Pricing Transparency & the Online Shopping/Price Comparison Tool

We are nearing the 1/1/23 requirement for health plans to provide online shopping/price comparison on health plan member portals for around 500 services. This is part of the Transparency in Coverage Rule.

Members will be able to sign into their health plan member portal with their credentials – select a provider, select one of 500 services/procedures, and get back a personalized view of the cost that factors in their cost sharing and negotiated rate elements. With this, members get a clear understanding of what a service will cost with that provider. With this personalized view, members can make an educated decision about the cost of their healthcare services & procedures.

How is this different?

Health plans currently have a pricing tool that shows basic prices – such as an office visit, cardiologist visit, or echocardiogram. However, it’s not personalized. With this new requirement, members will have full transparency. They will understand what the cost for the service will be based on their specific benefit plan, which providers are in network, and where they’re at in their particular plan (deductible, max out of pocket).

Which plans are included?

All commercial plans must meet this requirement. This includes all individual and family plans on/off the exchange. This does not apply to Medicare or Medicaid.

What does this mean?

This is an exciting step forward toward healthcare becoming more digital and patient-centric. It also aligns with the soon-to-come Advanced Explanation of Benefits.

For example, say you have a knee injury and need replacement surgery. As of 1/1/23, with the Transparency in Coverage requirements, you’ll be able to log into your health plan portal and compare prices for that procedure. A broader scope of shoppable services must be made available to you in 2024.The Advanced EOB will be the next generation of this service. With the Advanced EOB your physician would request one from your health plan with the specific codes for that knee surgery. This Advanced EOB tells you, if you have this service with this provider and everything matches, this would be your benefit. It’s like getting your EOB before you even decide to have the surgery. Versus today, where you get the knee surgery and then some time after you get your EOB, and know your cost share.

Pricing Transparency & HealthEdge – The Wave toward Digital

HealthEdge is on the forefront of pricing transparency and enabling health plans to empower members to make educated decisions about their health. HealthEdge has had tools in place for several years to consume the items and services and based on the member and provider return personalized cost sharing information.  HealthEdge’s suite of products provide accurate real-time data – the backbone of pricing transparency. Learn more here.

CMS is Requesting Feedback on Establishing the First, National Directory of Health Care Providers & Services

Have you ever tried to find an in-network doctor on your health plan member portal, found one, and called them – only to find out that they’re not actually in network? Or worse, gone to a doctor you thought was in network only to later get a bill and find out they weren’t in network?

This common, frustrating problem is on CMS’ radar and could affect CMS regulations down the road. In CMS’ ongoing work to support interoperability & prior authorization, increase access to care, and decrease clinical burden/provider abrasion – they have their sights set on establishing the first, national directory of health care providers and services.

What’s the challenge?

Currently, there is no central directory for providers and services. This fragmented system makes it challenging for patients to find up-to-date information on providers and to find providers who are in network. It’s also challenging for providers – who have to update multiple databases and follow the requirements for each database.

It’s cumbersome and tiresome to both patients and providers. This barrier to care negatively impacts healthcare, as easy to find, accurate provider and service information is critical to member and population health.

The future – an accurate directory of providers  

CMS is considering developing a directory that would be a ‘centralized data hub’ for all health care. This ‘National Directory of Healthcare Providers & Services’ (NDH) would include accurate data in a publicly accessible database, developed through streamlined information submission from providers.

What you need to know

CMS has released a Request for Information (RFI) seeking public feedback on the NDH concept. CMS wants to know if consolidating this data in a central repository would improve access to care and make it easier for patients to find, evaluate, and compare providers based on their unique needs – such as accessibility and languages spoken.

How to provide your feedback

CMS is seeking feedback to better understand current health care directories and information they should consider as they develop the NDH concept. CMS is particularly looking for public feedback on benefits, provider types, entities, data elements, priorities, and any potential risks and challenges.

The CMS RFI is open for 60 days. It ends December 6, 2022.

Learn more and submit your feedback on the NDH here:

6 Critical Cybersecurity Pillars

Cybersecurity is a constantly evolving threat with the potential for massive risk and impact. HealthEdge is always on guard against cyber threats with a security blueprint and technology stack. The main HealthEdge cybersecurity pillars are:

  1. Prevention

Prevention is a critical component of cybersecurity. HealthEdge secures the network infrastructure with segmentation and network traffic controls. We commit to continuous vulnerability and patch management, as well as security for incoming and outgoing data management with data loss prevention controls, Internet proxies for secure browsing, and email security controls to protect users from malicious attachments, links, and phishing. Endpoint devices are secured on and off the network, including mobile devices to ensure secure collaboration and sharing. HealthEdge ensures our team is regularly trained on information security through our robust Security Awareness For Everyone (SAFE) program. Targeted training is conducted for secure coding, which ensures security by design.

  1. Access Control

Identity and access management controls allow authorized user access to the corporate network. Security controls are configured for remote access using VPN and multi-factor authentication.

  1. Operations Management

Security Operations and Compliance work in tandem to monitor and enforce policy for cloud-based applications. Security data from across the environment is ingested and normalized into our Security Information and Event Management (SIEM) tool in real-time. Using the correlated data, the Security Operations team can quickly respond to security events using our Security Orchestration Automation Response (SOAR) tool.

  1. Securing Applications & Validating Controls

HealthEdge continuously tests our website, and applications for code vulnerabilities. We protect web applications from malicious attackers using our Web Application Firewall (WAF) and monitor third-party risk using public information to profile a company’s security behavior. These controls are validated through governance risk and compliance with penetration testing and continuous auditing to ensure the company is meeting compliance and risk standards.

  1. Intelligence

In addition to security controls managed internally, HealthEdge has a robust threat intelligence program through partnerships with healthcare industry peers and cybersecurity experts. Alerts and reports are continuously assessed, and security controls are regularly adjusted in accordance with intelligence findings and applicability.

  1. Response

Because the threat is always evolving, HealthEdge must be positioned to immediately respond to security incidents.  This response is a coordinated effort in which we collect data and correlate behavior to achieve comprehensive understanding during the investigation process. eDiscovery ensures data is collected, and integrity is maintained, for legal matters. Response strategies include Business Continuity Planning (BCP), Disaster Recovery (DR), and controls to support redundancy and availability, which are regularly evaluated for improvements.

HealthEdge understands what it means to be a good steward of customer data and we take this responsibility seriously. Our teams work around the clock to ensure maturity when it comes to pillars of security. Follow us next month when we dive into industry trends and top threats.

Collaboration in a Competitive Marketplace

Is it possible?  Can competitors also collaborate?  Do they already?  When is it acceptable?  When does it push reasonable boundaries and when does it cross the line?  This post will cover those thoughts and others surrounding the value of ‘collaborative competition’.

In a recent in-person discussion with multiple customers, some competing for market share within the same geographic region, we were told, admonished really, that we (the ‘vendor partner’) worry more about their competition than they do – and they would find value and appreciate the opportunity to collaborate more.

I’ve been in the health plan business since 1990 and reflecting on the 90s when managed Medicare was beginning to grow, then regulated by the Health Care Financing Administration (HCFA), a predecessor to CMS, fierce competition quickly followed.  Health plans offering Medicare coverage within the same geographic region became strong competitors.  At the time, competition was based on the variety of benefits offered, co-pays and co-insurance, and most apparent, the premiums.

Very shortly afterwards, premiums dropped dramatically, and zero premium plans surfaced and became commonplace.  No longer was competition based on premium – shifting to benefits and member/beneficiary out-of-pocket cost.  This has remained a competitive factor for the past almost 30 years, and in more recent history, individualized customer care/service, predictability of cost, and quality (effectively, “The Triple Aim”), sometimes now Quadruple or Quintuple (often adding staff satisfaction and equity).

Competition in the markets of Medicare as well as Medicaid and Commercial remain a focus for health plans today.  This was confirmed earlier in 2022 when HealthEdge commissioned an independent study of over 300 health insurance executives on a variety of topics.  Competitive pressure was selected as a top challenge by 35% of executives responding, ranking fifth.  Competition also showed up regarding member acquisition, with 23% of respondents listing this as a top concern.  However, when reviewing the responses regarding technology, competition did not appear in the results.  Instead, investments in technology and alignment of business and IT were consistently the top two technology goals – with 53% of executives confirming.  An opportunity for collaboration exists here.

All health plans must efficiently operationalize in essentially the same manner – and utilize similar internal processes.  Some developing processes, for example, the approach to handling value-based care, remain competitive.  During the past couple decades, competition has increased within the health plan marketing environment – with various marketing solutions offering competitive advantages for capturing increased market share.  Typically, marketing is managed separately from the core operations within a health plan.  Does this make operational collaboration more reasonable?  Many would say yes.

Take provider data as an example.  It’s not unreasonable to conclude that 100% of health plans have some challenges in managing their provider data.  Health plans within the same geographic region often have very labor-intensive processes surrounding activities such as credentialing.  Some geographic regions, even some entire States, have established a variety of credential verification services – a “one-stop-shopping” approach, per se, to ease credentialing for everyone.  This is a collaborative solution that benefits everyone in the region yet does nothing to inhibit competition.

Often, health plans have built-in trust issues with their software vendors.  Time and effort are required to establish an effective partnership based on mutual understanding and common goals.  While this trust and partnership is being established and built, health plans can find common ground with one another.  As with any challenge in life, we all know that we’re rarely the first to experience something – and the collective experience of others can help to address any challenge.  Customers with common solutions can share experiences, tips and tricks, hacks.  And we all know everyone hates to open a ticket.  How nice to address an issue without that.  Do you contact Apple® support for questions regarding your iPhone®?  More than likely, you find the nearest teenager!  Health plans, even competitive ones, can commiserate, communicate, and collaborate as they have the same challenges.  There is strength in numbers – solving a challenge together is more effective that going it alone.  Networking with others within our small world also has many unintentional benefits.

My answers to the initial questions posed…  Is it possible to collaborate in a competitive marketplace?  Yes, it is possible!  Yes, competitors can also collaborate (sometimes)!  And yes, some already are!  When is it acceptable?  More often than some think!  When does it push the reasonable boundaries and/or cross the line?  When using similar solutions, far less frequently and rarely crosses any inappropriate lines.

A way to begin to establish new collaborative relationships is also through customer user groups.  If you’re not already connected to your HealthEdge product user group, use this link to register for the user groups of your choice.  If you are already a HealthEdge customer, feel free to also contact your HealthEdge Account Executive who can guide you as needed.  Go forth and collaborate!

What Happens After Go-Live? How Health Plans Successfully Leverage Technologies Long Term

Long term technology success hinges on the last step of HealthEdge’s Transform Methodology, Execution

Transform Methodology’s Last Step: Execution

Traditionally technology implementations involved simply building on a firm’s operational competencies and short term needs by adding a product.

Instead, transform methodology is the insurance industry’s long term approach to change management. It requires working together with vendor’s expertise and software to align and achieve long term goals while transforming businesses from the inside out.

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.

HealthEdge has outlined 3 phases of successful technology implementation: 1. Evaluation 2. Envision 3. Execution. Because Transform Methodology is focused on long term success, the last phase of technology implementation is ongoing and the most intensive to explain. This article goes over in detail how to successfully execute technology implementation over many years.

To learn about the previous two phases read 3 Steps to Effective Technology Implementation for Health Plans.

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

Planning for the Go-Live

Planning for a technology’s Go-Live involves outlining the design, delivery tools and best practices which will be leveraged.


There are 3 aspects of design to keep in mind to ensure long term technology impact:

  1. Operational Efficiency and Scalability: Consider any needed maintenance. Are there any processes to outline which would promote sustainability and accuracy? As well, make sure the designs are scalable to meet throughput and performance needs.
  2. Modular Framework: It’s important to work in tandem with existing editors to enable additional editing opportunities and efficiencies.
  3. Security: Make sure to leverage secure cloud-based architectures with SaaS delivery.

Delivery Tools

When deciding which delivery tools are important for your go-live consider including tools that:

  • Ensure Operational Readiness: Tools that adapt to change such as those that correct language, edits and pricing
  • Leverage Agile Principles: Tools that enhance collaboration across teams to deliver iterative batches of work with well defined acceptance criteria
  • Promote Future Functionality: Tools that will allow your health plan to become better as your vendor’s solution becomes better

Best Practices

Best practices your health plan uses when executing a software deployment should encourage process optimization. This includes leveraging training materials like:

  • User Guides: Guides that provide organizations knowledge and recommendations on how to leverage features and functionalities
  • Training Suites: Trainings which empower your team to drive organizational change and implement operational efficiencies.

Vendors should also offer separate product support by customer type like Blues and Non-Blues. Upgrade cycles should also be separated by customer type.

“One Team” Principal

All execution efforts should promote a “one team” approach to software launches. This means integrating activities of all internal departments and vendor supports. In this way, deployment should be seamless and have a precise focus.

Most importantly, be sure to have unified:

  • Goals
  • Governance Practices including the governance team’s mastery of advanced operations
  • Collaboration Mindsets where work is encourages across business teams
  • Operational Model
  • Communications including agreed upon cadence and promotion of knowledge-sharing across teams
  • Decision-making structures
  • Focus on value driven work like reuse, scalability and flexibility
  • Capacity to accept changes quickly.

With the “one team” approach, vendors can be better partners to your health plan, helping you with implementation and setting your organization up for long term success.

Moving Beyond the Go-Live

It’s important that health plans think beyond the go-live date to ensure long term success of any implementation. This planning should include:

  • Maintenance of a strong release management process
  • Coordination of at least 1 upgrade annually
  • Implementation of an annual Health Check to analyze workflows and new features
  • Optimization of processes as new items are released

Other considerations involve adopting a continuous improvement approach when moving from an MVP (minimum viable product) to optimal functioning, removing manual interventions, as well as improving processing times and key metrics.

As new features and functionalities are released your health plan can take advantage of better optimized workflows and configurations. For example, with Source, new content and policy updates help health plans keep pace with business and growth.

When implementing new features ask yourself:

  • Are there new ecosystem partners we need to integrate with?
  • What does this change impact? (ex. input/output, technical, business, claims, manual processes?)
  • Who deploys the changes?
  • Which configurations or pricers need updates or changes?
  • Are updates required for automated or manual workflows?
  • How will testing take place for the changes? (pre-production testing for expectived results, go-live decision testing, export or import testing to update production environment?)
  • What training or communication should be send out regarding the change?

Health Edge Case Study: Results and Returns

Using these principles, HealthEdge has enabled savings for its clients through long-term partnerships.

  • Medicare Advantage payment integrity
  • Multi-state Medicaid implementations
  • Dual-eligible implementations
  • Automated claims pricing for LOB

Their Source solution consistently monitors and updates regulatory policies, rates, fee schedules resulting in effective contract configuration which:

  • Reduces repeatable processes
  • Reduces number of contracts
  • Minimizes needed maintenance
  • Optimizes existing processes.

The Source solution also applies claims pricing seamlessly with your health plan’s existing editors. To learn more about HealthEdge and their suite of solutions for health plans click here.