology leaders must understand and become a part of the business they support. Effective partnerships outside of IT will strengthen the CIO’s influence.

The IT department is at the center of business decisions and initiatives. Once a need is identified, the IT department will work with the business to deliver a solution. Before delivery begins, technology leaders often must handle the contracting process and act as the liaison between solution provider, procurement, and legal departments.

Because technology leaders work with so many systems and vendors, CIOs can spend significant time on contract negotiations and tracking contract renewals and expirations. This can be time-consuming and reinforces the importance of fostering strong partnerships with departments and leaders throughout the organization. These relationships, or lack thereof, can make or break the implementation of technology to address a business issue.

When it comes to purchasing decisions, technology leaders are also often faced with obtaining support for technology investments from other executives or the Board of Directors. Strong relationships are essential for success in this area as well. There’s ROI that comes into play, too, beyond just keeping costs low. When making new technology investments, there is often an increase in cost before savings are eventually recognized. When a CIO needs to convince stakeholders, who may not be intimately involved with the projects, it’s important to always tie the purchase back to how it drives business value.

With technology implementations, there will be bumps in the road. Technology leaders must acknowledge this reality and share this with their business partners. The goal is to react and resolve quickly. It is essential to be transparent and set realistic expectations from the beginning. Being transparent minimizes surprise and gives the CIO credibility. Sincerity is key to forming successful partnerships with stakeholders. Once stakeholder trust and support are established, work becomes more enjoyable, and relationships thrive.

If a CIO is solely focused on technology and does not appreciate the business perspective, it will make the job difficult and more stressful than necessary. Business and technology leaders must work together, share their insights, and form strong partnerships to achieve their organization’s goals.

Keeping Information Secure Remains Top Of Mind For Health Plans

Security incidents that involve customer or member data are completely debilitating for a health plan’s business. On average, a data breach costs health plans $6.45 million. In addition to insurmountable fines and reputational damage, depending on the type of information disclosed in a breach, many organizations need to pay for credit reporting for the customers the breach impacts. For smaller plans with fewer resources and smaller budgets, all of these things combined or alone can drive a company out of business.

As technologies and companies continue to expand into the cloud as well as technology modernization in data centers, there continues to be technological advances in ways to protect systems and prevent unauthorized access to systems.And as the ways to defend networks and systems improve, so do the methods that hackers use to try to infiltrate the infrastructure of those systems and gain access to data that can be used in devious ways.

Today, sophisticated cybercriminals are not only working to infiltrate the systems, but also the backup system as well, so it is crucial to not just protect data, but also protect those backups and means to recover if security incidents occur.

When it comes to disaster recovery, companies should look to their overall architecture and design to ensure they have high availability and redundancy in their systems; there must be backups and recovery means in place as well as disaster recovery plans. It is imperative to test those plans on a consistent basis as you must plan and prepare for the worst case.

Certifications like SOC2 Type2 and HITRUST prove that a health plan has achieved a high level of maturity that safeguards company and customer information. However, these certifications require significant time, executive commitment, and cost money and time. Onthe environment front, a health plan must ensure their systems and networks are secure and safe, and the policies and procedures in place are efficient and effective. Audits are time-consuming; it requires going through logs of information, validating that you’re following proper protocols and guardrails set up within each specific certification. It can take months of procedural validations to confirm you are aligned with controls of a certification.

Most leaders in healthcare are aware that it is vital to have security standards in place. But in my experience, it is the people or teams involved in day-to-day healthcare activity that must retain their focus on the importance of security. For payers of all sizes, but especially smaller organizations with limited resources and personnel, it is crucial that health plans have security training in place, so that all of the employees understand the importance of data privacy.  A solid security approach should also include Security newsletters and reminders to end users on safe guarding data and the correct security procedures.

Security around customer data is important to the business as well as the members. And without that in place, you’re putting your business at risk. Health plans are stewards of their members’ data and must do the right thing to maintain privacy and protection against that data.