3 Steps to Effective Technology Implementation for Health Plans

Transform Methodology: Change Management Framework

Transform methodology is the insurance industry’s cutting-edge approach to change management during internal project launches. Its principles can be found in many successful business transformation processes, but its phases and steps are designed specifically for vendor partnerships.

Traditionally technology implementations involved simply building on a firm’s operational competencies and short term needs by adding a product. Instead, transform methodology requires working together with vendor’s expertise and software to align and achieve long term goals while transforming businesses from the inside out.

When could you use transform methodology as a health plan?

When conducting:

  • Annual contract updates
  • Annual Contract Updates
  • Expanding or Adding New Lines of Business (ex. Medicare/Medicaid)
  • Mergers and Acquisitions

Transform methodology was developed leveraging HealthEdge’s extensive experience successfully implementing their suite of solutions with health plans of all types, sizes, and lines of business. From these real-life experiences, HealthEdge leadership incubates best practices and lessons learned to create this change management framework.

The Foundation of the Framework: Relationships

“Any successful implementation begins with a solid foundational relationship between our health plan customers and HealthEdge,” HealthEdge’s Anne Marie Gramling explains.

When you work with vendors who value partnership, together you can operationalize change and focus on long term success. At a minimum, vendors should provide:

  • A shared comprehensive review and evaluation of areas for improvement and optimization
  • Complete guidance through design, configuration, testing, roll-out and training
  • Configuration efforts to minimize maintenance efforts

HealthEdge’s Transform Methodology outlines the 3 step model insurers should leverage when working with technology vendors.

The 3 Phases of Transform Methodology

Phase 1: Evaluate

Key Steps

  1. Understand customer’s current state and transformation objectives
  2. Indicative migration scope, timeline, resources and cost
  3. Envision scope of work

During this first phase your insurance firm and the vendor assess your current state, business objectives and requirements. This will allow you to comprehensively develop the overall scope, timing and estimated effort for any project. 

Phase 2 will involve creating a more detailed timeline and governance bodies. The scoping in stage 1 should be for the project as a whole.

After the scope, timing and effort are estimated, it’s important to describe why you are undertaking this transformation: How does the initiative tie into your overall company mission and stakeholder incentives?

If struggling with “the why”, consider if the proposed changes will:

  1. Drive operational efficiencies through faster processing, increased accuracy, automation or scalability
  2. Improve member, provider and employee experience
  3. Allow you to change easily to adapt to the market demands and growth opportunities

Using this information communicate the planned changes internally and continually reinforce why this matters.

Phase 2: Envision Part One

Key Steps

  1. Establish program governance and milestones
  2. Formalize migration goals and objectives
  3. Project kickoff
  4. Requirements discovery
  5. Define business and technical future state blueprint
  6. Define migration, test and operational change strategies

During the envisioning phase, vendors and health plans work together to create a clear picture of the implementation’s desired result.

Whether it’s a more seamless patient experience or enhanced claims accuracy, define what you are trying to achieve and the impact it will have on your health plan.

For example, many HealthEdge solutions automate business workflows and coherently exchange data in real-time across ecosystems.

When considering implementing HealthEdge technologies, health plans should imagine what their company would operate like with:

  • Improved End-User & Consumer Centricity
  • Ever Reducing Transaction Costs
  • Ever Increasing Quality
  • Ever increasing service levels
  • Business transparency

Once a clear end result is outlined, use this as a starting place to list all the supports and organizational roles needed to achieve that vision.  In other words “start at the end and work backwards”.

These supports and organizational roles can include:

  1. A program governance model that outlines resources, timeline, communication plans and project structure.
  2.  A deep dive into validation of firm requirements
  3. The design of full implementation with business configuration, ecosystem, integrations and workflows
  4. A detailed implementation plan with:
  • Configuration sprints plans
  • Integration requirements for development grooming
  • Test strategy and use cases

At this stage you should also develop measurable goals and decide what metrics will be used and how they will be tracked.

Phase 2: Envision Part Two

Key Steps

  • Design future state
  • Plan iterations and releases and begin design/build
  • Plan iterative, successive test phases
  • Requirements grooming
  • Execute Scope of Work

Phase 3: Execution

Key Steps

PART 1- Implement

  • Build: Configure and Integrate products
  • Migrate data
  • Execute test phases
  • Plan operational readiness and training
  • Plan cutover and go-live

PART 2- Promote

  • Execute final end-to-end validation and assure operational readiness
  • Execute cutover
  • Go live
  • Begin monitoring user adoption and outcomes

PART 3- Transition

  • Stabilize customer business in production
  • Conduct handoff from project to operations
  • Initiate next phase and optimization opportunities

The last phase is Execution where solutions are built, tested and launched. This is where projects transition from Implementation to Production. The governance, education and enablement services previously set up in the Envisioning phase are central to support execution efforts.

Learn more about HealthEdge’s Implementation Services here.

Stop Recurring Post-Payment Issues with an Open Book Approach to Payment Integrity

Adobestock 304281967At HealthEdge, disrupting the status quo is part of who we are. When it comes to redefining payment integrity, we often think about it in terms of shifting from a black box to an open book approach—essentially empowering payers with technology that enables them to gain control of their IT ecosystems, address root cause issues, and reduce waste in the healthcare system.

But what does that mean? What does reducing waste and abrasion actually look like?

Here’s an example:

Say a patient sustains an injury to their foot and leg and has multiple diagnostic images taken by the same provider on the same day.

The claim they submit to the payer might looks something like this:

1 0

All claim lines are paid at 100%.

After a few months, the claims are reviewed post-payment by a payment integrity vendor. The vendor determines that these procedures are related and should be reimbursed based on multiple procedure payment reduction (MPPR) regulations.

The claim should have paid as follows:

2 0

After confirming the overpayment, the following steps are required:

  1. Payer resources are required to validate the findings for the existing vendor.
  2. The vendor notifies the provider and attempts to recover the overpayment of $295.75
    • Note – Post-payment vendors are only able to recover 60-70% of identified overpayments
  3. The vendor charges a contingency fee of 15-20% on the recovered savings
  4. The payer then needs to reprocess the corrected claim.

In this type of payment integrity environment, the above example can occur at a very high volume. Additionally, traditional payment integrity vendors identify this type of issue on a recurring basis but never address the root cause issue—so the overpayments, administrative burden, rework, and provider abrasion continues.

When we talk about striving for accuracy, we’re talking about shifting processes upstream so that claims are paid quickly and comprehensively the first time.

With Source, the above example would be handled differently.

Instead of the claim being passed through pricing and then editing, Source provides integrated claims processing of policy edits, pricing algorithms, and rate schedules. We call this function parallel processing, and it unlocks the ability to view and assess a claim more holistically.

In this scenario, through parallel processing of MPPR edits and reimbursement content, the line level reductions would be applied prior to payment. The root cause of the recurring issues would be addressed at the earliest possible intervention point.

Reimbursing accurately and upstream provides the following benefits:

  • Elimination of overpayments
  • Avoidance of contingency fees to the existing post payment vendor
  • Resource savings for all payer employees involved in the rework of claims
  • Reduction of provider abrasion

With Source, you not only have complete control and visibility over your payment lifecycle in one place, but a dedicated partner who wants to help solve your largest and most complex payment challenges. We want to eliminate administrative waste and provider abrasion so that payers can focus on what matters most—their members.

…if we redefined payment integrity as not recovery, but intelligence striving for accuracy, people’s thought processes would change. If people change the way they think about payment integrity, it will start to inspire people to work on improving the system….” – Ryan Mooney, GM & EVP of Payment Integrity at HealthEdge

Trends for Open Enrollment 2022-2023: What Every Employer Needs to Know

Enrollment Trend Drivers 2023

Key drivers for open enrollment trends 2022-2023 include:

  • The COVID-19 Pandemic
  • Labor shortages
  • Popularity of hybrid and remote work
  • Focus on emotional well-being
  • Implementation of the No Surprises Act

Due to these forces health benefits have become one of the top three drivers of employee attraction and retention (WTW’s 2022 Global Benefits Attitudes Survey). At no other time in the last decade have employees placed more importance on health and retirement benefits.

Because of the new importance placed on employee health, open enrollment this fall 2023 will be a unique opportunity to share the value of benefit packages to help stem high turnover rates. Many employers are already aware of the importance of health plans to employee retention as two-thirds of employers plan to enhance health and benefits offerings in 2023 to improve attraction and retention or better meet employee needs (Mercer’s Survey on Health and Benefit Strategies for 2023). In addition, 85% of employers are prioritizing employee physical, financial, social and emotional wellbeing (WTW research 2022).

Supplemental Benefits Enrollment

46% of employees are willing to pay more out of their paycheck each month for a more comprehensive healthcare plan.

Karen Sturdivant, benefits director with LandrumHR, an HR services firm in Pensacola, Fla. explained how fear is the main driver for increased demand for supplemental benefits including hospital, accident, critical-illness and legal policies.

“Now more than ever, employees are looking to be protected in the event of illness and to protect their loved ones,” Sturdivant says.

As well, many employers are adding surprising new features to existing plans or offering new benefits that fall outside the scope of traditional healthcare but enhance protection.

Mental Healthcare

“Beyond health insurance, employees are looking for emotional support [and] resources to bolster their resilience and financial protection,” Aldrich and Hauch say.

52% of large employers are planning to offer virtual mental health care in 2023 (Mercer).

Employers are also expanding their behavioral services through employee assistance programs and by offering self-help tools at little to no cost.

Financial Education

An employee’s finances are intricately tied to employer benefits.

Due to high inflation and a potential looming recession employers are starting to build out holistic financial well-being educational programs to add to benefit packages.

Abortion & Medical Travel

The recent Supreme Court abortion decision is impacting employee benefit decisions this upcoming year. Access to abortion services are harder to find or no longer available, causing many people to travel out of state.

  • 35% of employers now offer travel and lodging benefits for abortion services (WTW poll).
  • 16% of employers are planning to offer abortion travel benefits next year.
  • 21% of employers are considering offering abortion travel benefits next year.
  • 86% of employers provide the same travel and lodging benefits for those seeking abortions as those seeking other procedures like transplants.

Medical-travel benefits not only support employees seeking abortion services, but also can benefit those requiring care at centers of excellence for cancer treatment.

Affordability & Customization

High deductible health plans have been growing in popularity the past few years, but employers know they are not the best choice for every employee.

  • 41% of employers next year will provide a low-deductible medical plan option or a no-deductible plan with just premiums and co-pays.
  • 11% of employers next year will offer free employee-only coverage for at least one medical plan option

Affordability of health plans is important for low-wage workers and those with chronic medical conditions.

Although 29% of small employers already offer coverage to workers at no cost, it is a newer approach for large organizations.

Driven by an increasingly diverse workforce and greater hybrid work, offering customized choices for employees to select is imperative.

  • 49% of employers added greater choice in all benefits
  • 23% of employers are planning or considering adding greater choice to all benefits in the next year.

Providing more customizable healthcare options like a lifestyle spending account or adding culturally sensitive care programs are gaining traction.

Family Forming Benefits

Fertility treatment coverage and adoption and surrogacy benefits are expected to become increasingly popular in 2023, as one-third of large employers are slated to offer access to these services next year.

As well, 37% of all employers will provide at least one specialized benefit to support reproductive health.

Reproductive health benefits and resources include support for

  • High-risk pregnancies
  • Lactation
  • Pre-conception family planning
  • Pregnancy loss
  • Family-planning support during menopause


With increased consumerism increasing demand for one-click purchases, instant food delivery, virtual ordering and self-checkouts has led to accessibility expected in healthcare as well.

Accessibility features include flexibility in where care is delivered. More than half of all employees are working hybrid or full-time remote. Healthcare is expected to be provided from anywhere, at any time and from any device.

As well, employers are enhancing accessibility by customizing the enrollment process for those who are neurodiverse, colorblind, or suffer from decision-making anxiety.

  • 52% of employers have enhanced their enrollment experience
  • 34% of employers are planning to enhance their enrollment experience


Gartner Reports Next-Gen CAPS Technology Will Be Standard By 2024

Unlike legacy systems, Next-Gen CAPS like those offered by HealthEdge integrate seamlessly with third-party applications, offering more interoperable data and workflows across payer or third-party applications. 

What are Next-Gen CAPS?

Unlike legacy systems, Next-Gen CAPS like those offered by HealthEdge:

●      Integrate seamlessly with third-party applications, offering more interoperable data and workflows across payer or third-party applications

●      Enable all users to see real-time data

      Enable flexible delivery methods including value-based contracts

●      Are customized for each health plan and department including interfaces

●      Allow all team members to access, edit and configure data independently, without IT support

●      Effortlessly merge new and complex product lines

What Benefits do Next Gen CAPS Offer Over Previous Legacy Systems?

Comprehensively, these new features allow for:

●      Lower transaction costs, freeing capital for innovation

●      Improved data access including real-time data and transaction processing

●      Streamlined operations that support agile regulation updates

●      Greater customization in business models such as enabling value-based payments

●      Higher security and more utilization of economies of scale

●      Decreased reliance on IT or expensive professional services to update regulations

Why Will Next Gen CAPS Be Widely Adopted Within The Next Two Years?

There are a number of market influences making Next Gen CAPS like HealthEdge a must-have technology for payors in the coming months. These include:

  1. Payers diversifying their business models to include complex care delivery and retail vertical integrations
  1. More policy exceptions and innovations in areas like medical necessity and provider network alignment
  1. Regulatory mandates requiring payers to improve timeliness and transparency of administrative processes.

Why are Next-Gen CAPS Solutions Not Standard Technology Now?

The major reasons why Next-Gen CAPS systems have not already been widely adopted are:

  • Conflicting payer business priorities
  • Risk aversion
  • Solution costs
  • End-to-end implementation requirements, including replicating legacy processes
  • Difficulty with configurability

How to Start Implementing Next-Gen CAPS At Your Health Plan?

When you are selecting a vendor for your Next-Gen CAPS system there are a number of important things to consider.

You should place greater importance on strategic CAPS capabilities versus those that are commodity.

Your teams should analyze whether licensed applications, Saas or business process outsourcing solutions for each CAPS capability are the best.

As well, health plans should make sure considered vendors have:

  • New versions of CAPS as greenfield
  • Good previous track record with your company to date
  • Modular CAPS components for phased implementation
  • Configurable interfaces
  • Significant proof of concept in your primary market

Read the rest of the Gartner Hype Cycle report to learn more about Next-Gen CAPS like HealthEdge’s HealthRules Payor.

Why Prospective Payment Integrity Solutions Are Must-Have Tech for Health Plans

What are Prospective Payment Integrity (PPI) solutions anyway?

PPI solutions enable health plans to proactively avoid paying claims improperly. They include features like:

  • Claims editing
  • Data mining
  • Complex clinical Review
  • Advanced analytics and AI

With minimal payment leakage, they also address:

  • Contracts
  • Services
  • Eligibility
  • Payment accountability

How is that different from how claims are paid today?

The most popular payment method today for health plans is the pay-and-chase method. With this strategy, payers conduct claims quality assurance after claims are paid.

As per Gartner 3%-7% of healthcare claims are paid inaccurately the first time, with only a small portion of those claim payments later corrected.

Unlike previous payment strategies, PPI technologies like Source from HealthEdge ensure proper payment the first time, directly confronting improper claims payment activities.

Why PPI practices will become industry standard by 2027…

There are a number of reasons why PPI technologies like Source will become industry standard within the next few years. These include:

Increasing claims complexity due to:  

  • COVID-19 payment policy exceptions
  • Specialty drugs
  • Medically complex patients
  • Value-based payment arrangements

In-demand and complex capabilities built into PPI solutions like:  

  • Social analytics
  • Predictive modeling
  • Machine learning
  • AI-enabled fraud reduction, case management and payment integrity
  • Ongoing expansion and scaling of virtual care solutions leading to increased fraud in areas like durable medical equipment (DME) and prescription drugs.

 Why are PPI solutions not industry standard now?

Some health plans may be hesitant to implement PPI solutions today because the ROI for cost avoidance is harder to calculate than for cost recovery. Additionally, payers often implement incentives for staff to open cases for post-pay audits that create an unintended disincentive for PPI.

Finally, “Few payers have an enterprise payment integrity program that provides governance and oversight across all regions, products, provider networks, capabilities and vendors. Fragmented procurement and operations of PPI solutions diminishes the ROI of cost avoidance or, at least, accurate aggregation of savings realized across the organization and provider networks.”

Implementing change and choosing the right solution for the future

Implementing PPI solutions may include foundational change at some health plans—shifting focus from KPIs based on recoveries and other post-pay activities to prospective avoidance. It’s imperative that payers choose the right partners that offer a modular approach to implementation.

Additionally, Gartner outlines the following key offerings in PPI solutions that health plans should consider.

2022 09 12 11 49 31

To learn more about the future of prospective payment integrity solutions and other technology trends for healthcare payers, access the Gartner® Hype Cycle™ for U.S. Healthcare Payers, 2022.

GARTNER and Hype Cycle are a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and are used herein with permission. All rights reserved.

Advancing Care Management Through Digital Transformation

Stuart Myer, Chief Information Officer, VillageCare, a community-based, not-for-profit organization in New York, recently joined HealthEdge leaders Christine Davis, Vice President, Product Marketing and Len Rosignoli, Vice President, Customer Success in a live webinar to share how his health plan is advancing care management through digital transformation. The webinar was hosted by the Association for Community Affiliated Plans (ACAP).

In the discussion, Myer shared real-world scenarios that his organization experienced along its digital transformation journey and explained how every stakeholder in his organization is benefiting today. In case you missed the webinar, here is a snapshot of what the team covered.

1. Industry dynamics and challenges are driving health plan executives to realize that now is the time for digital transformation.

Workforce shortages, regulatory changes, evolving business models, and shifting consumer expectations are pushing health plan executives to seek new ways of reducing costs, improving efficiencies, and investing in innovation. Davis shared highlights from the company’s Annual Health Plan Market Survey that showed the majority of leaders are focused on aligning business and IT teams, as well as investing in innovation and moving to modern technology.

2. Digital payers are leading the way in transforming the industry.

“HealthEdge defines digital payers as those bringing business and IT areas together to create a modern, digital organization that constantly improves health and financial outcomes,” explained Davis. A digital payer can be identified by five key attributes:

  1. Leveraging digital tools to improve end-user and member centricity.
  2. Achieving higher levels of quality to deliver better outcomes for members and communities.
  3. Increasing business transparency, breaking down siloes and improving exchange of information.
  4. Advancing customer service by empowering teams with next-generation solutions.
  5. Constantly reducing transaction costs through automation and connectivity.

3. VillageCare leaders implemented a digital transformation strategy that enabled a more data-driven approach to every aspect of their business, which is driving better care for their community and more efficient operations.

“Using a digital foundation has allowed us to become a data-driven organization that operates more efficiently. We are in it for better outcomes for the community we serve. A more efficient workforce delivers better care,” explained Myer.

Using the GuidingCare® platform from HealthEdge, VillageCare was able to support their top business and clinical objectives in many ways, including:

  • Improving clinical and business operations through integrated work processes
  • Creating a data-driven organizational culture
  • Advancing clinical partnerships through data integration
  • Sharing data with members and clinical partners using industry standards
  • Using best-in-class applications that integrate to create a seamless systems environment

4. Becoming a digital payer transformed experiences for five key groups across VillageCare and the healthcare ecosystem in which they operate:

  • Members: VillageCare consolidated data and streamlined process to better enable a member-centric approach. They migrated disconnected touchpoints (such as finding providers and eligibility, benefits, and cost information), to easy-to-use, self-service tools within GuidingCare. With a frictionless member experience, they increased member engagement and satisfaction, while ultimately improving health outcomes.
  • Providers: The organization transformed their relationship with providers by delivering instant access to real-time patient benefits, claims data, authorizations, and more in GuidingCare’s easy-to-use digital collaboration tool.

“One way we were able to improve the experience for providers was the GuidingCare Utilization Management application that is tightly integrated with the claims processing system,” Myer explained “This process was a big pain point for our staff. Many health plans have staff managing these processes in separate environments, manually entering information into both systems. We solved this problem, and as a result were able to launch an authorization portal. So rather than having providers fax or make phone calls to request authorizations, they can now request them electronically. We also use a claims portal where they can check the claims outstanding.”

  • Member Services: VillageCare streamlined the disconnected workflows that were a result of multiple software systems and improved access to information to transform the experience for their member services teams. With better tools and more accurate, real-time data, member services teams have been able to improve service quality, reduce costs, and improve the member experience.
  • Care Managers: VillageCare also eliminated functional siloes and put accurate, up-to-date data in the hands of care managers to streamline workflows and improve outcomes.

“We aim for integrated, care management processes. Systems should support the work processes, which was not always the case. But through our digital transformation and using GuidingCare, we have much more structed work processes. This frees up our care managers to focus on care management, while also forcing compliance and regulatory adherence through the system. In addition, we now have proper segmentation of membership so that we can develop real-time alerts, improve population health, and direct efforts where needed as opposed to being the same across the whole organization,” explained Myer.

  • Information Technology: VillageCare has consistently focused on aligning business and IT teams to successfully use technology to address priority needs and challenges across the organization. By transforming the IT foundation, they delivered on their goal of becoming a data-driven organization. Now, the organization uses business intelligence to improve operations and deliver better care for members. In addition, through implementing solutions that use interoperability standards such as Fast Healthcare Interoperability Resources (FHIR), they have advanced integrations that allow for more streamlined processes and seamless workflows.

“The transformation has truly changed the way our teams operate, improving the experience for members, providers, member services, care management, and IT. All of these components are part of our digital transformation strategy. It is important to touch each of them and ensure that they talk to each other,” stated Myer.

VillageCare is addressing top challenges facing many health plan leaders today through their digital transformation journey,. They are delivering benefits for key stakeholders across the healthcare delivery systems by improving connectivity, enabling access to accurate data, and streamlining workflows.

Ultimately, the digital transformation is enabling VillageCare to deliver better health outcomes for the community they serve.

Learn more by watching the webinar here.