Want to Transform? Start with People, Process and Technology

When it comes to business transformation, the biggest roadblock is often resistance to change.

In a former role, prior to working at HealthEdge, I was among 30 consultants hired to tackle a company’s backlog of work. The client did not ask about our individual experience that they could tap into or recommendations for improving the process. The project was incredibly inefficient. We all had different skills and knowledge to help move their project along faster, but we faced resistance. The client wanted to keep the process as it was, having all 30 consultants working on the exact same tasks.

It was clear that everyone was working at different speeds. Some people were fast but had a few errors, while others were slower yet analytical. I recommended that we push to have a tiered system― the tier 1 people would quickly work through the backlog, tier 2 people audit the work, catch any mistakes, and tier 3 people focus on any complex issues that arose. Leveraging our talent in a different capacity, this process would allow our team to meet the production schedule, reduce errors and ultimately boost morale.

I finally convinced the client to let us try something new. We assigned people to the tiers where they would perform best and set up a model so that the process wouldn’t get caught in a bottleneck. As a result, we took care of the backlog that had been accumulating for months in less than 30 days.

With a fresh perspective, we implemented a new process that capitalized on the strengths and expertise of our people and allowed the company to transform and gain productivity moving forward.

That’s just one example; not every project is the same. To transform your business, it’s always key to revisit and improve processes, leverage the vast experiences of your people and find the right technology partner.

When it comes to software, it’s important for the company’s technical side and business side to work together and collaborate. When IT and business join forces, they can achieve so much more and faster.

Increasing Membership is Top of Mind for Payers

HealthEdge, in partnership with independent market research firm Upwave, recently conducted a survey of more than 220 health plan executives across the country; results revealed that increasing membership is a top organizational goal for payers.

With increasing demands to grow membership, market pressures are changing how health plans invest the resources made available from lowering costs and increasing efficiencies― top responses included consider new partnerships or acquisitions and invest in a new geography or line of business.

This year especially, payers are facing unique pressures to grow. Many health plans lost a lot of membership due to COVID-19 and businesses closing. As the economy opens back up, health plans will focus on different ways to establish themselves and attract members as consumers re-enter the market.

We’ll see large nationals strategically entering into new geographies and product lines to expand their market share. As a result of acquisitions, large national plans also often have multiple legacy systems. I also expect to see increased due diligence in potentially consolidating those systems to cut administrative costs and have a best-in-class ecosystem. Provider-owned regional plans, which were particularly hit hard in the last year financially, will also expand new product lines and focus on member retention. Overall, innovation in consumerism will be essential across the board.

The executive survey also revealed that one of the top challenges to acquiring new members is offering the variety of plans necessary to satisfy members. In order to create new plans that appeal to the consumer, health plans must make strategic business decisions; this requires the ability to model new benefit plan design and quality-based pricing in their system against real-utilization data to understand outcomes and predictability.

Additionally, with COVID-19 and society in general, we’ve seen an increased emphasis on behavioral health. This increased prevalence will certainly impact benefit design going forward, especially with new models to reach consumers, like telehealth.

Whether through new geography, line of business, innovative offerings, or acquisitions and partnerships, health plans today want to take advantage of all available resources to expand in the current landscape.

How Core Configuration Can Reduce a Health Plans PMPM

How many resources does it take to run the core configuration of your enterprise?  What type of custom external tools are required to build and maintain the configuration?  What are the financial impacts associated between the complexity of the configuration in a system and the cost per member per month (PMPM) or total cost of ownership (TCO) figures?

As we evolve into the next generation of core systems, these types of questions top the list for the potential vendors looking to modernize a core platform for a prospective health plan.  One thing is clear, as we continue forward in the market, the time of the core systems that require high administration costs in terms of the number of resources and custom solutions it takes to configure and maintain is coming to an end.

Currently, the savviest health plans in the market are shifting from the predominant solutions for configuring the system with offshore-based services and/or custom-developed utilities and toolsets to ones focused on out-of-the-box automation enabled by best-in-class configuration.

Can a system be both flexible and provide streamlined next-generation configuration capabilities?  Putting myself in the shoes of any given health plan in the market today for a core modernization and the surrounding ecosystem, one key focus would be on the core configuration and the level of automation that the system brings.

Is the system’s configuration overly complex, disparate, and requires custom external tools to build and maintain?  Can my current staff pick up the complexity of all the aspects of a system that need to be considered when implementing and maintaining my business?  Consequently, what does that ramp-up time look like?  The steeper the learning curve, the greater the chance staff will likely resist adopting the new technology, and the project suffers or fails outright.

In my career, I have seen far too many health plans that implemented their solutions 20 years ago and are faced with complete re-implementation of the existing platform.  Their current systems do not possess the flexibility nor the automation to provide the ability to implement enhancements to optimize existing configuration over time. The level of effort and analysis is simply too high when maintaining production states are the operational primary focus.

Regulatory Actions & Compliance Highlights Health Plans Need to Know

We had three very significant Final Rules in play at the end of last year. The first one, the CMS Interoperability Final Rules, was back in May. The Transparency in Coverage Final Rule came through in November, followed by the Consolidated Appropriations Act, which included the No Surprises Act and several Transparency items signed in the last few days of 2020.

Many of the components in the No Surprises Act have a January 1, 2022 implementation date. In the middle of all of this, any solutions developed for 1/1/22 will likely coincide with the Medicare Advantage annual enrollment period, so things will get a little hectic.

To start things off, on July 1, 2021, Medicare Advantage (MA), Medicaid, CHIP, and Qualified Health Plans (QHP) on the federally facilitated exchanges (FFEs) must implement the Patient Access and Provider Directory APIs from the CMS Interoperability Rule.

HealthEdge has created a Patient Access Data Mapping. The Data Mapping uses the Common Payer Consumer Data Set (CPCDS) to bridge to the FHIR Profiles, which will be exposed to the member selected application via the Patient Access API.  We have collaborated with several customers and will finalize the draft by the end of this month.  Of course, the mapping is subject to change because this is an evolving process. We had HIPAA back at the beginning of the century, and ten years later, the Affordable Care Act came and shook things up. I think interoperability and transparency is the next big wave in healthcare.

On January 1, 2022, the Payer-to-Payer Historical Data Exchange under Interoperability also becomes enforceable.  Members can request up to five years of historical data to be sent from their previous plan to their new plan, and the new plan must be able to ingest the historical data.

Consolidated Appropriations Act’s No Surprises Act, effective for plan years beginning on or after January 1, 2021, comes into play.  Many states already have no surprise billing rules; however, this is the first at the federal level.  While we await rulemaking by the tri-agencies, we can get started on what we know from the legislation. Insured, Self-Insured, and Individual Plans that provide in-network emergency coverage must provide out-of-network emergency services coverage without preauthorization requirements and with the same cost-sharing amounts as in-network.  The same applies to when non-emergency services are received without notice by an out-of-network provider at an in-network facility.  There are also provisions addressing Air Ambulance.

For these situations:

  • Cost-sharing must be applied to both in-network and in-network out-of-pocket maximums and is calculated as if the total charge is:
    • The amount required by state law; or if none
    • The median contracted rate of the plan sponsor (or issuer) for the same or similar item or service in the same geographical and the same market as of 1/30/2019 (increased by CPI-U)
  • Initial payment or issue of denial within 30 of claim receipt
  • Arbitration is available to resolve disputes between the Provider and Plan.

Meanwhile, providers may not balance bill except ancillary services with prior notice and consent.

Also beginning January 1, 2022, the Transparency in Coverage Rule requires virtually all non-grandfathered plans to post three machine-readable files (MFRs) to their public website every month.

The three files include the In-Network Rate File, which is the negotiated rates based on the benefit plan, provider, and service code with the rate expressed in dollars. The Allowed Amount File which is basically the out-of-network payments. The file is created from claims experience, using data beginning 180 days prior for the first 90 days of that period, where there are 20 or more claims found for a reported service code. The machine-readable file must contain the billed and the allowed amount attached to that benefit plan, provider NPI, and service code. The third file is for the Prescription Drug Coverage File.  This is out of scope for HealthRules Payer. A high-level requirement has been completed for the In-Network Rates and the Allowed amount Files and is in solutioning.

Additional items under the Consolidated Appropriations Act (CAA), all converging on January 1, 2022, include:

The Advanced Explanation of Benefits (A+EOB)

When a provider notifies the insurer or group health plan that an enrollee is scheduled to receive a health care service and provides a “good faith” estimate of charges, the plan must send an “Advanced” Explanation of Benefits (A+EOB). This advanced explanation of benefits must indicate if the provider is in-network or out-of-network, include the good faith estimates of costs and the required disclaimers.

Price Comparison Tool

The group health plan must make a price comparison tool available to members, online and by telephone. The tool compares the cost-sharing amounts that members would be responsible for paying different providers for the same service.

ID card requirements

All plan ID cards, Hard Copy, and Electronic must include the in-network and out-of-network deductibles and out-of-pocket maximums printed out.  Along with a telephone number and website for assistance.

Provider Directory Provisions

All provider directories must be verified and the information updated every 90 days. Plans must respond to member inquiries regarding a provider’s network status within one business day and then keep a record of that for a minimum of two years. The plan must also establish a database of network providers. And lastly, the plan must not impose out-of-network cost-sharing if directory or response indicated the provider was in-network as of a relevant date.

Looking ahead, most group health plans and health insurance issuers in the individual and group markets must offer an online shopping tool under the Transparency in Coverage Final Rule. This will allow consumers to see the negotiated rate between their provider and their plan, as well as a personalized estimate of their out-of-pocket cost for 500 of the most shoppable items and services, beginning January 1, 2023. The online shopping tool becomes all-inclusive on January 1, 2024, expanding to drugs, DME, and all other items or services covered by the plan.

To Remain Competitive, Health Plans Must Support Value-Based Care

I recently participated in an AHIP webinar, “Growth and Innovation with a Consumer-First Future,” with HealthEdge customer Sal Gentile, CEO and Co-Founder of Friday Health Plans, along with UST HealthProof’s CEO Kevin Adams and HealthProof President Raj Sundar. We discussed current challenges health plans face while competing to grow their business in today’s rapidly changing healthcare industry.

There are increasing market pressures for more health plans to move away from traditional fee-for-service models and adopt value-based care. However, an audience poll revealed that 34% of health plan employees say their ability to support value-based models is the top challenge inhibiting growth and efficiency. This correlates with the relatively slow growth of value-based arrangements between health plans and providers.

Value-based contracts and benefit plans can range from simple incentives to risk sharing, including full capitation. That’s why it is critical for health plans to have the supporting technology that can drive the business with whatever model fits.

“I don’t think it’s any surprise in this industry that change is a constant thing in our business. And what’s amazing is the degree of change never seems to let up,” said Kevin Adams. “If you implement the right capabilities, whether that be people or systems, you can adapt to that change very easily.”

Legacy systems with minimal business flexibility, convoluted configuration, custom code, and manual processes hinder a plan’s ability to shift to any form of value-based care and realize subsequent growth opportunities. Health plans need a system with the flexibility to configure all types of plans and can quickly respond to changing regulations with minimum disruption.

With value-based care, the exchange of information with providers is also critical for success. Health plans require technology that can provide comprehensive, actionable data and analytics about the patient’s health to their providers.

Actionable insights are not only valuable for providers in value-based arrangements, but they can also help health plans continue to innovate and offer new benefit plans and designs.

“We’re a very metric-driven organization,” said Sal Gentile. “It guides us in two ways. It helps us determine whether or not we’re meeting our objectives and hitting our results, and it also drives the new learnings that will dictate what we’re going to invest in next, what we have to fix, and where we want to go.”

To support growth and efficiency, health plans need a core administrative processing system that supports value-based models and new partnerships.

Embracing Cloud-Based Technology

Ten years ago, did you expect to see health plans processing claims in the cloud? It’s a significant shift the industry has experienced over the past decade.

Part of our mission at Burgess is to help drive down the cost of healthcare overall. Many health plans have disparate systems that lack interoperability between different applications, which leads to increased administrative and healthcare costs and strain on an organization’s limited resources.

In a recent survey of more than 220 health plan executives, when asked which factors would help reduce administrative costs at their organizations, 56.8% said increased interoperability across the health plan ecosystem, and 51.8% said increase financial accuracy of claims.

Cloud-based technology allows health plans to streamline their workflows and increase that interoperability to achieve a more comprehensive and cohesive ecosystem― and ultimately reduce health care costs.

At Burgess, the move to the cloud has certainly been the biggest technology shift I’ve encountered. When I started at Burgess, our first-generation solution was an installed product. Then, we moved to our second-generation product, which is all internet-based. And now, with Burgess Source, we’re processing in the cloud.

A decade ago, health plans were not completely open to the idea of processing their claims outside of their own brick and mortar. There has been a transformation in the way health plans operate and think about their business—this trend shows how quickly everything has evolved over the years.

With new technology also comes an increased focus on security. In the same executive survey, respondents cited ease of doing business, modern technology, and security as the top three priorities when evaluating a healthcare technology vendor. So, while cloud-based modern technology offers significant benefits, it’s also crucial for health plans to find technology vendors that take advanced security measures to protect personal health information and other data, all the way to achieving HITECH, SOC2 Type2, and HITRUST certifications.

Partnering with next-generation technology vendors that prioritize security will ensure that health plans can leverage the latest solutions to streamline their workflows, increase interoperability, reduce costs, and remain competitive.