Month: May 2023

What is the Transparency in Coverage Rule?

Prior to July 1,2022, most consumers of health care services were unaware of how much they cost, including myself.  My primary concern was whether it was a covered service and how much the copay or coinsurance was going to be after the insurance company processed the claim.  It never occurred to me that some providers may be charging vastly different prices for the same services.  The reality is that providers do have different rates for the same services.  The Transparency in Coverage (sometimes referred to as TiC) rule allows consumers to know the cost of a covered item or service before receiving them.

Beginning 1/1/2023, the Transparency in Coverage rule required that health insurance companies provide their members with an online tool that allows them to compare pricing data between different providers for several hundred covered services.  According to the rule, consumers should have the ability to access all their covered services using this same tool to make price comparisons no later than 1/1/2024.

How has this rule impacted the way consumers access healthcare services?

For me, the availability of price comparison data for my healthcare services is used to help me understand my potential out-of-pocket costs before I schedule services.  Even more importantly, this new ruling enables me to know how much of the cost is my responsibility before receiving the Explanation of Benefits (EOB) from the health plan.  Gone are the days when I would receive a bill from a provider indicating that I was responsible for tens of thousands of dollars for services rendered.  And yes, this did happen to me several years ago.

Providing consumers with this level of detail about their healthcare costs allows us all to engage in a more consumer-driven experience.  We now have tools to help us decide which providers we want to use, and this empowers each of us to play an important role in controlling the cost of our healthcare services.  As the saying goes ‘Knowledge is Power’ and it most certainly applies in this case.

Compliance with the Transparency in Coverage Rule

The good news is that health plans are complying with the Transparency in Coverage (TiC) rule and successfully implementing data processes and software applications to support this rule. Of course, this rule will continue to be refined and the processes in the background within health plans will continue to improve and evolve.  In the end, we will all benefit from the Transparency in Coverage (TiC) ruling by better understanding what is covered by our health insurance as well as managing the expected financial responsibility of our health care services.

Operationalizing Transparency in Coverage (TiC)

Making provider price comparison data available for use in an online tool for consumers is a massive undertaking for any health plan.  The data needs to include rates used for all covered items and services by in-network providers.  In addition, the allowed amounts, and billed charges from their out of-of-network providers are required.  Typically, this data is spread over multiple systems within a health plan, and consolidating the data is no easy task.

HealthEdge offers a suite of products to enable health plans to consume and transform the data needed to comply with this regulation.  Specifically, we can support health plans in the following ways:

• Adhere to the CMS mandate by understanding the health plans needs and system customizations
• Provide data in the required format that includes data dictionary updates
• Allows on-demand and monthly rate updates per contract configurations
• Enables data files access via SFTP line so they can be used to generate comprehensive rate lists

Learn more about HealthEdge’s suite of products here.

In the CY 2023 Final Rule, CMS made several changes that directly impact plans offering Dual Eligible Special Needs Plan (D-SNP) programs, which are a type of Medicare Advantage (MA) plan that are designed specifically for individuals who are eligible for both Medicare and Medicaid.

In general, the 2023 changes are intended to make the D-SNP population more attractive for providers, and therefore increase access to care for these beneficiaries. For payers, these changes are intended to increase clarification regarding different D-SNP programs and reduce the administrative burden of offering separate MA and D-SNP programs. However, many payers are concerned about the impact these changes will have on their bottom lines.

Here are four changes from the 2023 Final Rule that we believe deserve additional consideration.

1. Capturing Social Determinants of Health (SDOH) Data

The Final Rule requires D-SNPs to incorporate one or more questions in their standard health risk assessments (HRA) addressing beneficiary housing, food insecurities, and transportation. Acknowledging that many factors other than physical health go into a person’s ability to maintain their health, many physicians have already started collecting this type of information, which is commonly referred to as social determinants of health (SDoH). The goal of taking a more holistic view of a patient’s life, including psychological, functional, and environmental factors, is to increase the likelihood of better health outcomes and lower the total cost of care. Care management teams within many health plans are also on board with collecting SDoH data and are already using this data to tailor services beyond medical benefits to achieve optimal health outcomes. Some care management platforms, like GuidingCare^®, have already released capabilities within their platform that help health plans more systematically integrate SDOH into their care management programs.

2. Recalculation of the Maximum Out of Pocket (MOOP)

CMS also finalized changes to the way Medicare Advantage plans calculate MOOP, requiring plans to include all cost-sharing, including those paid by secondary payers, in the calculation of the beneficiary’s MOOP. Previously, MOOP was calculated only by the amount the enrollee had to contribute. The result? Beneficiaries are likely to reach MOOP faster, and health plans will have to pay 100% of the service costs sooner. Some industry experts believe this change will result in an additional $4B in costs to health plans, but the improvement in health outcomes and improved access to medical and non-medical care is projected to save $3B. Despite the pushback from health plans on this change, CMS proceeded with the implementation of this and made it effective June 1, 2023. The complexities and urgency of the implementation of this change is a perfect example of why health plans need a modern, highly flexible core administrative processing system (CAPS) like HealthRules^® Payer.

3. Enrollee Participation in Plan Governance

Medicare Advantage organizations offering a D-SNP must establish one or more enrollee advisory committees in each state to solicit direct input from beneficiaries on their experiences with the plan. Plans that operate D-SNPs in multiple states had to establish multiple committees, one for each state. Although these committees must have a representative sample of the population enrolled in this plan, very little direction was given about the committee meeting frequency, location, format and training.

4. Bringing Greater Definition to multiple Types of D-SNPs

Historically, the fully integrated dual eligible (FIDE) and highly integrated dual eligible (HIDE) SNP definitions have been confusing and inconsistent. Through this final rule, CMS is making changes to the definitions, which will support a greater understanding of the different types of D-SNPs, clarify beneficiary options, and improve integration. According to a National Law Review article, this means all FIDE SNPs, with the same legal entity holding the MA and Medicaid contract: 1) be capitated (with certain exceptions) for all Medicaid services, and 2) operate unified grievance and appeal processes. CMS also clarified the definition of HIDE SNPs requiring the plan to cover long-term services and supports, including i) community-based long-term services and supports and some days of coverage of nursing facility services during the plan year; or (ii) behavioral health services. For plan year 2025 and subsequent years, the FIDE and HIDE SNP must cover the entire service area for the dual eligible special needs plan. By helping health plans enroll the appropriate beneficiaries into the right categories and having the ability to create tiered or dual networks, HealthRules Payer enables health plans to quickly spin up whichever type of D-SNP program they believe would be most valuable for the communities they serve.

Turning Mandates into Advantages

While the only constant in government health plans, including D-SNP programs, is change, health plans with a highly configurable CAPS can turn mandates into competitive advantages. For example, health plans using HealthRules Payer now have the opportunity to pursue D-SNP populations with less IT and administrative burdens because the system can be configured to address the unique D-SNP requirements. Health plans don’t have to implement an entirely new system. Things like dual networks and tiered networks are completely configurable in HealthRules Payer. The business flexibility HealthRules Payer gives health plans is unmatched and dramatically lowers the cost of entry into new lines of business.

In addition, the requirement to capture additional data, such as SDoH, is another opportunity for health plans to convert mandates into competitive advantages. With modern data analytics and reporting solutions from HealthEdge, plans can easily turn data into actionable insights that can help drive improved member outcomes, higher HEDIS scores, and better Star ratings. For example, SDoH insights can help care management teams configure new non-medical services, like transportation or meal support, for certain populations. Utilization management data collected can be folded into benefit plan development, and even fed into payment integrity initiatives to minimize provider and member abrasion with more accurate payments.

Looking at the Whole Picture

When regulatory changes such as those mentioned above are put in place, health plans often make the mistake of just looking at the one part of their business that is directly impacted instead of taking an end-to-end approach to implementing the changes across their enterprise. That’s where the professional services team at HealthEdge can be a health plan’s biggest asset. With years of experience in helping government-related health plans properly configure their systems to support regulatory changes, the team knows how to guide health plans through all aspects of the business that may be impacted so that everything from enrollment to claims coming in and payment going out are aligned.

To learn more about how HealthEdge solutions help health plans turn mandates into advantages, visit www.healthedge.com or email [email protected].

Developing your Company Culture: 4 Key Principles 

Join us for a 4-part series that explores developing your company culture and taking your organization to the next level.

1. A Culture of Impactful Leadership
2. Continuous Development – The Path to Employee Engagement & Retention
3. 5 Simple Steps to Foster Inclusion & Diversity
4. 6 Secrets to Purposeful Collaboration & Equitable Experiences

Part 4: Hybrid Work – 6 Secrets to Purposeful Collaboration & Equitable Experiences

With some employees at home, some at the office, and some a hybrid of the two – creating and fostering a company culture that feels genuine can be elusive. And in the aftermath of the pandemic, and several years into widespread remote work, this hybrid lifestyle is a reality that’s here to stay.

There are many positives to the hybrid work environment. Employees have embraced the flexibility of working remotely and leaning into a schedule that allows them to maximize their personal schedule, productivity, and energy. But there are also challenges: Zoom fatigue, the mental exhaustion from back-to-back meetings on screens all day, and the dissipation of company culture are a few of the big concerns. Working from home makes it hard for employees to feel connected to the bigger picture, team, and company.

With hybrid work being the new normal, how do we maximize the effectiveness of this model & use it to our advantage?

1. Make the Office a Magnet, Not a Mandate

Fear has driven some companies to mandate employees’ return to the office. But why make your employees pay for the cost and time of a commute if they’re going to be doing the same work from the office as their house?

What could your company offer that makes the office a magnet? It could be offering free lunches, opportunities for collaboration, or a welcoming, comfortable work environment.

The key is to make returning to the office – even for a few days a week – enticing to your employees.

2. Foster Purposeful Collaboration

At HealthEdge, we are consciously fostering a culture of purposeful collaboration – where if employees are invited to come to the office, we provide a solid WHY behind that request. This could be creating connections, brainstorming/solving problems, celebrating, socializing, and/or building relationships. We want to encourage employes to get together when it makes sense – to solve a business need or to gather to form stronger bonds & relationships.

We also host ‘Collaboration Weeks.’ These purposeful weeks are designed to bring people local to the office together. The week includes community service, social activities, panel discussions, and more. They’re designed to get our people together to interact through different events. However, it’s critical to make remote employees feel included as well. We offer all the sessions virtually so any employee can join. The experiences of on-site, hybrid, and remote employees must be equitable.

3. Educate & Empower your Managers

Senior leaders are in the best position to both define and role model the desired company culture and connect employees to that culture. However, managers are in the best position to help connect their teams to the work and to why what they’re doing is important – linking back to the purpose of the company.

Educate your managers on:

• How to have successful remote meetings
• How to have successful 1:1 meetings
• How to assess performance in the hybrid world

Empower your managers to develop the right schedule & collaboration strategy for their teams. Rather than an Executive leader making a bold statement like, everyone must be at the office 3 days a week! Empower your managers, who know the composition of their teams & the individual members, to determine what the hybrid work model looks like to make the strongest connections and reap the highest levels of productivity.

4. Minimize Remote Meeting Fatigue

Staring at a screen all day, switching from meeting to meeting, is draining and has proven to be mentally exhausting for employees. Encourage your employees to turn their screens off and walk around during meetings where they just need to listen. Make it a norm for employees to block time off on their calendar for lunch and breaks in the morning/afternoon. With remote work, it’s easy to spend a whole day glued to your screen and desk chair – a surefire recipe for burnout and disengagement. Actively tell your employees to take breaks and get away from their screens. Without this active encouragement, it’s easy for remote employees to fall into the trap of feeling guilty when they aren’t immediately available via Slack/email. Managers can play a huge role here by role modeling this behavior.

Companies can also provide equipment/stipends that encourage movement throughout the day. This could include things like standing desks or under-desk walking pads. Companies can also encourage walking challenges with fun prizes to get employees moving.

5. Establish Meeting/Deep Work Norms

When you work in an office next to your neighbor, you can see when they have their headphones on and are deep in work. However, when you’re working remotely, you can’t see that – all you can experience is an unanswered Slack and wondering why your coworker isn’t responding.

Furthermore, when you work in an office, you get up from your desk and go to a meeting room. Then you get up and walk around after the meeting. When you work remotely, it’s easy to go from back-to-back meetings and never get up from your desk.

This is why it’s critical for managers to establish deep work, response, and meeting norms for their team. For example:

• Deep work: managers can actively support their employees to set the time and space for deep work each day/week. This can be as simple as encouraging employees to set their status as away so they have the time and space to focus. Managers could also establish deep work blocks of time – such as a 3-hour window on Wednesday mornings with no meetings.
• Response times: Managers can support their employees by setting expectations for response times for email and Slack/teams messages.
• Meeting norms: Managers can mandate that meetings be a maximum of 25 or 55 minutes, so employees have a chance to get up and move around throughout the day.

6. Lean into Synchronous/Asynchronous Work

Synchronous work is normal – we talk, we meet, we Slack – all in real time. But with remote work, there’s the opportunity for asynchronous work, which enables team members to work when and how they’re most productive.

For this to be successful, managers need to be empowered to establish the cultural norms for their team. These cultural “rules” can include how the team can expect to work together in an asynchronous fashion. For example, Slack response time expectations. The “rules” could include:

• When to use Slack versus email
• When Slack is to be checked (every time it dings or at set times like morning, noon, and end of day)
• What to put in Slack versus email

The Future of Hybrid Work

With remote and hybrid work, employees, especially highly performing ones, have more choice of employers than ever. Creating a hybrid culture of purposeful collaboration, equitable experiences, and flexibility is critical to engaging and retaining employees long term.

Learn more about life at HealthEdge here.

Developing your Company Culture: 4 Key Principles 

Join us for a 4-part series that explores developing your company culture and taking your organization to the next level.

1. A Culture of Impactful Leadership
2. Continuous Development – The Path to Employee Engagement & Retention
3. 5 Simple Steps to Foster Inclusion & Diversity
4. 6 Secrets to Purposeful Collaboration & Equitable Experiences – Coming soon!

Part 3: 5 Simple Steps to Foster Inclusion & Diversity

The business case for committing to diversity & inclusion is compelling. It has been shown that companies with above-average diversity produced a greater proportion of revenue from innovation (45% of total) than from companies with below average diversity (26%). This innovation-related advantage also translates into overall better financial performance. It follows that with the workforce becoming increasingly diverse across all categories, 57% of workers believe that employers should be doing more to increase workplace diversity. A study by McKinsey demonstrated that gender and ethnic diversity are clearly correlated with profitability.

Furthermore, when you bring people with diverse backgrounds together, it drives innovation. Instead of collaborating with a team of homogenous people – all with the same education, thinking, and background – the diversity of circumstances, ideas, and perspectives leads to enhanced problem solving and advancements in innovation.

When you diversify your employee base, your company culture benefits from the wealth of those perspectives, experiences, and approaches to problem solving. Diverse backgrounds include gender and ethnicity, but also age & generation, gender & gender identity, sexual orientation, religion & spiritual beliefs, disability, education, and socioeconomic status & background.

Diversity is a powerful force to drive revenue and profitability. Here’s how you can foster diversity in your organization.

Simple Solutions to Foster Diversity

1. Offer Diverse Benefits

Organizations can foster a welcoming environment to diversity by offering benefits that are inclusive. Employers should address the gaps and disparities in benefit plan offerings to optimize the health, productivity, well-being, and financial protection of underrepresented groups. This might mean providing benefits that don’t just cater to a heterosexual married couple with two kids. Building an inclusive benefits package shows employees, and prospective employees, that the company isn’t just talking about DEI – it’s taking action, making investments, and enacting changes.

The Diversity, Equity, and Inclusion efforts at HealthEdge have led to a conscious decision this year to enhance our US benefits package with more inclusive offerings. This includes things like infertility services, gender affirming services, travel & lodging reimbursement to ensure employees have access to covered women’s health services, and an increased parental bonding leave policy from 4 weeks to 14 weeks for birth and adoptive parents.

2. Seek talent with diverse backgrounds

Understand the current composition of your workforce – look at it by type, role, and function. Determine how you can diversify, and how you can attract/appeal to different candidate pools. Make it a goal to have a diverse pool of candidates to pull from. A hybrid/virtual workforce can help with this – when you expand your geographic boundary for hiring you get a broader pool of diverse candidates.

3. Educate your hiring managers

Hiring diverse candidates can take a little longer – which is why it’s crucial to educate your hiring managers on why diverse candidates are so important. Help them understand the business case for hiring diverse candidates and why it’s worth the investment in time and effort.

4. Foster an Environment of Inclusion & Belonging

It’s critical to create a work environment where people feel like they can bring their most authentic self and highest potential to work. What good is it to hire for diversity if your employees don’t feel like they can be themselves – where the work environment doesn’t support diversity. This is where inclusion and belonging come into play. Create an environment that fosters and welcomes diversity.

5. Internal Inclusion Best Practices

There are many ways to make diverse employees feel included in the organization:

• Create a community for them to be a part of. At HealthEdge, we have an iBelong group that seeks to include employees throughout the organization with ongoing virtual chats and a monthly event. Events serve to provide awareness and education in an interesting and engaging way.  The community also offers a safe space to seek support and discuss challenging topics.
• Educate managers on how to make employees feel welcome within their group. For example, recognize there are introverts and extroverts in our Zoom meetings. A simple technique during meetings is to present a topic and give everyone a minute to think about it before soliciting a response. Another is to go around the table during a discussion and give everyone a chance to contribute – not just the most loquacious extroverts.
• Encourage managers to build 1:1 relationship with their team members to build trust and provide support throughout their career journey.

Diversity & inclusion is a powerful way to increase revenue, profitability, and innovation. Learn more about HealthEdge’s culture of belonging here.

Developing your Company Culture: 4 Key Principles 

Join us for a 4-part series that explores developing your company culture and taking your organization to the next level.

1. A Culture of Impactful Leadership
2. Continuous Development – The Path to Employee Engagement & Retention
3. 5 Simple Steps to Foster Inclusion & Diversity
4. 6 Secrets to Purposeful Collaboration & Equitable Experiences – Coming soon!

Part 2: Continuous Development – The Path to Employee Engagement & Retention

At HealthEdge, our vision is innovating a world where healthcare can focus on people. With this vision in mind, we hire the best and brightest from around the world – as our ability to achieve this vision hinges on our employees’ skills, creativity, capabilities, and leadership from within.

Continuous development is becoming a critical pillar of our company culture – as keeping and engaging top talent requires an intentional approach to their short- and long-term development.

Since “development” can mean different things, these are our top 4 continuous development tenets:

1. Embrace the uniqueness of your team members

As a manager, you have the great responsibility and wonderful opportunity to lead and develop a group of individuals. You get to engage your employees in their current role, help them grow their skills, build the bridge to their next role, and develop the framework for the trajectory of their career.

The key is to get to know your people for who they really are – their unique interests, strengths, and ambitions. How does this role, that’s so vital to your team, fit into their career? How can you help them develop and prepare to be ready for that next step?

Good questions to consider and discuss include:

• What are their career goals?
• In what ways do they need to grow and develop to achieve that next career goal?
• How can you help them achieve their career goals?
• What skills do they need for the future?
• What are creative ways to help them achieve those skills?

2. Understand the Many Facets of Development

When we talk about development, many often think only of attending formal training. Training can be a relevant component of learning – however, it’s only a small part of how we learn and master a new skill. Research (link) shows that learning takes place by doing, trying, and experiencing. It means working on new projects, interacting with new people, and experiencing new things.  All of this can be done “in the flow of work”, meaning deliberate learning can take place while someone is working in today’s role.  This keeps employees engaged and more likely to stay because they are continuously developing new skills.

Facilitate your team members to:

• Attend meetings at the next level above – to see the level of discussion, level of preparedness
• Work on an assignment within a different functional group
• Take on a stretch assignment
• Creatively think about team members, their unique skills and who they can connect with
• Connect with senior leaders and facilitate mentoring opportunities
• Get more exposure – such as speaking opportunities and interactive panels. This is especially helpful for emerging leaders.

3. Leverage Hybrid Work

The rise of flexible and hybrid work environments has led to fewer spontaneous hallway chats, chatter around the watercooler, and opportunities to have those unexpected run-ins with folks from different departments. In this new flexible world, employees often work exclusively with their functional team and only see folks around Zoom meetings.

With the importance of creating opportunities for your employees to grow and learn, how can we do this in a hybrid environment?

Here are some ideas to consider:

• Be purposeful & bring people together when it makes sense – for in-person team meetings or 1/1s, to brainstorm or workshop a topic, to celebrate, socialize, and/or participate in fun or team building activities
• Encourage and empower your team members to come together in the office and create norms that help the team feel engaged and productive
• Create networking opportunities for your team – invite folks from other teams, departments, and levels (both in person and virtually)

4. Change your Mindset to Our Talent to Enhance Engagement, Retention, & Company Performance

Employees join a company to perform a specific role, and it’s common for managers to think about them as my person, my talent, who adds so much value to my team, what would I do without them?

However, when we shift our mindset to being enterprise- and employee-centric, we bring a host of value to the employees, company, and company culture. Each employee represents not only the value they bring to their current role, but the time, energy, and expense of finding, training, and folding them into the company. Retaining employees reduces waste, cost, time, and energy.

When we focus on this enterprise- and employee-centric mentality, our company culture is strengthened. With this outlook, we help employees navigate the organization, grow and expand, and continuously develop so they remain constantly engaged and challenged at the company.

Investment in employee development is priceless.

Learn more about continuous development & life at HealthEdge here.

Readiness

March 2020 represented a critical shift in business operations for local and global companies. For many companies, it was just another day at the office – albeit you were working remotely versus coming to the physical office. Were you prepared? Was it an IT and cybersecurity scramble or were you appropriately equipped? The difference is derived from proper business continuity and disaster recovery readiness, communication, and continuous preparation.

HealthEdge understands the requirements needed to keep up in a fast-paced world. At a moment’s notice, things could change, whether it is a natural disaster, cyber-attack, or other unforeseen events that could have an impact on our ability to meet customer needs. HealthEdge prepares for the unexpected with Business Continuity Planning and Disaster Recovery to mitigate damage, minimize downtime, and reduce the impact on business operations.

Similar to the Global COVID Pandemic, HealthEdge ensures that our business processes, workforce, IT infrastructure and cybersecurity controls are ready for unexpected events – large or small. Our team identifies critical business functions, which includes systems, applications, and essential data that is needed for business operations to continue. Risks and vulnerabilities are assessed for critical business operations and considerations are made for the likelihood of various disasters and the potential impact of data loss or disruption.

Plans

Disaster Recovery and Business Continuity Plans are developed to outline how our teams will quickly recover, relying on backup and contingency plans and alternate work arrangement locations. These plans are tested and updated regularly to ensure they remain effective. While aligned with common themes and content, individual and custom product and facility-centric Disaster Recovery, Business Continuity and Emergency Preparedness Plans are maintained to ensure we are prepared based on geography and product group. The HealthEdge IT Security and Compliance teams maintain these plans. We augment internal efforts with external expertise to help ensure we identify and constantly mature the program based on emerging best practices and global threats. Copies are maintained in the HealthEdge Governance Repository for offsite backup purposes and are readily available should the need arise.

Testing

Team simulations help us to identify gaps or weaknesses in the plans, as well as ensure the plan is consistent with changes to business operations or IT infrastructure. These simulations and live tests occur among small teams, multi-offices and business products, or directly with customers. The ultimate objective is to stress test and be prepared – whether our workforce is located in a major metropolis with regional redundancy or in their village in India where local Internet and communications systems could have reliance issues.

Recent examples include:

• Testing Key Leadership Response Times – Our team uses recent regional events, such as flooding, to determine how prepared Leadership, Human Resources, and IT are to account for and maintain communications with the workforce as the community recovers.
• Testing Remote Access – Our team sends groups to work remotely to assess latency, communications system constraints or home bandwidth issues.
• Testing Alternative Work Sites – Our team evaluates the potential impacts of destruction of physical office space and safely reroutes employees to an alternate location.

As the Boy Scouts motto says, “Be Prepared” since that is what our customers expect of us: safeguard their data, maintain high availability, and deliver as promised.

Education and Awareness

Employee awareness is key in ensuring everyone knows their role should a response be initiated. HealthEdge conducts regular training for employees who work onsite, hybrid, and remote. In addition to this training, we produce education alerts and messages to not only support the employees but also their families. We are accountable for ensuring our systems, networks and data centers are prepared, as well as the home environment of our employees and their families. Protecting the family and home is critical for a “family first HealthEdge”, but to also ensure they are prepared in the event they are called upon to primarily work remotely.

Getting Our Ducks in a Row When Disaster Strikes

We value the trust our customers place with our business and strive to always deliver service, even when the unexpected occurs. As with other facets of information security, business continuity and emergency preparedness is another critical way HealthEdge protects you, your members, and the entire HealthEdge family. It’s also another way we ensure our ducks are in a row.