Month: March 2021

HealthEdge has hired over 100 people every year for the past three years. In 2020, we added 108 new full-time employees and 22 interns. When other companies in this space were forced to do hiring freezes and layoffs, we were fortunate enough to keep growing.

With COVID-19, we saw a change in the market and our candidate pool opened up tremendously. For recruiters that allows an even greater level of selectivity, so trying to stand out becomes key. For some roles we saw an explosion of applications. Instead of 30 people applying for a job, we would receive 150 applicants.

In such a competitive job market, how can a candidate stand out?

It’s all about first impressions. First, have an updated LinkedIn profile. Recruiters love to see a profile that’s current and showcases your work and personality beyond the resume. Follow different companies and thought leaders, share articles that interest you, and post your own content. For engineering roles, it’s great to see people that participate in open-source code sites like GitHub.

In a sea of applicants, referrals are also an excellent way for an individual to rise to the top. We trust our employees look at their network and connect us with people who were standout colleagues in the past. We received over 200 employee referrals last year. It’s our recruiting policy that every referral gets called. We give our employees credence for taking the time to refer someone, and we want to ensure those connections have a good experience.

The next step is the phone screen. The phone screen is not to test if you’re qualified for the role or have the right skills. At this stage, recruiters look for your interest level, communication skills, interpersonal skills, and how you would contribute to your team. It’s important to engage with the recruiter; being open and authentic is a big part of helping us make sure you’re the right fit for the company. Talk about your experience, what interests you about our organization, show us you’ve done your research. I love when applicants have followed HealthEdge and pay attention to what we’re posting about our culture and our business. Active, thoughtful conversations make a candidate shine, whether it’s for the current role or something in the future.

It’s not uncommon that we will have a call with a candidate, and it turns out they aren’t the best match for the position they applied for, but their personality and character are a great fit for HealthEdge. We will keep those people on our radar. We’ve stayed in touch with candidates for an entire year before a role opened up. If someone makes a good first impression, they open the door to endless opportunities.

HealthEdge was recently named national Elite Winner in Employee Achievement and Recognition designation for the 2020 Medium-Size Best and Brightest Companies to Work For, Top 101 in the Nation®. We are also a proud winner of 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.  Want to work with us? One of our goals is to stand out as an employer of choice and if one of your goals is to work in an environment that challenges you and cares about you bringing your whole self to work, please check out our current job openings.

Interoperability remains front and center for compliance. HealthEdge continues to focus on the Patient Access API, which has an enforcement date of July 1, 2021. All of the data required for our clients’ compliance is in our data warehouse. Our HealthRules Payer customers can use the Common Payer Consumer Data Set (CPCDS) to move their data from our data warehouse to the HL7-FHIR-enabled solution. We are creating a patient access data mapping document to enable our customers to easily collect the data elements required by the CPCDS.

Also with a July 1, 2021 enforcement date is the Provider Directory API.  The data within HealthRules Payer can support this requirement, but it is likely plans will use the system of record they use today to produce their Directories.  HealthEdge will address following the Patient Access API.

Effective January 1, 2022, the Transparency in Coverage Final Rule will require all payers to post three machine-readable files (MRFs) to their public website every month, including in-network negotiated provider rates, in-network drug pricing, and out-of-network coverage rates. HealthEdge is working on the high-level requirement to map the data they need to create the in-network and out-of-network provider rate files every month.

Key provisions of the Consolidated Appropriations Act—which went into effect on December 27, 2020— impact payers.

The No Surprises Act includes federal protections against surprise medical bills from out-of-network providers for emergency services, including air ambulances. The Act also applies to out-of-network providers when the patient is at an in-network facility unless the patient agrees prior to the services.  Under this act, cost-sharing amounts are capped at those that apply to in-network services, providers cannot send bills for any higher amounts, and there is an arbitration process to resolve payment disputes between insurers and providers. The act borrows from the enforcement and state preemption frameworks from HIPAA and the ACA. There is also a clause for the Continuity of Care when a health care provider drops from an insurer or group health plan’s network.

This all becomes effective January 1, 2022, so we expect to see activity related to the No Surprises Act ramp up soon. The Tri Agencies must issue a new rule to implement these provisions, allow for at least 60 days for comments, and then have a six-month runway for implementation. They will also need to generate and authenticate data and reporting, particularly around these air ambulance providers and the insurer, and conduct studies on the effect on provider consolidation, health care costs, and access to care across the lines of business. The federal government will also need to issue several different reports, as defined in the Act.

The CAA also includes Transparency Rules requiring health plans to have a price comparison tool, available online and by phone, that will compare cost-sharing amounts for certain items or services at any provider. The intent is to improve disclosure of cost-sharing requirements by listing plan-specific deductibles and out-of-pocket maximums on insurance cards alongside a phone number and website where an individual can ask about network status.

There is also an “advanced” explanation of benefits. When a provider notifies the health plan that an enrollee is scheduled to receive health care services, the plan must send an advanced explanation of benefits that indicates if the provider is in- or out-of-network and includes estimated costs and disclaimers.

The CAA also includes protocols related to provider directory updates. Health plans must update provider directory information at least every 90 days and remove any providers with information that cannot be verified. They also must respond to enrollees about a provider’s network status within one business day of their request. If the provider directory is not up to date and the employer enrollees relied on inaccurate information, the health plan must treat the member as if they went to an in-network provider.

When it comes to the price comparison tool, advanced explanation of benefits, and provider directory, HealthEdge will continue to monitor the agencies for rulemaking and prepare to  support and enable compliance with these components.

The government is granting some funds for states to establish All-Payer Claims Database (APCD) which is a voluntary program to collect health care claims data from payers. Right now, 21 states have established or in the process of implementing APCDs, and 11 more states have indicated a very strong interest.

The states cannot require TPAs or self-funded group health plans to contribute data. The Secretary of Labor will provide guidance regarding the data collection process and standardized reporting formats because the APCD hits all lines of business.

Lastly, we have two proposed rules in the comment period. First, the comment period for the proposed modifications to the HIPAA Privacy Rule to support and remove barriers to coordinated care and individual engagement ends on March 22, 2021. The proposed changes align with the current interoperability and transparency rules aimed at becoming more member-centric in the release of information. We also have Medicare and Medicaid Programs, Contract Year 2021 and 2022 Policy and Technical Changes, which comes out every year for CMS programs. The comment period ends April 6, 2021.

HealthEdge works with our clients to help them achieve full compliance with the laws, rules, and standards when these regulations impact our products and services.

I serve on the board of a rural health system. Prior to the pandemic, the health system had existing plans to stand up telemedicine to reach remote and underserved patients—many living more than 75 miles away from the nearest hospital or clinic.

Initially, the health system’s plan was to roll out telehealth over the course of 12 months, with a budget of several hundred thousand dollars and resources allocated to implementing the telehealth system. Once in place, the health system would need to convince the doctors and staff—who were already reluctant to work telehealth into their already busy schedule.  The initial adoption rate was planned to be less than 10% of physicians and only 10-20% of their visits would be virtual.  The physicians and staff worried it would interfere with their work, and many felt very strongly they would lose the connection with their patients.

Once the pandemic hit, the rural health system implemented telehealth in three days with over 50 successful virtual visits the first day.  It proved that the health system could innovate quickly, by doing things differently with great results while not compromising quality. The health system has increased its visit capacity by 25% with an anticipated increase in revenue while eliminating a key access barrier to care by bringing specialty care close to home for rural families.

Rural health systems face unique challenges, serving remote communities with limited providers, and extremely tight budgets. The telehealth virtual visits’ success opened the door for additional innovation and digital initiatives to create a better patient experience.

Sometimes, the best view of one’s soul is on the edge, looking back. Providers were pushed off the cliff for virtual visits because they did not have a choice due to the pandemic. And the results are incredible.

With telehealth, the physicians experienced increased efficiency that allows them to see more patients, have longer visits, and maintain a strong connection. Virtual visits have also provided an additional value with a window into their patient’s social determinants of health.  Observations during virtual visits provide not only the ability to clinically assess the patient, but they can also assess their social situation.  Virtual visits Telehealth has become a preferred method of accessing care in rural communities.

With this shift and change, telehealth increased the volume of visits physicians could take on, aligned reimbursements better, and provided improved access to quality, convenient care for members.

This pandemic has forced everyone to adapt and innovate faster than we ever thought possible. With technology and focused resources, this health system can now reach more members and continue improving care across the communities they serve.

Like all health plans, Safety Net Health Plans are gearing up for the explosion of data that will come with interoperability. Altruista Health Chief Technology Officer Craig Wigginton recently moderated an online panel of IT colleagues from health plans that serve the most socially and economically challenged members of society. These plan leaders have learned many lessons during the pandemic that are relevant to the coming wave of change interoperability will create in the industry.

Some members faced distinct barriers in accessing telehealth during the pandemic, as just one example. Some had problems with bandwidth in the home, a lack of technical skill, or even a preference to not have their home environment as a backdrop while they were speaking over video.

“The technology needs to be an enabler, not a barrier,” Wigginton said. He predicted similar concerns will arise when interoperability hits.

“Members are going to get data they’ve never seen before,” said Dan Dunkers, Vice President of IT at Johns Hopkins Healthcare. Members will head straight to the internet to understand what they are reading. Then they will call their health plan with questions.

This sparked a lively discussion about the impact to member services representatives who will answer these calls. How can they be trained to deal with the range of questions that might come in? Reps may be asked about technical issues that arise from the data download, along with related benefit questions and clinical inquiries. Will these reps be able to deal with all of this or will the call get dragged out trying to chase down answers? Plans need to handle this correctly, the panelist said, because members’ satisfaction with the process is going to affect Medicare Advantage scores.

Small Time Window to Impact Member Behavior

Wigginton said with the wave of data coming, there will be a wave of consumerism. “People are going to wonder, “if my Amazon purchase can follow me to Facebook, why can’t my health data follow me to the pharmacy or to my caregiver’s phone?”

The real-time nature of that data is important to capturing a member’s attention at exactly the right time to impact member behavior, the panel agreed.

Panelists weighed in about where plans should focus investments to get ready for interoperability. They agreed that data governance and security should top the list. The organizational siloes need to come down.

“The chief medical officer and IT have to work hand in glove,” Wigginton said.

The panel strongly agreed that technology should not create inequities among members.

“There should be no member left behind,” Wigginton said.

Other panelists were Stuart Myer, Chief Information Officer, VillageCare, and Kalyan Narayana, Chief Information Officer, Commonwealth Care Alliance.

Unlike a startup or smaller regional plan, many national health plans have grown their businesses by acquiring multiple smaller health plans along the way. While national plans gain new members through these acquisitions, they also often accumulate older and disparate technologies. As a result, national plans are often disjointed in terms of process and workflow.

Whether they are looking for operational improvement, administrative efficiency, medical savings, or any other initiative, it can be challenging to move quickly. Even with adequate resources and funding, national plans’ size creates more steps they must take internally and, in the industry, to transform their business. As a national plan continues to grow and increase the number of people, departments, and locations, these decision-making hurdles and issues escalate.

I often hear national plans ask, “how can we bring these different areas together to make things easier and improve operational efficiency?”

To modernize and innovate, national health plans need interoperable solutions that seamlessly integrate and connect their operations across the country. Cloud technology and cloud-enabled software can bring all these different areas together, even while physically separate from each other. With cloud-based solutions, everyone at a health plan is always working with centralized data and up-to-date information, reducing maintenance delays and potential errors.

This is extremely valuable for larger health plans. Once everyone at the health plan is working on the same tools, it makes collaboration easier and more streamlined.

The COVID-19 pandemic highlighted where outdated technologies present administrative deficiencies and the need for cloud-based solutions.

The pandemic created an entirely new regulatory environment that health insurers needed to accommodate immediately. Things were changing quickly. A large plan with disjointed systems did not just need to make changes in one place; they had to make them in several areas. The health plans that invested in cloud-based solutions had the flexibility to react quickly to the regulatory changes with minimal business interruption.

Cloud-based solutions can completely transform a national plan; however, it takes investment for progress. Health plans need to think differently about where they want to be in ten years, partner with next-generation technology creators, and invest in their future.

Sometimes, issues people face might not even cross someone’s mind until they are in the same situation and feel the impact. It’s helpful to have ongoing conversations to share our experiences, and in turn, recognize someone else’s experiences. Even if their reality is not your reality, it’s essential to come from a place of understanding. Recognizing that everyone has a unique perspective is when real change will happen.

George Floyd’s murder last summer was a catalyst for change across the country, including HealthEdge. Our Human Resources team initiated individual and group conversations with the African American employees to share our experiences, feelings, and how the company could do better. These were raw conversations. Everyone listened. Similar to what was happening across the country, these conversations led to a broader, thoughtful dialogue that could focus on how a company can influence societal change.

We needed a safe forum to create more conversations about diversity and inclusion and sharing our experiences. It was clear that the HealthEdge leadership cared and did not want diversity and inclusion to just be a moment or hot topic. They were invested in taking steps to make a change and do it the right way.

HealthEdge signed the Mass TLC Compact for Social Justice aimed at increasing diversity programming and training, self-reporting demographic information, and expanding their talent acquisition pipeline resulting in more diverse hires.

After a few meetings, we decided to add more structure to these discussions and open them up to everyone. This sparked the idea for IBelongHE, an internal group that has regular, open conversations about diversity, equity, and inclusion. I serve as the employee champion of IBelongHE to ensure our employees feel heard and have a voice in charting our path forward to real change.

We’re making progress with the monthly IBelongHE meetings and recently launched a speaker series bringing in outside experts to guide our company in tackling such topics as unconscious bias that help us think of others’ perspectives and experiences.

Our work is not yet done.  The first step is acknowledgement followed by making a plan to do better. We’re best served by being thoughtful and purposeful in what we’re doing. We will continue to have conversations, learn from each other, and move toward being a more diverse and inclusive workplace.