The 5 Big Fails of DIY Software: #1 Getting Out of Your Lane

More than ever, health plan executives see their IT and business strategies as deeply intertwined:

According to Accenture Research Global Survey 2021, 83 percent of IT and business executives say business and technology strategies are becoming inseparable – even indistinguishable. Furthermore, 77 percent say that their technology architecture is becoming critical to their organization’s success.

Yet, for anyone leading an organization, cost is always a top consideration.

What executive hasn’t asked themselves at some time, “Couldn’t we just build this software ourselves?” It’s not unheard of to wonder whether in-house development will deliver a less expensive custom product. These decision-makers should heed the cautionary tales of “build” decisions that resulted in longer timelines, cost overruns and poor results. No less than General Electric embarked on an ambitious in-house digital transformation that quickly became mired in organizational dysfunction and conflicting priorities that have dragged on for years. I believe there are many more “build” stories that never generate headlines because they remain internal failures that no one wants to discuss.

The scenario is even more complicated in healthcare.

When Altruista’s parent company, HealthEdge, recently asked 222 health plan leaders what steps they plan to take to achieve their organizational goals this year, 59 percent said they plan to modernize their technology and 50 percent plan to make a significant investment in innovation, up from just 19 percent in 2018. It’s clear they see the importance of technology investment, but will they choose wisely?

As the president of a high-tech company serving health plans, I can tell you that our customers operate in one of the world’s most challenging environments. Reinventing the wheel just doesn’t make sense, especially in ecosystems like healthcare that are defined by flux. I would advise organizations in any industry to stay focused on their core mission. Developing software is not the strong suit of anyone outside of technology, and executives are advised to rely on the expertise of people who have devoted their careers to software development.

In an era of highly specialized knowledge, it only makes sense to trust the innovators who have purpose-built a platform for your exact needs and who will continue to stay ahead of the market. Therefore, the key to avoiding Big Fail #1 is to stay in your lane.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.” 

How Successful Health Plans Transform Their Business

The health insurance industry is constantly evolving with the introduction of new regulations, the need to adopt value-based reimbursement (VBR) models, and changing customer expectations. Innovative health plans are transforming their business operations — discovering ways to efficiently tackle these challenges and better meet market demand while reducing costs.

Business transformation requires your organization to objectively examine the people, processes, and technologies that drive your core business, with a focus on automation.

A recent survey revealed that competitive pressures (39%), lack of alignment between IT and the business (39%), followed by member satisfaction and managing costs (37%), are the top three challenges facing their organizations today. This is a notable shift from a 2018 executive survey, where lack of alignment between IT and the business ranked at the bottom (22%). Payers are waking up to the fact they must meet consumer demands to remain competitive, and IT must actively participate in achieving these business goals.

Changing market dynamics continue to encourage health plans to grow their businesses, develop new services, increase membership, and ensure a positive member experience. To achieve these goals, the first step is to find a modern technology that helps plans quickly adopt new business models and automate processes to achieve optimum operational efficiency.

If your organization wants to take the first step in the transformation, ask yourself a few basic questions:

Can my current system:

  • Improve my member satisfaction?
  • Improve my claims adjudication rates, speed, and efficiency?
  • Help me launch new plans/benefits/services in a matter of hours?
  • Help me easily expand into new geographies?
  • Help me reduce my claims backlog?

If you answered no to any of the above questions, your first transformation opportunity might reside in your core administration system.

Legacy core administration systems were designed in a different era. Today, members and providers demand to access real-time information online, and plans must be responsive to all inquiries. While many health insurers have made significant investments to modernize and integrate these systems, their architecture does not offer the flexibility and speed needed to succeed in today’s marketplace.

Do not underestimate the need for flexibility. A health plan must be agile enough from a people, process, and technology perspective to proactively embrace new regulations and reimbursement models, exceed customer expectations and develop and introduce new plans/benefits/services fast.

Enabling the Why

We speak early and often about why we do what we do. We want to help people live the best lives they can, no matter their circumstances. We help care management teams achieve this “why” by offering the latest generation care management system.

It’s all about automation to allow clinical teams to work at the top of their license. For example, our prior authorization portal allows providers to enter a request, and if it passes the criteria, the service is automatically approved without human intervention. Provider satisfaction increases because they don’t need to wait for an answer, and as a result, the care clinicians can spend more time focusing on how they are going to help members live the best lives they can.

When you think about GuidingCare, the name, it should hopefully tell you that it is to guide the care journey—the platform offers evidenced-based next steps the provider should take to ensure the member receives the best care in their journey.

Compliance is another critical piece of care. The Affordable Care Act (ACA) caused the most significant shift in our business. After the ACA, health plans realized that the way to grow their business was through government programs. And, when it comes to government programs, regulations are complex, and compliance has a revenue implication. Take Medicare Advantage (MA), for example. As MA plans seek to grow their businesses, potential members are looking at which plans have the highest star ratings. If a health plan cannot achieve at least four stars in MA, it is very challenging to make it financially.

From the beginning of implementation, we’re focused on compliance. We help the customer avoid configuring their system in a way that would impact their ability to report on compliance, whether they’re NCQA, URAC or have CMS requirements for Medicare Advantage. We help our customers maximize their stars and make sure that they’re successful when they get audited by whatever governing body.

Our customers want to know they’re taking the best next step in the care model, that their people are efficient and working on the things that matter, and that they have the tools for regulatory compliance and reporting. GuidingCare enables all of that, and we’re always enhancing our capabilities.

Understanding the Intent Behind the No Surprises Act

We have an Interim Final Rule for the No Surprises Act, referred to as Part I. The comment period closed on September 7, 2021.

This is the administrative piece of the No Surprises Act, the federal level law that addresses group health plans and providers’ responsibility to the member for emergency care by an out-of-network provider or facility, an out-of-network provider during an in-network care episode (when the patient is not made aware before the services are rendered), and air ambulance.

Although some states already have surprise billing protections, states didn’t have the ability to reach self-funded employer insurance plans formed under the Employee Retirement Income Security Act (ERISA plans).

At a high level, the intent of this rule is to hold the patient harmless in these situations, without impacting their cost-sharing, as if they were in-network.

The provider and health plan are on the hook to ensure the patient is aware when they are entering an out-of-network situation and must work together to keep the member whole.

For example, let’s say a member goes to an in-network facility for surgery. The member believes all services are in-network, yet the anesthesiologist happens to be out-of-network. If the member is not aware and agrees upfront (consenting) to having an out-of-network doctor perform services, then the claim must be processed as if it was in-network. The provider and the plan will have to agree on a particular payment arrangement or the amount or the rate. Some arbitration and mediation can occur if the provider and the plan cannot come to terms, but there will be no balance billing to the member.

For health plans, there’s a bit more red-tape in the back end to ensure they’re not showing cost share as in-network and that the provider is on board with accepting our payment. Many processes will need to be updated from the plan’s perspective, but the intent behind the rule is important.

Consider this: when you’re in an emergency situation, the last thing on a person’s mind is, “does every provider in this ER take my insurance?” Or, if you require an air ambulance, “Are you calling an in-network ambulance?” That’s why these protections are being put in place.

People, Process, Technology—A Cliché That Still Rings True

With a track record of selling core/claims administration technology to health plans for more than 30 years, I’ve heard all the reasons as to why health plans want or need to convert from their legacy systems to something more modern. The key complaints typically include some or all of the following reasons: Lack of agility or trouble keeping up with change, high operating costs, quality/compliance issues, vendors ending product support, challenging to integrate, needing to consolidate, and/or unhappiness with current vendor support.

Any of these can be a viable reason to change core systems. However, leadership and organizations still often find themselves very disappointed with the change. In fact, our recent survey of 245 health plan IT executives found that 99% of respondents plan to evaluate their core administrative processing system in the next two years, even though 31% implemented the system less than four years ago.

The leaders may be experiencing unanticipated consequences of adding a solution to their organization holistically. Typically, they never looked at their “people, process and technology” together as part of their implementation. As a result, they find their operating/quality metrics are still down, customer satisfaction scores are suffering, they are out of compliance and management is unhappy.

What happened? Why is management again feeling the need to change course after buying a state-of-the-art system to solve their problems? These same execs will hear echoes of the same old complaints: “The new system does not work … it does not operate like our old system/service provider … we cannot get support from the vendor … we are losing key people.” Sound familiar?

With a bit of due diligence, we often find these same organizations are not leveraging major features and capabilities they already have in their systems. They simply took “the way they did things in the past” and implemented that into their new system. They never invested in quality training or change management, resulting in many of their workers being left unaware of new and important features. Furthermore, IT and business goals are not aligned. In our recent survey of 222 health plan executives, 38% said alignment between IT and the business is currently the top challenge facing their organization.

It is critical for health plans to take time at the beginning of the implementation process to properly look at their existing processes and then map out and train respective employees on the new processes in order to harness the power of technology. Frankly, some health plans would have been better off staying with their older legacy solutions or service than making the change without addressing their implementation more holistically!

I often advise clients upfront: “I can sell you the most advanced core administrative system in the industry; however, if you do not factor ‘people, process and technology’ into your implementation, you will fail.” This includes not only “the people” you want to implement your new system, but “the processes” needed to fully leverage your new system. We as a company have walked away from a few opportunities over the years because health plans were simply looking to replace their old systems with HealthRules Payer® without factoring in change management. For example, one plan admitted to me that while they wanted HealthRules Payer, they wanted the interface to look the same as their old system so they would not need to change the way they do business or train employees. While I understand the desire to save time early on, this is a recipe for failure and will be costly in the long run.

So, the bottom line is if you are truly going to change systems or technology, make sure you budget and consider “people, process and technology” together. Sometimes your core or clinical solutions vendor can help you, and other times, you may want to consider an outside services provider who can help you step back and objectively show you “best practices” at plans similar to yours. They can also help you build in the proper change management to leverage your new technology.

Tri-Agencies FAQ: What Health Plans Need to Know

Tri Agencies published a Frequently Asked Questions (FAQ) document on August 20, 2021, addressing the Transparency in Coverage (TiC) Machine-Readable Files (MFRs) and much of the transparency and consumer protections in the Consolidated Appropriations Act (CAA). This signaled the intent to take a more methodical and intentional approach to the rulemaking and acknowledged that the components are more complex than first blush.

Machine-Readable Files (MFRs)

First, they looked at the requirement for all non-grandfathered plans to post three MFRs to their public website by January 1, 2022. They deferred enforcement for In-Network Rates and Allowed Amount files―the two categories that HealthEdge plays a part in―to July 1, 2022, for complete compliance. Regardless, we’re staying on schedule and developing the utilities in-process for these two files and are targeting a release date in Q4.

The Tri Agencies also delayed, until future rulemaking, the prescription drug machine-readable file requirement due to disparities between the various prescription drug rules.

Price Comparison Tool

The FAQ also impacts the CAA requirement for group health plans to make a Price Comparison Tool available online or by phone. The Tri-Agencies acknowledged that this requirement is essentially a duplicate of the TiC Online Shopping Tool, except that it adds the ability to access by telephone. To better align the shopping tools, the Tri Agencies delayed enforcement until January 2023.

Advanced Explanation of Benefits (A+EOB)

A+EOB will require the provider to send a good faith estimate of an upcoming service a member is scheduled to receive to the health plan. The plan will then process it, much as they would process any claim, except that it’s a trial claim―and that’s what HealthEdge is going to be enhancing.

The Tri Agencies cited the complexity of the development around the standards for the good faith estimate and the communication from provider to plan. They intend to issue a notice of proposed rulemaking along with a comment period. So, we will not see enforcement on January 1 of 2022, until the rulemaking process is complete.

HealthEdge is collaborating with clients and working through discovery and solutioning, and identifying enhancements we can make to our trial claim functionality to accommodate the A+EOB along with the Price Comparison Tool.

Interoperability and Transparency

Although not included in the FAQ, beginning on July 1, 2021, the Patient Access and Provider Directory APIs went into effect. HealthEdge published material on the patient access data mapping for the API. This data mapping can also be used for the payer-to-payer data exchange, which goes into effect on January 1, 2022. This rule will allow members to request up to five years of historical data to be digitally sent from their previous plan to their new plan. The patient access data mapping guide provides the data element mapping for the previous health plan to export and send to the new plan.

With a little breathing space from the more calculated implementation of the TiC and the CAA, I expect we will begin to look at ways the historical data will benefit new members; and quickly realize the value in using the historical data to look at the members’ current health stats, identify care gaps, and recommend treatment or preventive care.


With any compliance mandate, there is a good intention behind it, including the interoperability, transparency, and other consumer protections that we’ve seen come through rulemaking in the last couple of years.

These rules make the healthcare industry more member-centric, with the intent to reduce the overall cost of care by getting members involved in their decision-making. The digital movement of data will help facilitate these efforts; if members know what preventive services they should receive and understand their supplemental benefits, the outcomes should improve.