The Path to Point-of-Service Payment Success

Imagine an expectant mother has high blood pressure and sees a specialist. After the visit, the provider submits the claim to her insurance plan, and from there it goes through a lengthy administration process. The insurance plan performs complex eligibility and benefits checks, provider contract checks, claims editing and pricing checks, and pushes the claim through several internal and external third-party solutions. Eventually, a reimbursement amount returns, but it moves to a medical records review, and is sent back for another trip through the process.

This case illustrates the complexities that often occur in the claims workflow. There are many time-consuming and redundant steps — sometimes more than 100 — to proper reimbursement. With this system, it’s evident why there is so much uncertainty about how much the expectant mother will have to pay.

But what if patients could pay the correct amount for the care they receive with full transparency of fees the moment a healthcare professional renders service? We can move closer to accurate point-of-service payments in healthcare, but we need advancements in technology to get there that include:

Provider Satisfaction: Why Data Matters for Health Plans

Just about every health plan that I have talked to in my career is currently experiencing, or has had experienced, problems keeping their provider population at a high level of satisfaction. Accurate provider data matching is a great example of a consistent pain point for health plans that contributes to lower provider satisfaction, no matter the health plans’ size or solution. If a health plan cannot match a provider accurately through integration for provider data management or claims processing, payment delays or incorrect payments occur.

What I have seen is, without the right integrated solution, something as simple as an accurate, reliable provider match can drain a payer’s time and resources. Incorrect payments lead to appeals, disgruntled providers, phone calls, the need to rework and reprocess claims, and ultimately negatively impact the bottom line driving up the precious PMPM that all health plans live and die by.

Worse yet, many other factors can impact the claims payment process, whether it is human or system error, unpredicted provider billing behaviors, or even outdated technology stacks. The myriad of issues like unprocessed authorizations, incorrect benefits, or pricing, missing electronic medical records, or lack of payment integrity and payment accountability are just some of the problems health plans experience daily. Customer service teams, provider appeals, and adjusted claims drive increased overhead and decreased provider satisfaction as a result.

With the right technology, health plans can use a provider-focused ecosystem leveraging advanced analytics to track provider satisfaction and work to understand different characteristics related to billing and claims administration. Actionable data can enable operations staff to put issues into context to adapt their business, introducing new pricing and reimbursement models accordingly. My colleague Diane Pascot recently published an excellent blog on the value of analytics, Leveraging Real-Time Data for a Meaningful Customer Experience.

Health plans have discovered one obvious key to provider satisfaction is having a solution that automates and accurately matches providers, which is also key to high auto adjudication rates (arguably the most valuable statistic, next to accuracy, for any given health plan). Additionally, they understand how accurate payments lead to lower administrative costs and overall increased satisfaction. For health plans, while it is critical to keep persistency in their membership, so is maintaining high levels of provider satisfaction. The most successful clients use a comprehensive, integrated ecosystem that can provide the best-of-breed in care management, pricing, clinical edits, and analytics that increases both provider payment accuracy and satisfaction.

As Medicare Advantage Grows in Popularity, Health Plans Must Meet Market Demands

According to Medpac, the country’s baby-boom generation (born between mid-1946 and 1964) began aging into Medicare in 2011 at a rate of about 10,000 people per day, a rate that will continue until 2030.

Over the next 15 years, Medicare’s enrollment is projected to increase by almost 50 percent— rising from 54 million beneficiaries today to more than 80 million beneficiaries in 2030!

Accordingly, the impacts of this enormous demographic shift will drive the evolution of market demand and the corresponding effective responses from providers and health plans alike.

Some of the key market driver questions include:

  • How will the incoming baby boomers affect the age structure of the Medicare population? Will the Medicare population be more racially and ethnically diverse, given the growing racial and ethnic diversity of the total U.S. population?
  • Given the improvements in life expectancies, will the next generation of Medicare beneficiaries live longer and healthier lives than previous generations? Or will the longer life expectancies increase the oldest age groups in Medicare, thereby increasing the rates of disease and chronic conditions?
  • Have baby boomers and especially the oldest baby boomers had time to recover from the 2007 to 2009 recession before entering retirement?
  • What is the outlook for the Medicare program’s financial health as the number of taxpaying workers per beneficiary declines?  
  • What is the projected growth in the share of enrollment in private plans, and what do health plans do to be best positioned to address these unique needs?

With sufficient input from market demand, public policy, and the adoption of best practices in other industries, healthcare, and health insurance technology suppliers can offer scalable, data-driven solutions.

There are key areas of focus to address these business challenges, including value-based benefit plans and contract reimbursement development and administration. Customer service is also crucial, including enrollee navigation tools that help older members shop and choose the right health benefit for them and access to expert knowledge-based analysis and provider channeling. In addition, easy-to-use and highly-integrated “traditional” customer service support (e.g., call centers) and increasingly popular self-help tools (e.g., portals, “enhanced CRM,” handhelds). There is also increased use of customer-focused artificial intelligence (AI), particularly utilizing integrated payer/provider data that spans the full continuum of both “member” (health plan view) and “patient” (provider view).

While crystal balls are “foggy,” enrollment in Medicare Advantage and or Advantage-like plans is anticipated to increase at a healthy rate. In turn, the demand for seamless support will continue to evolve. Whether a health plan is regionally owned/provider affiliated or spans the country in a traditional insurance setting, the demand for integrating this population will require significant technical and organizational transformation investment. To do anything less risks missing the next frontier.

IT Leaders Agree: For Successful Investments, Align Tech and Business Goals

Technology, especially next-generation technology, plays a massive role in allowing health plans to embrace change, innovate, and remain competitive. However, when it comes to significant technology purchases, in most instances, the decision-making authority does not reside with one person. Major decisions involve a group of key players —c-suite, technology leaders, board members, and more—who, at some point in time, are instrumental in a comprehensive, enterprise-wide investment.

I recently moderated a webinar featuring HealthEdge customers Independent Health and NeuGen.  John Church, VP and CIO of NeuGen, provided some advice for those thinking about moving to a new core administrative processing solutions (CAPS). “When you evaluate a new CAPS, it’s taking what technology best fits your lines of business, your business model, and how quickly, as an organization, you need to push products out into the marketplace. [Next is] aligning those requirements back to which is the best technology out there for you, because with that, you will see longer-term savings in budgets, you will see shorter times to market.”

For Independent Health, Eric Decker, SVP of Information Technology said his organization saw potential in switching to a new CAPs and took time to look at their options.

“About ten years ago, the Affordable Care Act created uncertainty as to whether our legacy system could handle things like member level benefits, or how it would perform and integrate with exchanges,” said Eric. “We closely evaluated different products in the space at the time and immediately realized HealthRules Payer® would enable us to significantly cut down the time of our new product development. Now, what used to take weeks and months actually takes hours or days.”

Although the process can seem daunting at first, the results can be transformational. To get all key stakeholders on board, technology leaders must help the decision-makers understand that moving to a new core system will benefit the organization at all levels.

“Organizations need cross-functional support between IT and the business involved in evaluating the platform to ensure they are aligned,” said John. “As we look at the success we have with our HealthEdge claims processing system, our billing system, and our eligibility requirements; there is shared coupling between IT and the business.”

Eric agreed with the importance of a tight partnership between IT and the business, not only in what the operating model will look like after the organization completes the migration. “Our system configuration teams, operations teams, and IT work closely together to evaluate upgrades, evaluate new products that our sales team wants to implement, and how it will fit into the core administration platform.”

“The long-term operating model of how you’re going to support the system is key,” added John. “In what was traditionally all core IT functions before, now can reside in the business, and there are good reasons for them to….getting the right people together can be successful and have a lot of long-term efficiencies.”

When it comes to efficiencies, both Eric and John mentioned their high auto adjudication rates, both in the low 90s. John gave credit, once again, to the solid understanding and relationship between IT and the business.

“We can’t get to these numbers with just claims, or just IT. Everyone needs to work together, identifying how we’re going to get there, and [within] the timeline we want to achieve it,” said John. “The key thing is to be in lockstep. If you have a partnership, you will get there. Without a partnership, you will struggle.”

Improving Provider Relations

Many factors can impact the claims payment process. With so many legacy solutions still present in the market, there is significant opportunity for inefficient processes to slow down work or create inaccuracy. Without the right tools, even the processing of a single claim can drain a payer’s time and resources and strain provider relations.

Consider this. When a claim is submitted on some older systems, edits and errors come back one-by-one – only returning the most egregious error. The claim could be missing date of birth; the claim processor fixes that. Then they send in the claim again and find out the address is wrong and need to fix that. Sometimes these edits require contacting the provider and either resubmitting the claim or gathering the correct information. There could be dozens of bounce backs with a single claim and multiple changes and phone calls that need to be made separately. Health plans need a system that automates this process in real-time. They need a technology solution with advanced logic that can match a claim to the correct provider contract, know when and if a claim needs to run through a third-party solution, and allow the claims processors to resolve all errors at once. Streamlining the parallel process of edits means less back-and-forth and a faster resolution.

Another major factor in improving provider relations is the ability to quickly answer questions and give providers the confidence that payments are handled appropriately. In HealthEdge’s recent independent Voice of The Market Survey, tapping the insights of 245 IT executives at leading health plans, 28 percent of respondents cited lack of transparency for internal/external stakeholders as a top challenge with their core administrative processing system.

A payer does not want to take time and effort to chase down information from a variety of sources. Whether for internal or CMS audits or provider inquiries, health plans with access to a complete audit trail of how a claim was processed can readily defend payments, and providers can clearly understand the reasoning.

By employing new technologies that enable parallel processing and complete transparency of claims adjudication through audit trails, health plans can enhance operational efficiency, improve communication, and ultimately strengthen provider relations and overall satisfaction.

Health Plans See Positive Results With Value-Based Care Reimbursement

Value Based Reimbursement | Healthedge

Value-based reimbursements have been much debated since both houses of Congress overwhelmingly passed the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) in 2015, setting the stage for Alternate Payment Models in Medicare, with incentives for providers embracing pay for value. CMS has been pushing value-based reimbursement models aggressively for years, recently introducing new reimbursements for Medicare and Medicaid members to address social factors such as isolation, food insecurity, and chronic conditions.

IT executives who responded to a recent HealthEdge-commissioned survey, conducted by Survata, cited value-based reimbursement as a top reason for modernizing their infrastructure. Of 245 IT decisionmakers surveyed, 96% said that the expansion of the value-based Medicare Advantage design factors into their recognition of the need to change.

The COVID-19 pandemic has also highlighted the flaws of the Fee-for-Service, with providers of all types experiencing delay of preventative and elective medicine resulting in revenue disruption. This has combined with the wave of hospitalizations of patients creating claims and requiring more manual processing, leading to higher costs for both health plans and providers.

Market pressures to adopt value-based reimbursement create an operational imperative for health plans, and core administrative systems must have the flexibility to configure all types of value-based contracts and benefit plans, from simple incentives to risk sharing, including full capitation. Configuration must also respond to changing regulations and competitive challenges quickly and easily, with minimum disruption and at low cost.

“The ability to stand up new plans and benefits and pivot to satisfy new CMS requirements has become very, very significant for us… a few years ago our claims and data platform was very old. We are on HealthEdge today. And it’s made a difference in how fast we can turn things around.” – Ghita Worcester, Senior Vice President of Public Affairs and Chief Marketing Officer of UCare.

UCare, a regional health plan in Wisconsin and Minnesota, has sustained a 96 percent retention rate over 20 years of proven experience with their Medicare Advantage line of business.

Another key to successful value-based arrangements is the partnership between health plans and providers, a traditionally challenging one. Health plans must not only construct value-based contracts with aligned goals for mutual success, but they must also provide actionable data on a real-time basis to their providers to avoid expensive encounters or hospitalizations. With this information, providers can quickly and confidently take key actions necessary for their patients to remain healthy.

HealthEdge customer Humana recently shared in its “2020 Value-based Care Report” that collectively, its 2.4 million Medicare Advantage members benefitting from value-based models spent 211,000 fewer days in the hospital and emergency rooms. Overall, the value-based agreements resulted in 10.3% fewer emergency room visits and 29.2% fewer hospital admissions, with a cumulative savings of $4 billion compared to original Medicare.

The premise of value-based models depends on operational readiness and data transparency. The results can be overwhelmingly positive for health plans, providers, and patients. HealthEdge customers report great success working with their provider networks to bring down costs while improving outcomes.