Payer organizations today face significant obstacles as they navigate a new era of member and provider “relationship management.” Members and customers have increased expectations and payers are responding by working towards executing transactions more quickly and identifying incorrect payments and their root causes.

While the spectrum of payment integrity is broad, the goals of all segments are to encourage the affordability of healthcare by preventing poor quality claims upfront, avoiding downstream costs where possible, and recovering improperly spent funds postpay when necessary.

However, trying to achieve these goals is challenging for the average payer organizations due to the following factors:

• Fragmentation within payer organizations requires top-down leadership to break the cultural, technical and organizational silos.
• Quantifying the value of education and prevention is difficult.
• Coordinating workflows across internal organizations is a large challenge.

Prepay vs Postpay in Healthcare: Advantages of Shifting Towards a Prepay Model

Moving “left” from postpay to prepay allows payers to have more predictive control and addresses the challenges payer organizations face. While doing so can be organizationally and culturally challenging, there are many benefits and advantages of this shift:

• Increasing accuracy of claims reimbursement and transparency of payments, leading to improved provider relations
• Removing redundant tasks, reducing staff frustration, saving time
• Decreasing claim spend
• Improving claim denial rate
• Reducing the number of claims requiring rework
• Lowering the cost per claim processed
• Reducing the significant claims-related provider inbound call volume
• Improving the member and provider experiences
• Identifying and educating providers by revealing patterns of poor payment integrity practices

An Alternative Approach to Payment Integrity

As the landscape of healthcare payer technologies evolve, an alternative approach to payment integrity is emerging: single, one-stop-shopping solutions. Source, HealthEdge’s payment integrity software, is a single payment integrity solution that offers a centralized repository of data that can be used for multiple functions, such as claims reimbursement, editing, clinical reviews, modeling and analytics. Transitioning to a single-solution system offers payers the opportunity to streamline operations, form authentic vendor partnerships, and take control of a comprehensive approach to their claims payment operations. Learn more about partnering with Source, a transformative, single-solution partner.

Shifting Trends in Healthcare Payments: A Focus on Prospective Payment Integrity

Lately, payers have been making some interesting shifts to better meet their organizational goals such as executing transactions more quickly and identifying root causes of incorrect payments. As member and customer expectations continue to increase in these areas, such as expecting prepay instead of postpay organizations are taking action to address new internal and external pressures.

In the IDC Spotlight: Prospective Payment Integrity: Moving from “Pay and Chase” to Predictive report, 7 key industry trends which positively impact payer challenges were identified:

1. Advancements in Internal Workflow Solutions – Internal workflow solutions are being improved by bringing together different components to streamline efforts. Consolidation of the vendor solutions/IT stack translates to less internal lift for payer organizations.
2. Optimized Ecosystem – Externally interoperable solutions with best-of-breed content and functionality are being acquired, allowing payers can optimize their ecosystem of solutions. Improved workflows externally improve automation so internal efforts can focus elsewhere (e.g., expanding into new LOBs, improving member and provider satisfaction).
3. Vendor Alignment – Payment integrity vendors are aligning and merging to accelerate a “technology push” for various organizations and functions to work together.
4. Claims Digitization – Advancements in claims digitization and adjustment automation are being made to support payment integrity in core administrative processing systems (CAPS). Over 20% of all claims are submitted as physical copies and require high amounts of manual labor to process, drastically increasing costs, errors, and processing time, and leading to potential risks to an organization.
5. Transparency through Open APIs – Payment integrity solutions designed for transparency can work to consolidate and coordinate sound, useful data through open APIs. Centralizing data can help payers understand root issues, make informed business decisions, and effectively communicate with and educate their provider network.
6. Improving Coordination of Benefits (COB) – On average, it takes a plan nearly 5x times longer to settle a COB claim than a regular claim. Improving the coordination of benefits that apply to a person who is covered by more than one health plan has the potential for significant time savings for payer organizations.
7. Administrative Audits as a Tool for Improvement – Organizations are applying administrative audits to medical claims that are complicated and costly if not managed correctly. A claim audit of any kind can identify root causes of errors, find methods for improvement and ensure compliance.

To learn more about key trends in healthcare payments and enhanced processes payers are leveraging, including the application of analytics and coordination of workflows, you can read IDC Spotlight: Prospective Payment Integrity: Moving from “Pay and Chase” to Predictive.

On March 11, 2020, COVID-19 was declared a global pandemic by the World Health Organization. The accessibility of portable, electronic communication technologies had already begun to change our habits, from shopping to personal interactions with our friends, family, and neighbors. But in the three years that have passed since the COVID-19 pandemic struck, the way we live in this world today has changed even more, most specifically in the way we access healthcare. Due to COVID-19 precautions, rather than walking into the doctors’ office many patients saw their providers by way of virtual visits, and many families had to leave loved ones at the hospital entrance in the anticipation of returning to them later. Where is the world heading? Will digital healthcare remain as successful as it was during the initial days of COVID-19? Is the use of digital health and the use of electronics for family support and communication here to stay?

What is Virtual healthcare/Telehealth/Mobile healthcare?

Virtual healthcare is a remote two-way digital conversation between patient and their healthcare practitioner. These exchanges can take place via phone call, email, instant message, or live video chat.

Telehealth is the use of technology (Computers and mobile gadgets like tablets and smartphones) by the healthcare provider to enhance or support healthcare services. This technology can be used from home by the patient, or a nurse or other healthcare professional could offer telehealth services out of a clinic or mobile van. By providing timely care to those who might otherwise postpone it, or who reside in locations with a shortage of providers, virtual care can provide a chance to dramatically enhance patient outcomes.

mHealth (mobile health) is the use of mobile phones and other wireless technology in medical care. It can close gaps in care by enabling patients to speak with their doctor or other members of their care team without physically being present. Users can continuously track and manage specific health data using wearable technology and other mobile technology.

The Rise of Digital Healthcare post COVID-19 – 5 Lessons Learned

1. The rise of telehealth and its adoption

Patients felt that telehealth was convenient and were more satisfied with telehealth than virtual visits and would continue to use telehealth for their healthcare. However, physicians felt that telehealth was expensive, and they had concerns about the effectiveness of telemedicine compared with in-person care, had physician burnouts, and had concerns about protecting their patient’s personal health information.

Nearly half of doctors stated they think telemedicine is a viable option for treating persistent chronic diseases. Remote healthcare enables patients to be treated more effectively, relieving pressure on medical facilities, and lowering operational expenses and common infections associated with healthcare. Expectations seem to differ by age and income level category, payer status, and service type. Higher income earners and those with individual or group insurance through their employers are more likely to use telemedicine. The demand from patients for virtual Mental and Behavioral health is also rising. Chronic care providers were able to do more virtual visits, while Pediatricians, Gerontologists, and Gynecologists were not.

2. Triage of urgent and non-urgent patients can be aided by digital tools

Using Digital Technology, patients can be effectively screened and evaluated where they live, prior to being admitted to a hospital. This protects healthcare professionals, other patients, and the community from exposure, and relieves pressure on the limited resources of the healthcare system.

3. Using eConsults to Expand Access to Specialty Care

Another aspect of telehealth that benefited from the pandemic was the development of applications like electronic consultations (eConsults). While not suitable for emergency care, eConsults offer the opportunity for specialists and primary care clinicians to work together on challenging situations despite distance or time zone issues. They have also improved access to specialty treatment while reducing wait times, according to several studies. eConsults offer the ability to simplify the referral process and give access to specialty expertise that was previously overextended or unavailable by minimizing referrals, enhancing care coordination, and lowering costs.

4. Patient and provider satisfaction with Telemedicine for consultations

Research showed that during the pandemic, patient satisfaction with in-person, video consultation, and telephone visits was comparable. Physicians expressed favorable opinions toward the use of telemedicine, with treatment being on par with in-person consultations. But it all came with its own challenges. Most new caregivers had to swiftly acclimate to this transition to offer secure and exceptional care. It was difficult to try to match the in-person visits with the virtual visits because it had to resemble the customary in-person visits. Being professionally dressed, choosing a quiet environment, employing high-quality webcams, and having a robust internet connection were all vital and were only learned over time through experimentation.

5. Measures taken by the healthcare payers

The COVID-19 pandemic has demonstrated how the American health system’s inefficiencies and disparities are a result of misaligned financial incentives and the dispersion of services across sectors. The pandemic has both accelerated ongoing attempts to restructure payment systems and given fuel to long-overdue improvements in health care delivery, such as flexibility for virtual care. One example is the transition to alternative payment models (APMs).

Notably, COVID-19 has also encouraged new, creative collaborations between payers and other sectors, such as joint projects with the pharma companies to promote biomedical innovation, coordination with community-based organizations to meet patients’ social needs, and collaborative partnerships with public health departments to enhance disease surveillance. Accelerating the shift to value-based payment, trying to extend flexibilities for virtual health services and solutions, rethinking advantage layout using the principles of value-based insurance, aligning incentives and investment opportunities to address health inequities, and developing mechanisms for collecting data on health care spending.

HealthEdge & Digital Healthcare

HealthEdge’s healthcare SaaS software provides payers with a digital foundation that enables them to deliver a transparent and consumer-centric experience at lower cost while offering higher quality and higher service levels to their members, providers and partners. Learn more here.

In today’s world, health plans are challenged with improving care, reducing costs, and remaining compliant with ever-changing regulations. This is especially true when it comes to providing care management and population health management for government lines of business and dual eligible populations. While care management programs are highly recognized as valuable, not all programs and platforms are the same – and keeping compliant with federal and state-specific regulations further exacerbates the challenges that come with adoption and effectiveness.

A Growing and Complex Market

To better understand the challenges of implementing an effective care management program for government or dual-eligible populations, it is first important to understand the growth and complexities of these groups. ‘Dual-eligibles’ are persons who qualify for both Medicare and Medicaid coverage. Medicare covers their acute care services, while Medicaid covers Medicare premiums and cost sharing, and—for those below certain income and asset thresholds—long-term care services. Dual-eligibles are typically a particularly vulnerable subgroup of Medicare beneficiaries. By virtue of their eligibility for Medicaid coverage, they tend to be poor and report lower health status than other beneficiaries. Dual-Eligible Special Needs Plans (D-SNP) are a special kind of Medicare Advantage Plan for these dual-eligible individuals who qualify for both Medicare and Medicaid and Part D coverage.

Enrollment in D-SNPs increased from 3.8 million beneficiaries in 2021 to 4.6 million beneficiaries in 2022 (20% increase) and accounted for about 16% of total Medicare Advantage enrollment in 2022, up from 11% in 2011. In 2022, the number of D-SNPs offered grew by more than 16% from the previous year, double the growth of general enrollment plans during the same period.

Health plans serving D-SNP members need a holistic platform for end-to-end care management and population health that is effective at simultaneously reducing overall costs and improving care, while ensuring the plan is compliant with state and federal regulations.

A Complex Population: Dually Eligible Individuals Need Care Management

People who qualify for D-SNPs are the most vulnerable and high-risk population with the most complex health needs. Compared to individuals enrolled in Medicare only, dual eligible beneficiaries are:

• More likely to be under the age of 65
• More likely to live in rural areas
• Four times as likely to have high food insecurity needs
• Three times as likely to speak a language other than English at home
• Twice as likely to have depression
• Nearly three times as likely to have cognitive impairment

Care Management Works

The complexity of the dual-eligible experience, from a medical and social perspective, coupled with the fragmentation created by the Medicare and Medicaid systems, often results in an uncoordinated experience with misaligned incentives.

These individual and system level complexities contribute to high levels of spending. While dual-eligible beneficiaries represent just 20% of the Medicare population, they make up 34% of Medicare spending. Similarly, they make up 15% of the Medicaid population but account for nearly 1/3 of the spending.

This opens the door for implementing a care management program that works. Not only does care management lower costs and improve health outcomes, but those plans that execute it well set themselves apart from the competition with improved Star ratings.

Elderplan & HealthEdge’s Care Management Platform GuidingCare

GuidingCare is a leading next-generation care management solution suite that enables health plans to provide all members, from the healthiest Medicare Advantage member to the most medically complex dual-eligible beneficiary, with the most effective care management services. Plans that rely on GuidingCare can maximize coordination and member engagement for improved Star ratings, better health outcomes, and increased member satisfaction.

Elderplan, the only 5-star Medicaid Advantage Plus (MAP) plan in New York State, uses GuidingCare and shared the following:

“Elderplan specializes in intense, complex care management of our membership, and [GuidingCare] supports these care management goals as well as our compliance goals, as far as STARS ratings, HEDIS scores, and other initiatives.” – Craig Azoff, Senior Vice President, Health Plan Information Services, Elderplan

Read the full Elderplan case study here.

 

The 2022 Verizon Data Breach Investigations Report (DBIR) found Internet-facing applications, such as web applications and mail servers, were among the most common methods for attackers to slip through organizational perimeters. Once the perimeter is successfully breached, attackers can trigger ransomware, stopping critical services while demanding a ransom payment. Web-based threats, such as malware and ransomware, are threats that originate from the Internet. Additional web-based threats include phishing campaigns, DDoS, worms and viruses, spyware, cross-site scripting, and SQL injections. Some of the ways HealthEdge defend against these threats are with geolocation technology, 24×7 alerting and monitoring, and vulnerability management.

Geolocation data allows system administrators to create Geofences that can limit or prevent access based on the source or destination of the traffic. For example, an embargoed country can be blocked from accessing the website, or a user can be prevented from accessing a page hosted in a sensitive country. While this does not prevent all attacks from the location, it does raise the bar of difficulty for an attacker.  

Additionally using this geolocation data security, teams can identify anomalous activity, or even spot a new superhero. If access is attempted from an authorized location but is not the “normal” location for that specific user, rules such as challenge questions, or designated timed lockouts will trigger before access is granted. If a user successfully logs in from New York, NY at 8 AM, and that same user tries to login from Los Angeles at 10 AM, we’ve either identified a super-hero, a user with access to a transporter, or a potentially compromised credential. No matter what’s happening the organizations 24×7 monitoring and alerting systems need to be activated so the activity can be investigated further.

Asset inventory and vulnerability management are also major components of a security program. At HealthEdge we routinely scan and test our environments, which helps us identify security weaknesses from things like system and software patches, device misconfiguration, and/or other vulnerabilities related to human error. Vulnerability management, with regular scans, ensure security is continuously assessed and improved for greater maturity.

Technology Enablers 

The 2022 Verizon DBIR state attackers view malicious exploits as “a numbers game.” If attacks can remain at a high rate, or even increase, eventually minimal access can be gained to advance their attack plans. With this level of persistence in mind, HealthEdge adopts a layered security approach with technology enablers used to strengthen each layer of defense.

• Web application firewall (WAF) tools protect web application servers by mitigating application layer attacks through analyses of each HTTP/S request. Application layer attacks, such as DDoS attacks, seek to disrupt services from the web application. WAF tools ensure only authorized data is transmitted and prevents malicious, or unsafe traffic, based on a set of configured security policies.
• Firewalls are used to restrict inbound and outbound traffic in a private network to mitigate web-based threats.
• Content filters are used to prevent malicious content from being delivered in the first place and assessed again at the point of click to ensure the content hasn’t become malicious.
• Source code analyzers are used to scan software for flaws and defects during the development cycles.

Stay tuned for next time where we will explore the value of using cyber intelligence alerts to complement our security strategy.

At health plans today, reports are often found in the form of spreadsheets – which offer a flat and siloed view of reimbursement insights. Analytics can be more informative when they have accurate real time data and provide multi-dimensional views. Health plans have a lot of data, and it is important to get the most out of it to drive informed decision making and positive change.

The Reimbursement Information Payers Need

It is important to fully understand how your health plan’s claims are performing during reimbursement. Having an overarching view of a health plan’s entire reimbursement use case will provide insights on where problems are starting and how they ultimately affect reimbursement. As a starting point, health plans should identify the areas that aren’t receiving enough information and identify blind spots. Additionally, it is helpful to have comparison data to flush out the areas where improvement is needed or has been needed for an extended time. Having reimbursement data in one place instead of siloed individual reports can help a health plan find and remediate issues faster.

The Big Issues

Health plans often struggle with issues surrounding provider education, medical economics, and finance. These issues may result in underpayments/overpayments or delayed claim adjudication resulting in late fees. When any issue arises, swift detection and resolution are imperative to ensure quality and accurate reimbursement, and prevention of abrasion between a health plan and its providers.

Highlighting Your Successes

It is just as important to understand the areas where your health plan is excelling. Maybe your health plan has recently cut down in over-payments. With this being the case, it is important for a health plan to understand what changes were made and if they can be applied to other places within reimbursement. Reflecting on effective and modern changes that positively impact reimbursement can be beneficial across a health plan’s claims ecosystem.

But what if …

Once areas needing improvement have been identified, it is important to simulate results before applying changes and answer the question ‘what if this change was made?’. This allows for health plans to make informed and confident decisions that will foster positive change into the claims ecosystem. A couple of examples include:

• Benchmarking
• Forecasting
• Contract Modeling

Better Insights Lead to Better Decisions for Claims Operations

Predicting the financial and operational impact of pricing edits and configuration changes to claims has been a challenge for decades. But advanced business intelligence solutions from HealthEdge’s payment integrity platform, Source, allow health plans to eliminate the guess work and adapt claims operations with confidence.

The Source Analytics Module allows leaders to:

• Accurately assess the impact of changes before applying to a particular product, region or provider contract
• Avoid unnecessary overpayments
• Improve provider relations through accurate communication of a new policy’s impact
• Reduce internal effort needed to manage and review results
• Proactively adapt to policy and rate changes to remain in compliance

 Learn more about Source Analytics here.