Regulatory and Compliance Updates Payers Should Know

The Patient Access API has an upcoming enforcement date of July 1, 2021.

HealthEdge has all of the data required to enable compliance at the client site. However, we’re taking a deeper dive into the mapping to the Common Payer Consumer Data Set, the bridge to the FHIR Profiles required by member-facing applications. We are looking at what tools we can readily provide to our customers, in addition to the Data Warehouse Dictionaries, which are published routinely to see if there is room to improve upon the availability of that data for our customers.

We are also working on Bridge Mapping for the Patient Access API. We can expose the data required using HealthEdge API services. We are working to create an implementation guide and verify and document the data map from the system of record to the CPCDS (common payer consumer data set) format. Potentially this can be used to create flat files that will go over a bridge to the solution and easily map to the FHIR profile.

Recently sparking a bit of controversy, the CMS Interoperability and Prior Authorization Proposed Rule came out with a swift turnaround—less than two weeks.

This proposed rule builds on the policies finalized in the CMS Interoperability and Patient Access rule. It emphasizes the need to improve health information exchange, increase data sharing, and improve prior authorizations.

Achieving appropriate and necessary access to complete health records for patients, providers, and payers is driving this process. Some of the fallout from the pandemic has highlighted the need to be a more interoperable industry and have this information still protected but readily available.

We are monitoring the developments at the federal level and will keep everyone informed.

The first deadline for the Transparency in Coverage Final Rule is January 1, 2022, regarding machine-readable files.

Payers must post these files to their website, open to the public, and include all in-network negotiated provider rates, in-network drug pricing, and out-of-network rates.  We are looking at the file formats and will have more information to share in our next session.

We also received several questions regarding the only shopping tool, a tri-agency rule, effective January 1, 2023. The online shopping tool, or similar platform, includes out-of-pocket cost estimates and negotiated prices, specific to each patient, for 500 of the “most shoppable” services (it will expand to all customers in 2024). We have all of the data required available, as well as trial claim and additional tools that will help our customers accomplish this mandate.

As a reminder, the 2020 Medical Loss Ratio (MLR) reporting will allow plans to include in their numerator of the MLR any shared savings payments the issuer has made to an enrollee due to the enrollee choosing to obtain health care from a lower-cost, higher-value provider.

The 2021 Appropriations and COVID-19 Stimulus Package will impact health plans, including several Medicare reimbursement provisions.

One of the key things that came out of this package is a No Surprises Act at a Federal level, a bipartisan effort to address surprise medical billing. The COVID-19 pandemic highlighted situations where individuals seek emergency care and end up with surprise bills due to the physician being out of network or balances they were not anticipating.  Many states have Surprise Billing Statues, and we will need to look at how the federal rules impact those states.

The Tri-Agencies (departments of Health and Human Services, Treasury, and Labor) will issue regulations and guidance to implement a number of the provisions. That’s where we will get our compliance requirements. Most sections of the legislation will go into effect on January 1, 2022.

Another item that came out of recent legislation is the drug price transparency provisions that require drug manufacturers to report drug average sale prices to HHS for drugs covered under Medicare Part B beginning January 1 of 2022. This may impact Medicare Part D and CMS pricing in other settings.

President Biden announced a regulatory freeze of all items that were pending review in a Memorandum to the heads of the Executive Department and agencies.

Under the freeze, no rule shall be proposed or issued in any manner until Biden-appointed department heads review and approves. The memo also directs decision-makers to withdraw any rule sent to the Office of the Federal Register but not yet published, which applies to the recently finalized Prior Authorization and Interoperability Rules.

We will see some delay, but we will likely see a flurry of activity once all appointed department heads in place.

The freeze could also impact the proposed modifications to the HIPAA Privacy Rule to support and remove barriers to coordinated care and individual engagement.

The comment period ends March 22, 2021. Most of the changes center around the individual privacy rule, the right to inspect and obtain copies. And that, as you know, goes hand in hand with interoperability, payer-to-payer exchange, and the advent of being able to access your information using smart apps. Although these will likely see a delay,  I think we will see some of those modifications take hold.

Another Final Rule, likely to see a delay, requires health insurers operating on the federal exchanges participating in the Children’s Health Insurance Program and Medicaid to release faster decisions on prior authorization requests and use application programming interfaces to share prior authorization with data with patients and clinicians. Comments are due April 6, 2021.  We will continue to monitor and provide updates as they occur.

Choosing a Long-Term Partner for Growth and Success

Change is a constant in the healthcare market. So, when healthcare payers are evaluating new technology investments, it’s imperative that they look beyond deploying a quick fix and seek out solution providers that care about—and can accommodate— your long-term transformation goals. Solution providers that challenge the status-quo, focus on functional design, and continuously reinvest in their products ensure that their solutions go beyond addressing your immediate needs to deliver partnerships for proactive change.

An internal culture that challenges the status quo

Technology solutions are ultimately a reflection of the people that build them. Organizations that encourage an internal culture of questioning the way things work is important. Not only does this mindset foster a sense of excitement, but it also helps employees seek out answers to the question, “how can this be better?” Much of today’s healthcare technology remains focused on short-term solutions that are not designed to adapt. But an internal culture that not only tolerates, but encourages questioning, breaking, re-building, and pushing the boundaries will continuously evolve—and this will show in their products.

Focused on functional design

While several providers may be able to offer a solution that meets your needs, many are limited to niche functions and require additional solutions or workarounds to accommodate the intricacies of your unique workflow. These cobbled-together solutions and processes complicate the claims payment ecosystem, creating manual rework and IT drag, ultimately leading to disjointed activities that result in inaccuracies and waste. This approach, however, is far less effective than using a system that is thoughtfully designed to allow all processes to work together seamlessly, eliminating all errors and delays.

Companies that are focused on design consider the ever-evolving nature of your claims payment ecosystem and build products that can adapt and grow with you. Cloud-based, interoperable, extensible solutions with open APIs are designed to deliver synchronization of payment guidance. These foundational capabilities, in turn, increase automation, reduce IT lift, and enable more rapid innovation to accommodate market needs.

Reinvestment in the products they build

An organization that continuously reinvests in its solution and prioritizes the build-out of features, capabilities, and support for its clients is a sign that they can provide a successful long-term partnership. Solution providers that understand the ever-evolving demands on payers will create a road map that considers immediate client needs while also anticipating future needs, like increased AI and machine learning capabilities. Their solutions are designed to grow and remain agile as new functionalities and content are developed. Furthermore, SaaS solutions that can deliver these updates via the cloud with minimal internal IT lift enable health plans to focus on other efforts instead of maintaining their technology solutions. As demand for transparency grows, organizations that invest in interoperability will ensure payers have insight into all aspects of their claims payment processes.

Choosing the right technology partner ensures long-term success for payers while enabling easy upgrades, interoperability, and automation—all without demanding additional lift from your internal IT. When you partner with innovative providers, they will help shine a light on the path for your organization—instead of holding you back, they will guide you, continuously, towards growth, agility, and not just accommodating, but anticipating an ever-evolving market.

What Can Software Vendors Learn From Health Plans?

Having a wide range of experiences with both health plans and software vendors, it is intriguing to explore how each operates in tandem with the other, creating symbiont relationships that are crucial for one another’s success. Reflecting on those common experiences many of us have, there are many things one could learn from another.

One experience stood out to me recently while reflecting on my employment at my local health plan, first entering the healthcare payer space many years ago. I will never forget what my boss told me on my first day. He said, “We may not be the cheapest game in town, but nobody else is going to provide a better customer experience.”

As my journey through health plan operations continued, that commitment to customer service was always consistent. No matter the department, we went above and beyond for our customers; whatever they needed, we did our best to make it a reality. It was our commitment to our customers that drove our daily business decisions. Anyone who came from this health plan and, as I would discover later, many other health plans like it, will tell you their number one priority is, and always will be, the customer. It is simply engrained in the culture.

Software companies certainly care about customer relationships. In fact, I have led optimization efforts to re-establish that rapport that is so critical for collective success. Where understanding the issues and being patient with our approach to the solution was required. Our Chief Revenue Officer Chris Conte wrote about patience and understanding our customers’ challenges and how critical it is to remain sensitive to the issues facing health plans, providers, and members that are out of their control.

While the level of commitment to customer satisfaction are likely equal between the two comparative entities, the biggest business problems encountered are navigating factors such as the strategy and logistics of servicing/delivering the many needs of a health plan with a streamlined, efficient process. Software organizations tend to matrix resources around the delivery of contracted products and services to best meet the quality and deadlines associated with the customer. As a byproduct, this means if someone at a software customer has an issue, they may need to go to a sales executive, account manager, program manager, project manager, project lead, product SME, or technical analyst, or business analyst, or application support ticketing process to get an answer or assistance. This means there are times a customer may experience delays or, worse, confusion about getting what they need.

As a software vendor, I feel we can learn a lot about changing the relationship dynamics to increase rapport while providing a modern white-glove service. Healthcare is an emotional experience, and vendors who do business with health plans need to design their experience with that in mind. Creating a disruptive single contact-based model that breaks the existing state.

From a technology point of view, intelligent automation or hyper-automation should be playing a huge role in reshaping and redesigning the customer experience.

As we look to the future as software vendors, we can evolve the model to reinvent the customer experience going forward using state of the art technology.

A modern digital one-stop-shop experience that goes above and beyond for anything our customers need is the customer service model of the next generation.

Recognizing Employees’ Positive Impact on Colleagues and Customers

Employee feedback drives our decisions as a company. To create a forum that allows us to hear directly from our people, human resources created the Employee Council. The council meets once a month to discuss HealthEdge happenings and ways to do things better, share news, initiatives, and ideas, and improve cross-collaboration.

Last year, the Employee Council launched the EDGIE Awards to recognize our consistent contributors and unsung heroes that may not necessarily be visible to the larger part of the organization.

What makes the EDGIE Awards special are that all recipients are nominated by their peers across different categories, based on HealthEdge’s five pillars: Customer Value, First Principles, Cross-Functional Collaboration, Continuous Improvement, and Engineering Excellence.

HealthEdge employees submitted more than 200 nominations across all categories! Congratulations to the 2020 EDGIE Award winners:

Internal Customer SuperHEro: Shirish Dandge, Principal Support Engineer, and External Customer SuperHEro: Yu-Bing Chen, Principal Software Engineer, for always putting the customer first and consistently adding end-to-end value. They take time to understand the customer’s problem and determine the best approaches to fix the root cause.

The Principle Award: Arijit Das, Manager, Engineering, for constantly finding ways to do things smarter and uncovering ways to better approach the way we work.

Cross-Functional Champs: Gail Winslow, Director of Marketing Communications, and Dina Maiorana, Product Manager, who always know when to pull in their stakeholders. Other departments and teams view them as valuable resources and the first points of contact.

Continuous Improvement, Continuous Delivery: Ram Mamidenna, Manager, Engineering, for demonstrating superior proficiency in the use of open communication and seeking feedback. They are skilled at defining, measuring, experimenting, mastering processes, and determining improvements through retrospectives.

Excellence Award: Liz Black, Executive Assistant to the CEO, who takes an “engineers” approach to all areas of her work by using creative thinking and problem solving, demonstrating behaviors and skills to drive positive results. 

In addition, VP-level individuals and above are not eligible. However, the Honorable Mention category recognizes individuals who may fit into more than one category or are all-around an irreplaceable piece to our organization: Brittany Long, Senior Operations Manager, Wilda Todd, Sales Solution Engineer, and Amaresh Panda, Manager, Customer Services.

The EDGIE Awards foster a culture of recognition and thank the individuals who practice HealthEdge pillars in their day-to-day work, making a positive impact on their teams and the larger organization while serving our customers’ needs.

The Employee Council and EDGIE Awards are just two of the reasons HealthEdge was named to Boston’s 2020 Best & Brightest Companies to Work For® award, three years in a row, Boston Globe Top Places to Work, and Top Places to Work in the Nation in 2021.

Data Science and Data Lakes in the Payer Space

Historically, HealthEdge has focused on optimizing the transactional side of the payer business. As a core administrative solution provider, we touch all parts of our customers’ workflow, and this requires us to store and host volumes of data. By better understanding the data, we can use it to drive value for customers.

With a data lake, any kind of data, irrespective of structure and source, can quickly provide valuable insights that improve our customers’ business outcomes and operations.

With a traditional data warehouse, users must transform data into a well-defined schema before storing it in the warehouse.  In order to generate insights from the data, one is limited to the particular schema design. Furthermore, these traditional schemas face design challenges when new sources of data become available for ingestion.

With a data lake, there is no longer a barrier. The data does not need to be clean and perfect or come from a single source; it can come from anywhere. A data lake allows for the storage of data from core admin systems, pharma, EHRs, or other proprietary sources in its original format until it’s required for analysis. Furthermore, a data lake is scalable and can easily support large volumes of data at once or incrementally, enabling analysis that would not be possible with traditionally pre-defined hardware constraints. With the data lake’s distributed systems, a user can ask extremely complex questions as well as create computationally intensive predictive models.

For example, a model could be built to determine how to process claims more efficiently and improve auto adjudication rates using machine learning techniques. With a data lake, a user can perform complex data transformation of millions and millions of claims—including the claims history, adjustments, processing on reason codes, and more —and do it in a fraction of the time of a traditional SQL-based data warehouse.

A second example of leveraging data lake technologies is with predicting membership churn. Retaining members is a significant issue for health plans, but they can only compare the return rate versus the percentage of people leaving. With a data lake, there may be enough historical data to model member characteristics and behavior before they left the plan in the past and use this knowledge to predict if current members will leave a plan in the future. With that information, health plans can adjust their offerings accordingly to improve retention rates.

This year, HealthEdge built a data science team that is currently pursuing these and other hypotheses. Through close collaboration with our customers and a series of near-term proofs-of-concept, we anticipate unlocking new types of value for the health insurance market not possible five years ago.

Addressing Unconscious Bias in the Workplace

Every talent development team can tell you. Attracting quality candidates and attracting ethnically and gender diverse candidates not only strengthens an employer it results in creating an authentic and truly representative workforce.

At HealthEdge, our goal is to create a culture where employees feel comfortable and proud to bring their whole, authentic selves to work. However, we know that with a workforce spanning a range of social identities —gender, ethnicity, religion, sexuality, age, and more —not everyone experiences the same levels of comfort and openness.

HealthEdge has embarked on a focused journey to address building a global workforce where diversity, equity, and inclusion (DE&I) are at the forefront.

As part of our Black History Month kick-off, we launched a new speaker series inviting HealthEdge team members, around the globe, to listen to an engaging presentation by Cindy Joseph, Founder and CEO of The Cee Suite, addressing unconscious bias.

As humans, we all carry biases; they help us navigate the world as we face millions of pieces of information at any given moment. Our brains create these biases like shortcuts to help us process our environment. By their nature biases are often subconscious and unintentional. The danger is that these biases are persuasive and encourage us to make assumptions without us even knowing that it’s happening. If left unchecked, our biases can cause errors in our decision-making that significantly impact those around us.

Many of us found ourselves last year asking, “what can I do to make a difference?” At HealthEdge, we offer a series of opportunities to learn and grow and to explore the dialogue of DE&I in a safe space.  We all agree that our work culture is where we can exert the greatest amount of impact.

And that is why we are strengthening our employee-driven, I Belong HealthEdge (IBelongHE) committee, with monthly presentations, welcoming all voices to the table. HealthEdge has taken every effort to ensure that we learn from our past and grow into our future. The initiatives that we are committed to extend beyond window dressing. As a company, we committed to the MassTLC Compact for Social Justice. Our work on rooting out racial inequity was spotlighted in the Boston Globe’s Top Place to Work.

As Ms. Joseph said, “you cannot recruit your way out of diversity challenges; it goes beyond representation.” This is why we are focusing not just on recruiting but also on community, training, and communication. We believe this multi-prong approach will help us create an organization where people of all backgrounds and social identities feel a sense of belonging and have the opportunities to do their best and succeed.

While there is no quick fix to this work, HealthEdge is committed to taking concrete steps to facilitate change and making strides to improve every day. Understanding and addressing biases will help us become more inclusive and dynamic as a community and create a better and more equitable work environment.

Do you have what it takes to be on our team? Are you as committed as we are to building a culturally-enhanced workforce.  Check out our career openings or follow us on LinkedIn to learn more.