Becoming a Digital Payer Series: A Deep Dive into 5 Key Attributes of a Digital Payer

5 Attributes of a Digital Health Payer

Rising consumer expectations, growing regulatory requirements, changing payment models, and new market opportunities are causing significant disruption across the health insurance marketplace. As a result, health plans are rethinking the traditional ways they do business and turning to digital technologies to help them respond.

HealthEdge offers health plans a digital foundation on which they can transform their organizations into digital payers to meet the demands of these new market dynamics more effectively.

But what does it mean to be a digital health payer? HealthEdge has identified five key attributes that drive digital payers, enabling them to rise above the competition and lead the way to better outcomes across the healthcare delivery system.

Digital health payers turn to technology to help them:

  1. Improve end-user and member centricity
  2. Achieve higher levels of quality
  3. Increase transparency
  4. Advance customer service
  5. Reduce transaction costs

In this five-part blog post series, we will dive deeper into each attribute, delivering resources, information, and insight to enable health plans to transform into digital health payers.

Let’s get started. First, we dive into the topic of improving end-user and member centricity.

Improving End-user and Member Centricity

Today’s economy is all about the experience. Whether the experience is in healthcare, retail, dining or entertainment, a heightened focus on the consumer experience is front and center for all business leaders. The evolution is being driven by consumers’ everyday experiences with digital giants like Amazon and Google. Consumers are experiencing new levels of simplicity, personalization, ease of communication, instant access to information, and seamless connectivity across every location, space, or device where they might seek to interact with the company.

Payers, providers, employers, pharmacies, and all healthcare stakeholders are taking notice and prioritizing the consumer experience. Some are even calling it the “digital front door.” But in healthcare, the member experience goes beyond protecting or generating revenue and satisfaction. It actually impacts member outcomes, which is at the core of what payers were originally created to do.

Payers have an opportunity to lead the way by putting the member at the center of their digital transformation. Now is the time for health plans to become attune to member needs and transform their interactions to improve the experience – and the outcomes for members and for their own organization’s success.

Member Challenges

Today, members navigate a hodgepodge of interactions to effectively understand, manage, and pay for their care. They research providers online and through multiple plan-provided sources, working to piecemeal information and understand which providers are in-network, deliver quality care, have availability, and are within their preferred geographic area.

When seeking care, members also struggle to get insight into pricing, coverage, and benefits, making it even more difficult to pick the right path. As a result, healthcare consumers often lack strong guidance to direct their care decisions, especially when multiple specialties or providers are involved.

After seeking care, understanding claims and payment processes becomes even more complex. Consumers often make payments through multiple channels and access points, creating frustration for the member as well as administrative burden on the health plan and provider.

Finding a Solution

To address the challenges members experience in today’s environment, it requires payers to have a sharp focus on the member, which is difficult to do when their many different, disparate systems cannot talk to each other. However, digital payers using modern systems can do this through three ways:

  • Deliver resources and information to coordinate care and navigate members through the care delivery system in a way that promotes better health
  • Implement technology systems that put the member first – easy to access, single point of information
  • Collaborate with other stakeholders to effectively integrate systems based on real-time data in a way that makes it easy for their care managers and members to navigate.

Considerations to Becoming Member-Centric

As health plans contemplate their digital transformation journeys, leaders should address the following questions:

  • What is the process members will follow to obtain information about their health, benefits, coverage, care plans, and payments? How can we make this process more seamless and intuitive?
  • Across each member touch point, how is information being shared? How can we make this information more accurate, up-to-date, and available in real-time across each point of access?
  • How are our processes, technology, and information improving health outcomes for consumers? What more can we do?

Get started with HealthEdge

HealthEdge enables payers to become digital payers by providing a digital foundation on which they can build a more consumer-centric approach to member and provider interactions. When digital payers implement a transformative digital strategy that puts the member and users first, everyone can more effectively navigate the complexities of the current health insurance landscape, while improving health outcomes and reducing the cost of care for everyone.

To learn more about how HealthEdge can help your organization become more end-user and member-centric, visit or email [email protected].

Top Five Challenges Medicaid Payers Face

The growth in our country’s Medicaid population has reached an all-time high in this post-pandemic society. Years of Medicaid expansion under the Affordable Care Act and increasing job losses due to economic conditions are just two of the many factors driving up the number of Medicaid beneficiaries. According to the latest enrollment numbers from CMS, 76M+ Americans are now enrolled in Medicaid. That’s a nearly 20% increase since February 2020 before the pandemic began.

In addition to helping our country’s most vulnerable citizens, payers have the opportunity to generate positive financial outcomes for their organizations with the growing number of Medicaid beneficiaries.

However, managing a Medicaid program can be tremendously complex, and many leaders often underestimate the time, money, and labor required to have a successful program.

Source, the payment integrity solution from HealthEdge, recently conducted a study of more than 400 health plan leaders to better understand the challenges and trends they are facing when it comes to their managed Medicaid programs. The survey uncovered what many leaders have learned the hard way – running a managed Medicaid program is hard to make profitable.

Top Five Challenges Medicaid Payers Face

The research revealed some interesting statistics about how complex and manually intensive Medicaid claims management and reimbursements can be. Survey respondents reported their top challenges to be:

The manual labor required to keep fee schedules and reimbursement policies updated is at the core of the issues that can wreak havoc on the profitability of your program if you do not have a modern payment integrity system in place.

Each state Medicaid has its own fee schedules and payment policies, all of which are being constantly updated at different intervals. And these updates are published on websites and downloadable files that require someone to manually review and identify what has changed. Those changes must then be incorporated into a claims system so that claims can be processed correctly and payments can be made accurately. 91% of survey respondents state that this process is done manually. For 45% of survey respondents, they have more than 100 FTEs dedicated to Medicaid fee schedules and payment policies. Another 42% have greater than 50 FTEs dedicated to the cause.

All of these manual-intensive workflows require qualified people to run them. Unfortunately, the health insurance industry, like many other industries, is experiencing extreme workforce shortages. 89% of survey respondents stated that they were challenged to find and retain qualified resources at this time.

The combination of being so heavily dependent on human resources plus the scarcity of those resources plus the rapidly growing complexities across state Medicaid programs creates a significant threat to a payer’s ability to run a profitable and successful Medicaid program.

What happens if you don’t keep up with the changes?

  • Wasted time and resources reworking claims: The survey reports that payers are too often having to rework Medicaid claims, with 44% saying “most of the time” and another 22% saying “often.” Lack of automation in the claims editing process has the potential to delay cash flow and eat away at profits.
  • Inaccurate payments: When claims are either under or overpaid, payers not only have to consider the amount of effort associated with repaying or recouping the inaccurate payment, but they also must consider the negative impact these actions have on member and provider satisfaction. Getting it right the first time makes a lot more sense.
  • Missed revenue opportunities: If the claims are inaccurate due to outdated fee schedules and policies, payers often miss out on revenue opportunities that are key to driving the profitability of their programs. When survey respondents were asked about the reasons they felt like they were missing out on revenue opportunities, 68% said higher administrative costs, 12% said lack of qualified resources to rework claims, and another 9% said outdated fee schedules. For a struggling program, leaving money on the table is like pouring salt in a wound.

Getting it Right. Making it Easy.

There is a better way to handle the process of keeping your fee schedules and reimbursement policies up to date. Source recently announced a new service that automates these complex, manually intensive processes. Just as Source has done for years with its Medicare offering, they are now rolling out the same service to payers running Medicaid programs.

Payers who wish to improve the profitability of their Medicaid programs and take advantage of the growth the industry is expecting to see should consider Source as a better way to manage their Medicaid offerings.

To learn more about Source’s state Medicaid program, visit or email [email protected].

New Survey Reveals Top Impact Points for Medicaid Programs Experiencing Workforce Shortages

The old saying goes, “If you’ve seen one state Medicaid program, you’ve seen one state Medicaid program.” The increasingly complex and dynamic state-by-state regulatory and payment environment across Medicaid has become nearly impossible for Medicaid-managed care plans to keep up with the pace of change and scale their Medicaid lines of business.

With varying fee schedules that get updated at different intervals and policy updates that can change on a dime, most health plans have accepted the fact that much of the work required to keep up with Medicaid has to be done manually.

In fact, in a July 2022 HealthEdge survey of more than 400 health plan leaders serving Medicaid populations, 91% reported that they depend on human resources to manually perform this work on a monthly or quarterly basis.

During normal times, keeping up with these complexities can be challenging and expensive, but also rewarding for those organizations who get it right.

However, we are not living in normal times.

The healthcare industry has been hit hardest by “the great resignation” as the survey results show that 89% of health plans are experiencing clinical and administrative shortages.

The combination of severe workforce shortages and intense reliance on manual resources to maintain accurate and timely Medicaid payment data has introduced new risks for many health plans. More specifically, survey respondents claimed their top five challenges to be:

  • Staying compliant with changing reimbursement policies, 75%
  • Installing updates to the fee schedule in a timely manner, 62%
  • Having transparency within your system to response to audits, 54%
  • Keeping up with changing fee schedules, 50%
  • Too many manual processes, 33%

To date, there has been very little innovation and automation in this space due to the unique, state-specific schedules and policies. But that is changing with Source, the prospective payment integrity solution from HealthEdge.

Source dramatically improves efficiencies when it comes to Medicaid claims processing by automating the delivery of in-depth, state-specific fee schedules and payment policies across a wide range of facility and professional provider types.

The Source team has an aggressive plan to leverage their renown Medicare expertise and content development and apply it to state Medicaid programs. And they’re moving fast, already delivering schedules and policies every two weeks for many states. Their goal is to cover 35 states over the next few years. The Source solution for Medicaid programs also includes a comprehensive range of provider types such as hospital inpatient, hospital outpatient (HOPD), professional services, suppliers, home health agencies, hospice organizations, nursing facilities, dialysis centers, and ambulatory surgery centers.

To learn more about how our focus on automating state Medicaid updates can help your organization, talk to a Source specialist at

Source Launches Retroactive Change Manager

The first tool to automate repricing of claims, variance reports for over and under payments and monitoring of retroactive changes.

Today, payers looking to reconcile inaccurate payments rely on laborious manual processes, multiple (and disparate) vendor solutions, and toggling between multiple interfaces—resulting in inefficiency and waste.

Source’s Retroactive Change Manager alleviates these issues by automating:

  • Monitoring of retroactive changes
  • Reconciliation of inaccurate claims
  • Repricing of claims by payers
  • Variance reports displaying all claims needing adjustment and by how much

With this tool, payers can manage pricing, editing, configuration and policy updates internally from a single API.

For all retroactive regulatory updates, the Retroactive Change Manager automatically reprices affected claims. For configuration updates, users can run ad hoc jobs and reprice affected claims.

Additionally, no other vendors currently offer flagging of under payments to providers. By addressing under payments health plans will decrease provider abrasion and become more compliant with CMS audits.

The Retroactive Change Manager is deployed within minutes and seamlessly integrates into current claim adjudication processes. Health plans can continue to reprocess and adjudicate claims using their current methods requiring no additional resources or attention from internal teams.

How is the Retroactive Change Manager different from current retroactive solutions?

1. Comprehensive Pricing and Editing Management in 1 Platform

All claim pricing and editing activities are conducted in 1 cloud-enabled platform. This allows for an optimized user experience without toggling between interfaces. It also automates content updates into a single environment, to eliminate time-consuming and costly manual updates to multiple software solutions.

2. Identification of Underpayments

For health plans, identification of under payments prevents provider abrasion and helps maintain compliance with CMS. Vendor solutions working off contingency models are disincentivized to offer underpayment flagging simply because it is not as profitable to them.

3. Automation: Requires 0 Lift from Internal Teams

The unique automation capabilities of Source conducts optimized contract management without any internal lift from health plan teams.

Why haven’t health plans leveraged automated claims variance reports before now?

Any claims automation activities built in-house require significant upfront capital, time, and resources, which leads health plans to often outsource these activities to vendor solutions. But vendor solutions have traditionally focused on the most profitable activities to them: retroactively chasing payments.

Today, however, payers are realizing the benefits of prospective payment integrity, and understand that to achieve long-term payment integrity goals, they must invest in cloud-enabled, single-API solutions that enable productivity and provide complex business insights.

Payers are demanding more from their vendor solutions—and rightfully so. Equipping payers with the tools they need to improve provider relationships and member experience begins with delivering authentic transparency into the inner workings of claims IT ecosystem.

Will this technology cause current IT systems to run slower?

Source ensures health plan IT systems will continue to operate as efficiently as before.

Repricing happens off internal production servers.

Activities are also strategically scheduled for when IT systems have greater bandwidth.

In addition, health plans can customize how often reports are run, permitting scheduled and ad hoc reporting.

How long will implementation take?

For current Source clients, full implementation takes under an hour and requires no effort from your internal teams.

When will this tool be available?

The Retroactive Change Manager will be available in Q4 2022.

Money Will Flow to States for Mental Healthcare

States are about to get help for mental healthcare and substance use treatment because of the Bipartisan Safer Communities Act signed by the President in June. Some of this will flow through Medicaid programs, specifically the Medicaid Certified Community Behavioral Health Clinics (CCBHCs) nationwide created in 2014.

The Act also supports:

  • Increased telehealth flexibility
  • Pediatric mental healthcare and training for pediatricians
  • One-time funding ($150 million) for the existing Suicide and Crisis Lifeline or 988 crisis number, similar to the 911 system. (States have a preexisting July 16 deadline to have these up and running.)
  • School-based mental health services, crisis intervention and violence prevention, and mental health worker training

While mental health advocates are pleased by the new support, there are caveats.

  • Experts agree the mental health and substance use disorder impact of the pandemic has been significant and is still being felt. Future needs are expected to be long-lasting. Some predict the impact to last a generation.
  • A lack of psychiatric beds continues to be an issue. While crisis stabilization can reduce harm and identify resources, inpatient care is hard to come by in most states, resulting in emergency-room boarding and a revolving door through the justice system for the seriously mentally ill, who are often overlooked in mental health programs.
  • Provider shortages continue to be a concern, although telehealth flexibilities may help mitigate them in the short term.
  • Equity continues to be an issue throughout the system and mental health is no exception.

Sensing the opportunity in addressing mental health, private investors had poured $3.1 billion into mental health ventures by the third quarter of 2021 – a third of all digital health funding for that year. Technology isn’t likely to replace the human touch, but innovation and technology can certainly have a role in improving access.

First Inklings of Inflation Reach 2023 Health Cost Calculations

Anticipating inflationary pressures around healthcare costs, the IRS has spiked limits for 2023 on Health Savings Accounts (HSA) by 5.5 percent, much higher than the previous year’s rise of just 1.4 percent. These figures were released in April so payers can get the jump on rate-setting and employers can begin to plan their open enrollment periods.

The new calculations are:

  • Self-only HSA contribution limits – $3,850, up from $3,650 in 2022
  • Family HSA contribution limits – $7,750 up from $7,300 in 2022

The 2023 limits are intended to encourage employers during open enrollment to ease employees into HSAs and to boost employee dollar contributions. Employers are reportedly more interested in financing HSAs than before, especially for lower-paid employees.

More broadly, some of the cost drivers and variables for 2023 include the “table stakes” that employers add or expand mental health coverage to their offerings. Pandemic-related costs for treatment and testing are flattening, but there’s no predicting whether other COVID variants will emerge or whether a fall spike will occur as in previous years. Intuitively, it might seem that provider costs would rise across the board, but many are locked into multi-year arrangements and thus provider inflation trends usually lag the rest of the economy. For the segment of the provider/payer market up for contract renewal, negotiations are expected to be fierce – a major healthcare publication used the word “bloody” to describe the battles ahead.

Other uncertainties hang over the payer ecosystem, especially for possible Medicaid disenrollment and the potential end of pandemic-related subsidies for Affordable Care Act premiums. These effects of these shifts in the risk pool are hard to pinpoint but can draw employer-sponsored plans into inflationary patterns. Some states are requesting that payers submit rate approvals in two sets – one for the scenario in which Congress extends ACA subsidies set to expire at year-end and one in which it does not.

Other variables being mentioned by experts for 2023 are utilization patterns and cost-impacts or savings from telehealth, tweaks to the ACA “family glitch” and movement among small employers to self-funded or level-funded plans.

Employers should be looking now at their health plan options in anticipation of open enrollment this fall Their calculus is a difficult one, just as it is for payers.