Patient or Member? How About Calling Them Customers?

What are individuals called in a health plan? Members. What are people called when they meet with a provider? Patients. What is an individual person referred to in any other industry that uses end-to-end solutions? Customers.

The “unique” needs of a member vs. a patient in the B2C healthcare or health insurance setting aren’t really unique at all. At the end of the day, these needs are customer needs.

Not surprisingly, with the growth of government-based healthcare programs like Medicare, Medicaid, and Individual/Exchange lines of business, the migration from a dominant employer-based “customer” Business-to-Business (B2B) relationship has transformed and become more of a consumer-driven Business-to-Consumer (B2C) environment.  Health plans must find ways to treat members as customers and look at how to provide an end-to-end solution that best serves their needs.

How can different types of health plans cope with the consumer-driven B2C healthcare growth?

There are different paths to get there as plans can use their inherent strengths to meet this changing demand.

For larger plans, their respective budget capacity (and subsequent ability to invest in scalable solutions) have enabled them to heavily invest in front-end “consumer-experience” technology. While mid-sized (generally regional) type plans, the closer relationships between payer and provider and the willingness or, in some cases, equity structure (health plans that are owned or closely affiliated) provide a mechanism to more readily share data and collaborate on end-to-end processes, allowing members to enjoy a combined experience from a single entity.

Regardless of the means to “get more consumer-driven,” the common foundational technical requirement investment are back-office applications that are interoperable, data-integrity true, and secure. To move to the next generation of where healthcare is going, health plans must modernize their core system.

Building a Winning Culture

I joined HealthEdge seven years ago when, like most startup organizations, we were primarily focused on our mission, products, and exciting our customer base. At that time, there was a lot of work in front of us to build out our products and execute our mission, leaving our culture unintentionally to come in second. We knew we wanted to become an employer of choice, and so in those early days, we set about building a foundation of clarity, trust, and consistency.

This strategy was a commitment to the long game and wasn’t always linear, but we took meaningful steps forward over the years where we could action change. Progress was slow until Steve Krupa joined the team as Chief Executive Officer. Under his leadership, we began reflecting on our culture and seeking feedback for improvement. We recognized the opportunity to make a positive shift in our company culture and began to see the correlation between customer value and employee satisfaction. This journey led us to start talking openly about the culture we wanted, acknowledging areas the needed focus, and regularly solicit feedback through employee engagement surveys.

Asking for feedback is the easy part; the hard part comes when you need to take action on the feedback. We chose to be open and honest about the data despite the fact we were not proud of those initial results. We spoke continuously about what we heard, what we interpreted and encouraged people to ask questions and help us develop solutions. We formed an employee council dedicated to providing a forum for a live employee voice, not just one that lived through the survey data.

Building a winning culture is not about quick wins. It’s not about ping pong tables or creating a cool looking office. It’s about a shared sense of purpose and building an organization that supports, encourages, and empowers excellence. It’s about building a community to which we can all belong and contribute. When everyone is positioned to feel connected to the company’s collective success, it’s a huge motivator.

This is a journey, not a destination. While we have been named a Top Place to Work and a Best and Brightest organization, the work is definitely not done. We are only here because our employees were willing to share feedback with us along the way and co-own this culture. We are thrilled with our shared success but know our journey continues, and as such, we will continue to ask for feedback, listen to our employees, and work together to continue to innovate on a great employee experience.

2020 Recap: Key Factors Impacting Payers


With shifting business and consumer priorities and evolving regulatory mandates, the healthcare industry experienced massive disruption this year. Here are a few of the key factors impacting health plans in 2020.

Delays in Care Impact the Entire Healthcare Ecosystem

In-person appointments and emergency room visits decreased dramatically this year. Health Affairs projected a loss of nearly $68,000 in fee-for-service revenue per physician for 2020 and an estimated $15 billion in losses to primary care practices across the country over the calendar year.

One silver lining this year is the industry’s adoption of telehealth. While there are declines in in-person visits, providers have reported that telehealth visits have increased 50 to 175 times during the pandemic. Payers should seize this opportunity to keep up with consumer demand for this new way to receive care.

The delays in preventative and elective procedures and the associated revenue further expose fee-for-service’s flaws, highlighting the need to adopt value-based reimbursement and new care delivery models. To remain competitive, insurers require flexibility to design benefit offerings that meet their members’ needs and support their providers.

Prioritizing Consumer Satisfaction

Changes in care delivery this year amplified the shifting demands of health plan consumers. Health plans continue to launch digital transformations to compete for members who want more convenient, transparent, affordable, and personalized services. In fact, in a survey conducted by independent brand intelligence research company Upwave, cited 28 percent of health plan IT leaders say perfecting the consumer digital experience is their top business imperative today. Providing personalization and user-friendly digital tools to all healthcare stakeholders will drive enhanced quality, lower operational and healthcare costs, and improve member satisfaction.

Keeping Information Secure Remains Top of Mind For Health Plans

With new technology comes an increased focus on security. Forty-three percent of IT leaders say keeping information secure remains their number one concern with their core administrative system, as a data breach costs health plans $6.45 million on average. In 2020, many health plans’ IT teams moved to a completely remote work environment, highlighting the need for improved security protocols and policies.

Certifications like SOC2 Type2 and HITRUST prove that a health plan has achieved standards that safeguard company and customer information. However, these certifications require significant time and money. Building HITRUST to protect claims information and member data is an investment that many smaller health plans cannot make independently. Partnering with next-generation technology solutions that prioritize security is crucial to ensure sensitive data stays protected.

What’s Next? 

The innovative ideas and strategic shifts health plans made this year opened the door for endless possibilities in 2021.

We are on a mission to revolutionize the healthcare industry. Gartner’s “Hype Cycle for U.S. Healthcare Payers, 2020” report[i] has named HealthEdge as a Sample Vendor for the Next-Generation Core Administrative Systems category for ten consecutive years. With the recent backing of Blackstone, one of the world’s leading investment firms, and the acquisition of The Burgess Group®, and their innovative prospective payment integrity solution, Burgess Source®, HealthEdge continues to lead health transformation efforts and move our industry toward a boundary-less ecosystem.

[i] Gartner, Hype Cycle for U.S. Healthcare Payers, 2020, Analyst(s): Bryan Cole, Jeff Cribbs, Mandi Bishop, Published: 5 August 2020 ID: G00444809.

A Possible Survival Guide for Regional Health Plan Expansion?

Regional health plans have generally flourished in the respective local markets that they have served. However, regional health plans only “extended” as far as the affiliated providers employed by the delivery system in a staff model or contracted in a group model.

Today, competitive pressures from larger plans offering statewide (or beyond) employer group networks that meet their overall needs have put regional plans at a disadvantage and forced them to look at new ways to grow their business to remain competitive.

How do regional plans respond? Regional plans should continue to leverage the collaborative payer/provider relationships that exist in the original service area. With these relationships they can maintain ongoing optimization of collaboratively developed value-based care, enhance use of integrated payer/provider data integration, and further develop complementary business processes that can help to improve the customer experience.

Regional health plans should also focus on transforming business practices and underlying technology that can easily configure to better position and police relationships beyond the original service area. Where strategic business objectives might be slightly or significantly different between payer and provider, functions that were historically collaborative in a shared regional market are potentially competitive in an expanded one.

Some of these functions include:

  • Overall provider network management
  • Enhanced provider reimbursement / contracting
  • Customer-facing call center and self-help support to an increasingly disparate customer base
  • More policing of care/utilization management capabilities

The transformation curve is significant. The time required for planning, general design, eventual investment, and execution requires buy-in from all stakeholders. The risks are high for not positioning for growth. The risks (and poor results) are exponentially higher for organizations that fail to fully account for the overall investment required from underlying/foundational core systems integrated with other value-added applications/utilities.

Payment Integrity in 2020 and Beyond

Health plans with legacy systems, disjointed workflows, and paper-based anything struggled to handle the sheer volume and veracity of new care and payment models, regulatory updates, and new entrants forcing rapid changes upon the industry this year.

Payers lacking the agility and flexibility to make adjustments quickly and update their administrative operations to support new care delivery provisions, evolving quality measures, and payment rules related to telehealth, telemedicine, and remote patient care fell behind.

As the Everest Group noted in its blog post, “The healthcare payer industry is plagued with notoriously old infrastructure. While healthcare payers are working to increase data transparency, offer member-centric solutions, and adopt a value-based care model, they’re obstructed by high reliance on dated, disconnected, and non-interoperable systems.”

Missing information, inaccurate coding, and variability of authorization rules amongst insurers add to the backlogs and costs associated with slow and inefficient claims systems. The COVID-19 requirements, exceptions, and payment-related complexities have only intensified payment integrity challenges. To add to the bureaucratic and information burdens, payer employees working remotely during COVID-19 cannot access their mainframes (typically hosted in a single location and requiring on-premise operation) and struggle to approve and process claims in a timely manner.

Unexpected Impacts on Billing and Payments

Consider the following real-life example of the unexpected impacts COVID-19  on billing and payment across providers, payers, and consumers. A 25-year-old student experiencing coronavirus symptoms went to her doctor’s office. Her doctor ordered a series of tests to rule out non-coronavirus respiratory disease before conducting a COVID-19 test, as these tests were in short supply and reserved for more serious cases.

Long story short, due to insufficient coding, confusion around what services the Families First Coronavirus Response Act covered, and whether the provider, payer, or patient was responsible for the charges, the student received a surprise bill for hundreds of dollars. Coincidently, this student had worked at a physician’s office and was familiar with manually working through billing and payment discrepancies between providers and payers and could reconcile the bill in the end.

This experience exposed what providers, payers, and consumers face daily: missing data, inaccurate coding, and confusion on guidelines that can slow down what should be fairly straightforward administrative processing across the spectrum of care delivery.

However, the pandemic did not create these administrative deficiencies – it merely magnified where outdated technologies present obstacles to providing responsive services and highlighted the limitations of current payer administrative systems and solutions.

To remain viable and competitive, Health plans must take advantage of the technologies that enable transparency, efficiency and agility.

Looking Ahead

As healthcare transitions to a more efficient, innovation-driven environment, so must our technology claims adjudication systems; systems that can offer interoperability and adaptability will enable payers to quickly customize policies and fee schedules and apply exceptions, adjustments and custom carve-outs.

According to the Everest Group, payers leave a lot of value on the table when managing medical and administrative costs separately. Administrative processes and IT management accounts for 15-20 percent of total payer costs, and a cloud-based prospective payment integrity platform can significantly help to reduce this number.

The industry could save $15.5 billion per year if payers processed claims correctly the first time. While almost all payers have some form of retrospective payment integrity scanning in place, few utilize emerging technology to proactively avoid paying claims improperly, even when the retrospective review of overpayments is 1.5x as costly as prevention.

In August 2020, HealthEdge completed its acquisition of The Burgess Group, LLC, an innovative payment integrity software company focused on improving healthcare payment operations through technology.

“Payment integrity is one of the principal tools to manage medical costs and, hence, is a key functionality that payers value in core-admin platforms. By adding The Burgess Group’s offerings to its own expertise, HealthEdge’s goal is to create an integrated claims processing, payment integrity, and adjudication platform that addresses both administrative and medical expenses,” the Everest Group reported in its blog.

Health plan customers will now benefit from claims cost savings via Burgess Source®, a cloud-based, prospective payment integrity platform with a once every two-week update cycle to enforce compliance and an interoperable ecosystem to deliver accurate results. The platform’s ability to identify and reduce the estimated $1 trillion wasteful spending in the U.S. healthcare system leads the way to on-time, accurate payments for millions of covered lives.

In Today’s World, Health Plans Must Be Agile

Changes to the health insurance industry have been traditionally very slow. However, the global pandemic has forced health plans to move forward with decisions and initiatives at full speed. There was no opportunity to analyze every aspect of a benefit plan and take months to implement it, changes needed to happen immediately.

The Need for Agile Healthcare in a Rapidly Changing Industry

At the beginning of COVID-19, it seemed that state and federal authorities introduced or changed regulations every day. It was challenging to sift through the noise and keep up. Everyone experienced hiccups along the way. Payers and providers alike had to fix errors, re-submit and reprocess claims, and course correct.

The pandemic has demonstrated the need for health plans to be agile, flexible, and methodical; it all comes down to configuration. Behind-the-scenes, successful configuration comes down to two things: sound business processes and consistency.

The HIPAA electronic data interchange introduced standards for the communications for payers. It forced the industry to standardize business processes to ensure that the correct data is required and used throughout the lifecycle. Sound business processes guarantee the data continues to maintain accuracy; consistency is key for clean data.

For example, as a result of the pandemic, specific benefits were rapidly mandated and changed “on the fly,” but the value of having consistent data requires that there are minimal variations or outliers to ensure accurate data analysis.  Certain information and fields must be uniform so health plans can easily look at claims experience, identify all of the claims that fall into specific buckets, and understand the historical data and what it means.

The Need for Agile Healthcare

The truth is, many claims processing systems are not as agile as they need to be. Now that payers have experienced the pressure and expedited timelines around COVID-19, no one wants to go through that again. That is why consistency, business processes, and agility are all very crucial for success.