Month: June 2023

Legal compliance refers to the adherence to laws, regulations, and standards that are applicable to a specific industry or organization. At HealthEdge, Compliance is an essential component of business operations, as it helps to mitigate legal and financial risks and ensures HealthEdge operates ethically and in the best interests of stakeholders.

What is Legal Compliance at HealthEdge?

Legal compliance is the ongoing process of ensuring that a company, business, or other organization is adhering to the applicable laws, regulations, and industry standards. This can include complying with financial reporting requirements, implementing privacy and security safeguards, training workforce members, and conducting operations in accordance with the numerous laws that govern businesses, such as employment, tax, and insurance laws.

The purpose of having a strong compliance program is to help organizations operate at a high level and to avoid the penalties, financial losses, and reputational damage that can result from violations caused by non-compliance. The financial penalties for violations can be significant and have the potential to cause additional harm that can be devastating to the success of a business.

A quality compliance program provides assurance to prospects and customers that a business is well-managed, trustworthy, and reputable. A compliance program can be tailored to support an organization maintain its ethical standards (like transparency, honesty, and respect) which also helps build trust with stakeholders, customers, workforce members, and shareholders.

HealthEdge prioritizes compliance throughout the company so that all workforce members are aware of and involved with its success. The compliance group takes a cross-functional approach to engage company-wide support and increase the efficiency of compliance efforts. By working with multiple departments, HealthEdge ensures that the compliance requirements are met, and regular work is unaffected so business can continue as usual.

HealthEdge is committed to working for the best interests of its customers, and the strength of its compliance program helps demonstrate that commitment.

How does HealthEdge achieve Compliance?

Implementing company-wide compliance is a complex process that requires knowledge and awareness of the many laws, regulations, rules, and standards that require strict adherence. HealthEdge takes a detailed approach to ensure the compliance program is performing at a high level, and that the compliance program is working as intended. The program is designed around the seven foundational elements of a compliance program outlined by the United States Sentencing Commission, incorporating an additional element from the Department of Health and Human Services (HHS) Officer of Inspector General (OIG) Compliance Guidelines:

1. Governing Authority: HealthEdge has a Compliance Officer (CO) and the Risk Compliance and Governance Committee, that is comprised of members of the executive leadership team is responsible for the execution, correction, and oversight of all aspects of the compliance program.
2. Policies and Procedures, and Code of Conduct: HealthEdge commits to complying with all applicable federal and state regulations and standards–this includes providing guidance to workforce members on compliance-related matters. HealthEdge also provides procedures that assist in the identification and correction of non-compliance. These policies and procedures are reviewed on a regular basis and updated as needed based on requirement changes or regulations.
3. Training and Education: HealthEdge provides various training to its workforce members, including new hire, annual refresher, and role or product-specific training.
4. Reporting: HealthEdge is committed to fostering a culture of compliance, good corporate governance, and ethical behavior and encourages the reporting of improper, unlawful, or unethical behavior. Workforce members are encouraged to discuss any suspected violations with appropriate individuals within HealthEdge. HealthEdge has a strict non-retaliation policy–there can be no retaliation, penalty, or retribution for good faith reporting of any suspected compliance issue.
5. Monitoring & Auditing: Proactive auditing and monitoring of routine business practices is vital for the identification of potential compliance issues. HealthEdge routinely conducts audits and monitors business processes to identify risks. These processes help:

• Ensure compliance with policies and procedures, laws, and regulations.
• Confirm that corrective actions have been implemented.
• Evaluate the overall effectiveness of the compliance program.

6. Enforcement & Discipline: HealthEdge does not tolerate non-compliance with company policies or applicable laws. Any non-compliance could compromise HealthEdge’s operations, the services provided to customers, or its Violations of the HealthEdge Code of Conduct and other policies and procedures require a corrective action and reporting to the appropriate regulatory or law enforcement agency when applicable. HealthEdge has well-publicized disciplinary standards that:

• Prohibit authorization or participation in activities that violate HealthEdge policy.
• Articulate expectations for reporting compliance issues and assists in their resolution of issues.
• Provide timely, consistent, and effective enforcement of the standards when non-compliance or unethical behavior is detected.
• Encourage good-faith participation in the compliance program.

7. Response & Prevention: HealthEdge has a well-developed compliance program, with established procedures, processes, and system implementation for promptly responding to compliance issues. The HealthEdge compliance program ensures that:

• Issues are acknowledged as they arise.
• Potential compliance problems are investigated.
• Concerns are proactively identified through rigorous auditing and monitoring.
• Problems are corrected promptly and thoroughly to reduce the potential for recurrences.

8. Background Checks: In addition to the seven foundational elements of a compliance program outlined above, HealthEdge also incorporates Background Checks that include an investigation of criminal history, exclusions, and reference checks. HealthEdge makes reasonable efforts to ensure personnel and business partners are not engaged in illegal activities or conduct that is inconsistent with an effective compliance program.

Conclusion

Achieving compliance requires a thorough understanding of all applicable laws and regulations, the development of policies and procedures to ensure compliance, the implementation of controls and monitoring systems, and ongoing maintenance and updates to ensure compliance with changing requirements. HealthEdge’s compliance program ensures the company meets established standards, upholds its commitments, protects its business reputation, and avoids financial penalties. By prioritizing compliance, HealthEdge mitigates legal and financial risks, operates ethically, and serves the best interest of its customers.

What Health Plans Should Know as Interoperability Continues to Change the Game for Healthcare

Interoperability has transformed every facet of the healthcare delivery system, creating new opportunities to improve outcomes, reduce costs, and improve efficiencies. It has also been the key to enabling healthcare technology solutions to achieve their full potential.

By gaining a deeper understanding of the origins, current status, and future potential of interoperability, health plans can seize the opportunity to implement modern and innovative care management integration capabilities that deliver results for digital payers.

Defining Interoperability

Interoperability in healthcare refers to the ability of various information systems, devices, and applications to access, exchange, integrate, and cooperatively use data in a coordinated manner, in order to provide timely and seamless portability of information and improve the health of people and populations around the world.

Interoperability is the basis on which healthcare providers are able to deliver coordinated and comprehensive care to patients by accessing and sharing critical patient data in real-time. It also enables health plans to streamline administrative processes and reduce costs. As the healthcare industry continues to evolve and adopt new technologies, interoperability will also become an increasingly vital aspect of healthcare delivery and management.

Why Interoperability Matters

Interoperability can have significant positive implications across the healthcare ecosystem. Key goals of seamless integration include:

1. Advancing care coordination: Interoperability facilitates the sharing of member health information between payers, providers and systems, enabling better coordination and collaboration among organizations and teams.
2. Improving outcomes: By providing care managers and healthcare providers with access to comprehensive and up-to-date patient information, interoperability can help care managers create effective care plans and improve patient outcomes.
3. Streamlining administrative processes: Interoperability can reduce administrative burden, support new payment models, and ease claims processing.
4. Reducing costs: Interoperability can help reduce errors, streamline processes, and save time, leading to overall cost savings for payers, healthcare organizations, and members.
5. Improve member satisfaction: By improving data exchange, members have greater access to health and claims information, improving satisfaction and engagement.

The Beginning: Unlock the Power of Health Data through Interoperability

The need for interoperability originated as healthcare providers embraced widespread adoption of electronic health records (EHRs). EHRs were intended to revolutionize the way healthcare was delivered, enabling better coordination of care, reducing medical errors, and improving patient outcomes. However, in practice, EHRs created silos of health data that were not easily shared between providers or patients. This lack of interoperability led to fragmentation of care, duplication of tests, and unnecessary healthcare costs.

Recognizing the need to address these issues, the 21st Century Cures Act mandated that healthcare providers make patient health information available to patients and other providers in a standardized format through open, secure, and standardized application programming interfaces (APIs). The Act also created new provisions for healthcare data privacy and security, ensuring that patient data is protected when it is shared between providers.

These interoperability standards were important for several reasons. First, they empowered patients to take control of their health information and share it with any provider they choose. This increases patient engagement and allows for more comprehensive and coordinated care. Second, the rules helped to break down the silos of health data that had developed, enabling providers to access complete patient records, reducing the risk of medical errors, and improving the quality of care.

Finally, the interoperability rules promoted innovation in healthcare by encouraging the development of new applications and tools that can use healthcare data to improve patient outcomes, reduce costs, and improve efficiencies. Interoperability continues to be a priority for health plans and organizations across the healthcare ecosystem.

New Regulation and Innovation: Key Drivers Influencing Interoperability Today

Today, new regulations and continued innovation are driving urgency for greater interoperability. For example, the CMS Proposed Rule: Advancing Interoperability and Improving Prior Authorization Processes will directly influence integration priorities for many health plans. The proposed rule updates some of the policies included in the Interoperability and Patient Access Final Rule of 2020 and officially withdraws the December 2020 CMS Interoperability proposed rule. The objectives of the policy are to reduce the burden on both payers and providers, improve efficiencies, and advance patient access to health information. Some of the conditions take effect immediately, while others require implementation by 2026. Given the scope, it is important health plans to take action now and prepare their infrastructures for full implementation.

The proposed rule includes multiple requirements for payers that will directly influence their interoperability strategies:

Patient Access API: The rule proposes to require regulated payers to include information about patients’ prior authorization decisions to help patients better understand the process and contribution to their care. The proposed provision would also require impacted payers to report annual metrics to CMS about patient use of the Patient Access API.

Provider Access API: The rule proposes impacted payers build and maintain an API to share patient data with in-network providers where a treatment relationships exists with the patient.

Payer-to-Payer Data Exchange on FHIR: The rule proposes to require payers to exchange member data when a member changes health plans, with the member’s permission. The data elements include claims and encounter data, those identified in the USCDI version 1, and prior authorization requests and decisions – only if the patient opts in to data sharing.

Improving Prior Authorization Processes: The rule proposes a series of policies in an effort to improve the prior authorization process through greater efficiency and transparency.

The rule also outlines CMS’s recommended use of certain implementation guides for the APIs listed in the rule, but does not propose requiring their use.

The provisions outlined in the CMS proposed rule facilitate moving the industry toward more streamlined communication and better information exchange that can benefit members, payers, and providers. As organizations await the final ruling, there are steps that can be taken now to prepare:

1. Understand how the ruling will impact your health plan. Assess guidelines and determine which provisions will apply to your organization.
2. Evaluate your current data management processes. Is all member information available in a single source in order to create the full record required? If not, what changes need to be made to maintain a record for each member?
3. Evaluate your current interoperability strategy. How is member information exchanged between payers, providers, and patients today? How is prior authorization information managed and exchanged today? In what format are the data points being requested and can they easily be delivered via a Patient API or Provider API?
4. Assess resource availability. Who will be responsible for implementing the new standards? Who will be responsible for ensuring data is available to patients and providers within defined timeframes? What processes will need to change in order to accommodate the new standards?

Future State: Interoperability Considerations for Digital Payers

The proposed rule could be considered just the beginning for innovation in interoperability that will impact health plans moving forward. Rapidly evolving regulatory requirements, new payment models, rising consumer expectations, and new market opportunities will continue to drive payers to advance interoperability. The results promised by continual digital advancements across the healthcare ecosystem rely on seamless data exchange. In fact, interoperability can be considered a prerequisite for many health innovations.

Digital payers should consider their care management system’s ability to meet key requirements for modern and evolving integration criteria:

1. Exchange a variety of data types: Health plans should ensure their care management system can access, ingest, and exchange various data types across other systems with industry interoperability standards.
2. Support real-time data exchange: Informing decisions in a timely manner is critical when it comes to effective care management. Health plans should ensure care managers have real-time access to member information.
3. Work seamlessly with other systems and data sources: Care management systems function as the core orchestrator of member care. But the most effective care plans rely heavily on data from multiple sources to inform optimal care plans. In addition, care management systems must work in tandem with claims, payment integrity, and other administrative systems to streamline processes and reduce costs.

GuidingCare® enables digital payers to meet these modern interoperability needs, plan for future requirements, and support continued innovation. To learn more about how about creating a successful interoperability strategy with GuidingCare, visit the GuidingCare page on the HealthEdge website.

In recent years, Medica, a Minnesota-based non-profit health insurance provider, has experienced explosive growth. To keep up with its growth, Medica’s was using HealthEdge’s core administrative processing system (CAPS), HealthRules^® Payer, which had resulted in multiple instances of the system.

However, the growing complexity of the multiple configurations led to the need for a more efficient way to manage the HealthRules Payer infrastructure, and Medica turned to the experts within the HealthEdge team for guidance.

Medica faced two main challenges: Firstly, the company needed to create new efficiencies to help reduce complexities and administrative burdens associated with maintaining multiple HealthRules Payer environments, reducing the time spent on issue research and resolution, enabling faster system audits, and improving tracking of configuration changes to support more seamless configuration changes. Secondly, the company needed to maintain quality, reducing occurrences of early promotion of another user’s work related to multi-user risks of promoting someone else’s work and eliminating the risk of wiping out another user’s changes.

The outcome of this collaboration was the creation of HealthRules Promote, a web-based application that all HealthRules Payer customers can now use to manage complex configurations and multiple instances of the solution. Medica noted that the collaborative effort between the two teams resulted in a powerful solution that helped the company support more than 400 configuration projects in the past year.

HealthRules Promote provides insight into the complexities of HealthRules Payer configuration and ensures that all unique dependencies are considered prior to promoting the configuration to production. It also allows multiple users across multiple lines of business to control and understand which users’ configurations are ready for promotion and which ones have conflicting dependencies.

For Medica, HealthRules Promote provides delivers several meaningful benefits:

1. The solution saves time through configuration artifacts by removing the need to create and maintain exports, eliminating separate spreadsheets for tracking, and easily importing configuration sets to new environments in just a few clicks.
2. The solution allows the company to confidently migrate configurations without errors that ultimately cause problems in production.
3. The dependency-and-compare features of HealthRules Promote allow Medica to easily audit builds across environments and identify development changes over time that may be causing product issues.

To explore how HealthRules Promote can empower your organization with actionable insights into the complexities of your multiple HealthRules Payer configurations, visit the HealthRules Promote page on the HealthEdge website or email [email protected].