Public Health Emergency Clock Ticks Forward to July

As expected, the Biden administration extended the mid-April expiration of the Public Health Emergency (PHE) another 90 days, so the countdown again restarts for July 15. The stakes are high for many parties, even as many Americans are shedding their masks and moving on.

For some states, the pandemic influx of Medicaid members was the largest enrollment action they witnessed in the 50-year history of Medicaid. Industry experts and states are keeping a close eye on what happens next.

When the PHE expires, so does continuous coverage for Medicaid enrollees. Many will become ineligible or need to proactively re-enroll to stay covered. Some estimate as many as 15 million Americans could lose coverage or need a transition in coverage, such as to an Exchange plan.

The Biden administration has promised 60 days’ notice to state Medicaid programs before ending the PHE, so the administration could signal its intent in mid-May if July is the targeted end-date. Many states say they don’t have the time or resources to effectively discern eligibility, contact and re-enroll beneficiaries even at that. Some experts think Medicaid continuous coverage could be de-linked from the expiration of the PHE to accommodate these concerns.

Other impacts PHE expiration:

  • Most beneficiaries in traditional Medicare will lose significant telehealth access unless they are in rural areas or participate in Medicare Advantage.
  • Providers will lose substantial financial support. Major provider associations are pleading for more time. Providers say they face challenges in providing care postponed during the pandemic, and have supply chain disruptions and staffing problems.
  • Popular telehealth flexibilities will continue at least five months beyond the end of the PHE, thanks to 2022 Congressional legislation.

There is mounting political pressure to end the PHE. Various emergency measures, such as those affecting skilled nursing facilities, are already winding down. Many policy experts expect the April renewal to be the last extension. If the PHE is extended yet again, the new date to watch will fall in mid-October.

CMS Opens Portal for IDR Under No Surprises Act

In the ongoing struggle to achieve clarity around how Surprise Billing regulations will work, the Centers for Medicare and Medicaid (CMS) opened a Federal IDR Portal in late April to guide resolution of out-of-network rate disputes between payers and providers after direct negotiations fail. As the saying goes, “the devil is in the details.” This process represents the last resort for payers and providers if they can’t come to rate agreements on their own.

The portal reflects revised guidance independent arbiters can use in the Independent Dispute Resolution (IDR) process and what information they shall consider when choosing between two prices – one offered by the provider and one by the payer. The arbitration method is known as the “Major League Baseball” approach – both parties make offers and an independent arbiter determines which price prevails. The arbiter must choose one award without modification, so whichever number is chosen is final.

Some of the variables the independent arbiter must consider are:

  • The Qualified Payment Amount (QPR) for the relevant service. In general, this is the median of the contracted rates, factoring in geography, specialty and inflation. The methodology for this was established in the CMS July 2021 interim final rules.
  • Other credible information as submitted by either party that is not prohibited and is relevant to the offers made.
  • IDR arbiters may also consider, for non air-ambulance services, the level of training and outcomes for the provider; the provider or facility market share; patient acuity and service complexity; the facility’s teaching status, case mix and scope of services; a demonstration of good faith or lack thereof in attempts to reach a contract.

Factors that the IDR must not consider include:

  • “Usual and customary charges,” including when expressed as a percentage or share of same
  • The amount that the provider would have billed were key rules (45 CFR 149.410, 149.420, and 149.440 as applicable) not applied.
  • The reimbursement rates for most public payers, including Medicare, Medicaid, CHIP and TRICARE. The same rule applies as above for figures expressed as percentages or shares of those rates.

The rules are both similar and different for air ambulance services. In that case, additional variables an IDR arbiter may consider are the type of air ambulance vehicle and its level of clinical capability, and the population density at the point of pickup for the patient.

The IDR entity has 30 days to notify the involved parties in the dispute of their decision. The non-prevailing party must also cover the costs of the IDR services.

Note: Please reference the Independent Dispute Resolution link for complete guidance. This blog post is a partial summary and does not represent legal advice.

Healthcare Rules and Regulations are Constantly Changing, But Your Payment Accuracy Doesn’t Have To

Healthcare is unique in so many ways – services are customized to each person, experience is impacted heavily by the provider, and quality of care is affected by your coverage. Paying for healthcare services is also unique. Where else do you go to a place of business for a service, pay a co-pay (or not) at the time of service, and then a few weeks later receive a bill outlining how much that service cost, how much your insurance will cover, and how much you’ll be paying out of pocket? And, woven throughout that whole scenario are rules and regulations that play a significant role in the calculation of what the health plan pays and what you pay.

These past few years, payers have been challenged more than ever to keep up with volatile market dynamics and comply with regulatory requirements. It’s not an easy feat to accomplish. The health insurance industry must comply with federal regulations from the Department of Health and Human Services (HHS) and Centers for Medicare and Medicaid (CMS), as well as each state’s health departments. There’s the Medicare physician fee schedule adjusted by location and updated yearly, and the ever-evolving rules brought on by the pandemic, which in some cases were even changing on a weekly basis. And, with each new presidential administration, comes another new set of rules and regulations.

In these unique times, it’s critical to have technology in place that enables your organization to respond nimbly to rapidly changing regulatory mandates. Payers need to be able to ‘future proof’ their business and HealthEdge’s payment integrity solution, Source, is built for that purpose.

Source enables complete government compliance with first-pass payment accuracy. The unique two-week update cycle delivers all CMS and Medicaid regulatory updates automatically by a team of Medicaid and Medicare experts. Additionally, Source aims to streamline the workflow by removing the strain of manually loaded fee schedules.

One HealthEdge client, SummaCare, uses Source to manage regulatory updates and has realized significant process efficiencies saving their organization time and money. Join us for a more in-depth look at how Source helps SummaCare navigate the ever-changing regulatory cycles. Register for the upcoming AHIP webinar on May 5th.

Top 5 Challenges of Payment Accuracy

Health plan payers receive hundreds of millions of claims each year. With such an inundation, it’s easy to understand how complicated and challenging payment processing can be. And when the slightest mistakes can cost you precious time and money, paying claims right the first time is imperative. Here are the top 5 biggest payment accuracy challenges and how to fix them.

  1. Inaccurate claims

Processing claims is an arduous and complicated task for any health plan. Pricing varies by region, specialty, and provider group. Other considerations like member seasonal geolocation add to claim payment complexity. With the high volume of claims and their associated complexities, inaccuracies happen – and they occur more frequently when being processed manually. The importance of automation for first pass accurate claims is extremely important.

  1. Inefficient processes

The payer world is constantly shifting, merging, and consolidating different organizations into one. When two organizations join, they often use different technology platforms that are not interoperable or don’t do the same task. In addition to the challenges of organization consolidation, many payer departments are definitively siloed, working in vacuums. Often, different technology vendors are leveraged across the organization for the same purpose – but serving different business lines. Implementing one technology platform for all lines of business supports a more efficient and streamlined organization.

  1. Changing fee schedules and regulations

Fee schedules are updated every year and adjusted by region; healthcare regulations are impacted by presidential administrations and external factors – like a global pandemic. Since 2019, over 3,000 pieces of healthcare legislation have been introduced to Congress as listed on Ultimately, 25 of those were passed into law which may not seem like an impactful number, but when measuring the many ways in which one law can affect healthcare billing, those changes can be overwhelming to keep up with and efficiently navigate. Penalties for non-compliance can be very costly, so adopting a platform that automates the implementation of new regulations is essential in today’s healthcare environment.

  1. Staying audit ready

The amount of tracking needed to perform and pass an audit at any time is daunting. Many payers know the pain felt when receiving an engagement letter from the Auditor-in-Charge at the Centers for Medicare and Medicaid (CMS). Beginning at that moment, the payer is responsible for filling out forms and providing appropriate documentation for CMS to conduct their audit. If anything is incomplete or amiss, the payer is at risk of failing the audit and incurring penalties. Technology that tracks all documentation needed for an audit and essentially creates an audit trail so that it’s ready whenever it’s needed, is an absolute game changer.

  1. Flexible technology

Lastly, for too long many healthcare organizations have been using legacy technology that isn’t particularly flexible, interoperable, or transparent. The pandemic made it abundantly clear that organizations able to come out ahead during this time of great healthcare transformation are those embracing and investing in technology that delivers all three. Automation for efficiency is certainly important, but it’s only one piece of a technology puzzle that can really propel a payer to achieving or even exceeding business goals.

HealthEdge’s payment integrity solution, Source, was built to specifically address the burden of each of these challenges. Listen in to the May AHIP webinar on May 5th where SummaCare details how adopting Source enabled them to tackle these top five claims processing issues. Register now.

Taming the Mess of Medicaid Payments Through Technology

Bad data is estimated to cost the healthcare industry $314 billion annually and negatively impact an organization’s revenue by 10-25%. The claims payment structure is characterized by decentralized data and delayed pricing updates leaving plans scrambling to keep up with CMS and Medicaid policy changes and struggling to price Medicaid claims accurately.

Addressing this outsized demand on insurers and their technology partners requires getting control of your data. With annual stats like an expected Medicaid enrollment growth of 5.8% and a 9.5% claims payment error rate, technology that can make data more meaningful and actionable is the solution. Successful organizations have focused on three technology solutions to achieve consistent, accurate, and transparent payments:

  • SaaS technologies
  • Integrated ecosystems
  • Centralized data
  1. SaaS technologies

Challenge: Your traditional solution for first-pass accurate claims processing relies heavily on manual and infrequent data, and policy updates that are not aligned. Variability in pricing methodologies adds complexities to processing your claims.

Solution: A platform that delivers frequent updates to Medicaid baseline data with software as a service, so you’re always working with up-to-date prices and edits, preventing inaccuracies with real-time data. Because it’s in the cloud, no internal resources are required to deploy the changes. First-pass claims payment accuracy is increased dramatically – enabling your business teams to refocus on value-added activities.

  1. Integrated ecosystems

Challenge: Multiple and different technology platforms across the organization impact the integrity of your data and the information exchange environment.

Solution: A unified platform that brings software, data, and service into a single workflow. Implementing one technology platform that delivers up-to-date regulatory data, claims pricing and editing, and real-time analytics tools gives your organization an edge over the competition. A single source of truth and a single point of accountability is a transformational approach for payers to make payments with total confidence and make business decisions with real intelligence.

  1. Centralized data

Challenge: Your workflows and data are managed across multiple platforms that are not exchanging information in the same language, frequency, or format – wasting time and increasing the risk of errors.

Solution: A unified, cloud-hosted platform enables a single place to centrally update, maintain, and manage data with multiple entities. This automated approach reduces IT maintenance delays and delivers centralized, accurate data.

Source is HealthEdge’s prospective payment integrity solution, a cloud-based platform built to specifically address the burden of these challenges. Join our webinar on May 5 and learn how SummaCare modernized its processing and realized big savings. Register here.

Value Based Care Software to Improve Outcomes

Value-based care aims to improve the quality and outcome for patients by linking provider reimbursement to the quality of care provided. Under this system, providers are rewarded for helping patients achieve higher quality outcomes and thus lead healthier lives while reducing medical costs. Therefore, everyone benefits from value-based care.

However, when we talk about value-based care systems in the healthcare payer industry, there isn’t just one dimension to consider – there are many. It can mean disease management or compliance programs. It can mean programs that incentivize members with diabetes or heart conditions with waived office visit copays or gift cards. It can mean value-based reimbursement where providers are scored on analytics and capitated or paid on fee for services at higher versus lower rates depending on quality of care delivered.  Or it could be value-based referrals, where health plans refer patients based on the provider’s quality of care delivered.  The point is, value-based care can mean different things depending on who you’re talking to, what area of the industry they work in, the role they play, and the part of the health plan they represent.

These are the value-based care trends we’re seeing in 2022: 

1. Value-Based Referral Programs: How is this provider performing?

As part of the Value Based care model being created, Humana has added the analytical aspect to track performance of the provider quality of care being delivered. Higher quality of care showing reduced recurring costs identifies these providers as high quality.  Which translates to more referrals for higher quality providers and lower performance means less referrals over time until quality is improved.

This underscores the importance of analytics and advanced analytics enabled by artificial intelligence. Concepts such as data clustering or data labeling enables the business to define the criteria for these providers and the patients’ health overall based on claims volumes, costs, diagnosis, etc. The population can be looked at retrospectively and using predictive analytics trend the future for the health plan to help steer the ship of the enterprise. The result is the health plan is now empowered with the transparency to understand who their top performing providers and members are and to decide how to incentivize those constituents.

2. Provider payment & value-based care: capitation arrangements versus fee-for-service 

Provider performance is also being linked to capitation arrangements. Instead of having a fee-for-service approach, it’s taking the capitation arrangement approach and paying different capitation rates based on the quality of care that’s being delivered. One of the key business problems for a majority of the provider community is increasing revenue over time. In traditional for-fee-service arrangements, providers are paid per visit. They can see more patients and make more money based on volume, but that’s the complete opposite of the goal of value-based care and the adverse effect resulting in over utilization. The true goal of value-based care is increasing healthier populations through the quality of care delivered – which for health plans means a healthier risk-pool overall which translates directly to reduced PMPM costs.

COVID also raised a real challenge to providers that were predominantly working on fee-for-service arrangements. Initially patients had been avoiding the doctor for minor ailments, annual visits, or preventive care during the pandemic for fear of contracting COVID. In 2021, the AMA noted significant decreases in specialist spending noting drops of the hardest hit Physical Therapy (-28%) among others.  As a result, providers working on the fee-for-service type of reimbursement – where volume equals payment – have been struggling with the lack of patients. Capitated arrangements therefore really helped some physicians from having to close doors to their practices which has a direct impact on the patients that rely on them for care.

3. Medicaid & Value-Based Reimbursement 

If we think of value-based reimbursement from a fee-for-service perspective, that’s also something that we’ve seen in Medicaid for example. Where providers are being reimbursed at a higher level versus a lower level based on the quality of care that’s being delivered.  Being scored by the state based on performance, sending that score to the health plan administering that contract and paying at higher reimbursement rates for better performance is just another example or dimension of how we are seeing value-based care in the industry and provider payment practices.

HealthEdge: Enabling Value-Based Care

With all these different dimensions and players in the game. How does HealthEdge, or any software solution, enable value-based care for their customer?

1. Defining Quality of care: Quality of care is paramount and how it is enabled is a driving factor in value-based care. Disease management, compliance, quality of care referrals, and capitation rates all hinge on real-time, accurate data. Additionally, that data is used in the process of defining the quality of care metrics needed to identify top versus lower performing provider and member constituents.

2. Accurate, real-time data: Data becomes imperative to drive all of this. Data is the means to identify the metrics that health plans use to define their entire business landscape. In this case, a top performing or low performing provider is one small but powerful example. HealthRules® Payor enables our customers through the real-time data warehouse to critical insights that can be gained for membership, providers, billing, claims, benefits, contracts and much more. Empowering the business user to define their landscape as it relates to the specific dimension that relates to their role in health plan operations or the enterprise at large.

3. Benefits, Pricing, Capitation, Health Incentives: HealthRules Payor supports these areas from the core system in a variety of manners, mostly stemming from configurability. The HealthRules Language configurability is unmatched in the industry and automates benefits, pricing, and capitation in order to reduce customization costs that customers incur to meet their business demands. One of the many aspects of the HealthRules Language is it allows the business user to directly interact with their own user-defined terms in addition to 100+ first class system fields to create benefit and pricing rules that drive claims payments without the need to proliferate benefit plans. Additionally, User Defined Terms drive Premium Billing and Capitation rates providing the key to user empowered automation. That configurability and the automation that’s produced out of that is enabling our customers to develop these evolving pricing, benefit payment, and compliance program/health incentive models without creating custom code or requiring heavy IT support. We enable our customers through configurability of the system.

4. Health Incentive Programs: HealthRules Payor also provides Compliance Programs to automate the results of the benefit or pricing based on the members status in the compliance program.  The business is enabled to configure the applicable compliance for health issues like Asthma, Diabetes, Heart Disease, Smoking Cessation, Weight Loss, or Wellness as examples of what could be needed.  The nice features layered around the configuration is the ability to set automated reprocessing of claims based on retroactive changes in the compliance status of the member and automatically identify the claims impacts associated with these changes and provide the claims examiners the ability to review the financial impacts prior to impacting payments and approve or reject these adjustments based on their business processes.

HealthEdge MVP Value-based Care Ecosystem 

HealthEdge is enabling our customers through a best-in-class, MVP ecosystem for value-based care. Our accurate, real-time data warehouse powers determining compliance, provider quality level, reimbursement level, capitation versus fee-for-service, and more.

Our best-in-class products, HealthRules Payor, GuidingCare, Source, and Wellframe solutions enable our customers to achieve better outcomes that are critical for value-based care.

Contact us to learn more about HealthEdge and value-based care.