Month: November 2023

Strategic Plan Execution: Govern, Educate, and Enable

Once you have your digital transformation plan, the next step is to execute against that plan. It’s critical to follow it, document changes, assess impacts, and communicate. Governance, clear communication, and effective decision-making infrastructure are critically important. Do not underestimate the need for an Enterprise Program Management or Strategic Operating Model.

Top 3 Execution Best Practices

 

1. Project and Business Artifacts

Align on a standard set of projects and/or operational artifacts that you will use to track progress. Leverage schedules, reports and RAID logs to ensure that everyone involved and interested is following the same plan.

2. Change Management

Change is inevitable. Establish your internal change management processes to reach the grassroots. Change managements starts from the top and cannot be one & done. Plan on having a series of touch points (townhalls, weekly newsletters providing progress etc.) to continue to generate excitement about the new software at all levels.

3. Metrics

Keep your metrics front and center. Use them to motivate the teams, adjust and improve. Metrics need to drive your decisions. Test and stick to your benchmarks for an acceptable pass rate. Metrics also ensure accountability.

Top 3 Execution Mistakes

 

1. Limited Visibility

Limited visibility into progress, issues, and decisions that need to be made can multiply disruption in schedules and resolution. It can also build distrust amongst the teams involved. Always overcommunicate and ensure everyone is following the same plan. Sharing key artifacts across teams helps mitigate risk and disruption.

2. Confusion and Bad Decisions

Understand any impacts of the change to the overall project or business operations, reporting, timing, staffing, and support. The fastest way to sink a good plan is by not managing change effectively. Without a change management process, you will likely miss details around the impacts of the change.

3. Gut Decisions

Rely on metrics and data to inform decisions throughout the execution. Cutting corners on the time you dedicate to testing to hit a date means you will have to cut scope. Cutting scope means you are introducing unnecessary risk to your business. If you have a plan to test 100 E2E test scenarios that cover your critical business operations, and you reduce that to 50 E2E test cases you can expect at least half of your critical operations will likely have an issue that you discover in Production.

HealthEdge: Healthcare Payer Digital Transformation and Professional Services

HealthEdge’s Professional Services provides expertise and support to accelerate your digital transformation. To become a next-generation health plan, you need a digital foundation that enables you to provide a transparent and person-centric experience at lower cost, higher quality, and higher service levels. HealthEdge® solutions provide that foundation – and HealthEdge Professional Services deliver the expertise and support to make the process swift, sure, and effective.

Learn more about HealthEdge Professional Services.

Join us for the rest of the Healthcare Payer Digital Transformation series

• Healthcare Payer Digital Transformation: Navigating Change Through Strategic Planning
• Healthcare Payer Digital Transformation: Prepare & Plan
• Healthcare Payer Digital Transformation: Design Excellence
• Healthcare Payer Digital Transformation: Execute
• Healthcare Payer Digital Transformation: 3 Critical KPIs – coming soon!
• Healthcare Payer Digital Transformation: Optimize – coming soon!

 

 

 

When we think about your digital transformation a key part of it is designing for the future. This is where we examine: what do you want to achieve? Why do you want to achieve it? What will achieving it mean to your members, your staff, and your organization?  

You are not investing in this transformation to rebuild your legacy system on a new technology. You are modernizing and improving your business operations, driving increased quality, better service and driving cost out of the transactions. Design based on best practices to meet your goals and objectives. Don’t be handcuffed by lack of feature/functionality of your existing solution – encourage curiosity and question why.

Design for your future: Top 3 Best Practices

 

1. Organizational Change Management (OCM)

Organizational change management plans are a critical success factor. Invest in this area and focus on communication plans, processes, staffing, and desk level procedures. Ensure the people, process, and technology components are identified and accounted for in the design plan.

Define and deploy strategies for successful user adoption. If the end users are not on board, health plans are unable to realize the full ROI of their investment.

2. Ecosystem Design

Finalize and design your ecosystem in its entirety. Design for goals and objectives and identify workstream leaders that are excited about the future changes. Embrace best practice designs. Remember – the “Just because we’ve always done it this way” mentality won’t deliver a transformation. Instead, ask yourself, “why did we do it this way?” Give yourself the time and space to reflect on why things were done in a certain way and how they can be enhanced.

3. Centered on Goals and Objectives

Design decisions in support of desired outcomes. Reinforce the goals and objectives frequently. Address the fears that people will be replaced with technology. They are being freed from manual processes so that they can use their expertise to focus on things that have a bigger impact.

Design for your digital transformation future: Top 3 Mistakes

Be sure to avoid the following missteps:

1. The “Surprise” Factor

The list of people, processes, and technology changes is extensive. Develop an OCM plan to mitigate risk. Don’t underestimate the data clean up that will be required.

2. Disruption

Changing ecosystem partners will impact data, integrations, timelines, and budgets. Avoid changing key vendors while the project is in flight. This can cause disruption and rework to data requirements.

3. Rebuilding Legacy Workflows

Legacy workflows are not delivering on your future state goal and objectives. Don’t let the notion of ‘perfect’ get in the way of ‘good enough/better’ than today.

HealthEdge: Healthcare Payer Digital Transformation and Professional Services

HealthEdge’s Professional Services provides expertise and support to accelerate your digital transformation. To become a next-generation health plan, you need a digital foundation that enables you to provide a transparent and person-centric experience at lower cost, higher quality, and higher service levels. HealthEdge® solutions provide that foundation – and HealthEdge Professional Services deliver the expertise and support to make the process swift, sure, and effective.

Learn more about HealthEdge Professional Services.

Join us for the rest of the Healthcare Payer Digital Transformation series

• Healthcare Payer Digital Transformation: Navigating Change Through Strategic Planning
• Healthcare Payer Digital Transformation: Prepare & Plan
• Healthcare Payer Digital Transformation: Design Excellence
• Healthcare Payer Digital Transformation: Execute – coming soon!
• Healthcare Payer Digital Transformation: 3 Critical KPIs – coming soon!
• Healthcare Payer Digital Transformation: Optimize – coming soon!

 

 

 

 

The digital transformation shift for payers can represent a massive change. One of the keys to successfully navigating that change is through thorough planning and preparing. However, skipping, or skimping, on the planning phase can cause a ripple of negative outcomes.

Top 3 Most Common Digital Transformation Planning Mistakes

 

1. “Filling in the Blanks”

Insufficient information and lack of goal communication can cause people to make up information in the absence of details. Executive decisions can also be misunderstood by the project/operational teams without sufficient information and context. Proactively share information and bring people along on the journey. Always overcommunicate.

2. Scope Creep

Adding/changing scope without considering its impact to your goals and objectives can cause budget and operational consequences. Establish your scope based on your objectives and goals and stick to it.

3. Job Security Mindset

The fear of being replaced by technology is real for a lot of people. This can cause people to not share legacy information so that they can’t be replaced by technology.

Plan for the Digital Transformation

Don’t fall victim to the “Ready, Fire, Aim” approach. Slow down and build the plan, prepare to initiate the next phase, gather requirements, think about the organizational change that will need to occur, be mindful in your decisions, and build in mitigation plans for critical dependencies and dates. Comprehensive preparation empowers your team to pivot and keep going rather than losing even more time having to do that work later, or possibly redoing it.

Ensure your people, processes, and technology are fully aligned before the project commences. Include the following considerations:

Top 3 Digital Transformation Planning Best Practices: Goals, Objectives, and KPIs

In the words of Stephen Covey, begin with the end in mind. What do you want to achieve? Why do you want to achieve it? What will achieving it mean to your members, your staff, your organization?

Define why you have decided to do this, your business goals and objectives, the current KPIs, and what you expect to achieve after implementing this new solution.

1. Define the Why

What are the business and technology goals behind the decision?

2. Evaluate impact on decisions

What are your goals and objectives? Will this have a positive impact on them? How will this change impact your technology, process, and people?

3. Establish a communication plan

Transparency and communication support the change. Focus on building cascade, transparency, and consensus. Document and publish it. These goals and objectives should become core to how you make decisions about scope and changes throughout the implementation and ongoing management of the solution.

HealthEdge: Healthcare Payer Digital Transformation and Professional Services

HealthEdge’s Professional Services provides expertise and support to accelerate your digital transformation. To become a next-generation health plan, you need a digital foundation that enables you to provide a transparent and person-centric experience at lower cost, higher quality, and higher service levels. HealthEdge® solutions provide that foundation – and HealthEdge Professional Services deliver the expertise and support to make the process swift, sure, and effective.

Learn more about HealthEdge Professional Services.

Join us for the rest of the Healthcare Payer Digital Transformation series

• Healthcare Payer Digital Transformation: Navigating Change Through Strategic Planning
• Healthcare Payer Digital Transformation: Prepare & Plan
• Healthcare Payer Digital Transformation: Design Excellence – coming soon!
• Healthcare Payer Digital Transformation: Execute – coming soon!
• Healthcare Payer Digital Transformation: 3 Critical KPIs – coming soon!
• Healthcare Payer Digital Transformation: Optimize – coming soon!

Digital Health Payers turn to technology to help

If you are reading this blog, you are likely somewhere on your journey to becoming a Digital Payer. In fact, you are likely already a digital payer in some areas and continuously looking to optimize and expand your digital transformation.

Five key Digital Payer characteristics:

1. Improving Member Experience

You are working to improve the end user/member experience through access to information and digital tools, maybe through your member portals, price comparison tools, online PCP selection, etc.

2. Reducing Transaction Costs

You are always looking to reduce transaction costs; increasing your auto adjudication rates, eliminating manual intervention in claims processing, digital authorizations, etc.

3. Improving Quality

You are constantly on the hunt to improve quality; in how you operate the business, ensuring your staff is trained and taking advantage of all the ways they can leverage available technology, managing to key metrics and using data to identify improvement areas.

4. Enhancing Service

You are constantly working on improving your services levels; maybe through digital survey tools that allow you to capture data, analyze feedback, and adjust.

5. Increasing Transparency

You are operating your business with transparency; leveraging platforms and digital tools to provide information, self-service, and online collaboration tools to improve communication and information sharing.

Navigating Change

A key factor to consider, regardless of where you are in your digital payer life cycle (thinking about implementing a change, in the middle of an implementation, or actively running your business on HealthEdge) is that you are transforming your business.

The reality is that if we put our “continuous improvement” hats on we never really reach “the end”. This is why it’s imperative that we talk about how critical planning is to success.

Business Transformation is a Marathon…Not a Sprint

Adopting a “Marathon Mindset” is a critical mindset. When you decide to implement a new enterprise software solution, you are initiating one of the biggest business transformations you might ever be involved in. Typically, a health plan will migrate to a CAPs or Care Management system once in a generation

It’s important to prepare the team for a marathon not a sprint…meaning we have got to start to think “continuous improvement” and this approach will serve you regardless of where you are in your digital transformation.

Six Main pillars of Digital Payer Transformation

There are 6 main pillars of a successful digital transformation:

1. Define your Success
2. Plan & Prepare
3. Design the future state
4. Execute the plan
5. Measure key performance metrics
6. Optimize for continuous improvement

HealthEdge & Digital Transformation

By automating business workflows and seamlessly exchanging data in real-time across the ecosystem, HealthEdge customers experience the business benefits of: 

• Improved end-user experience
• Decreased transaction costs
• Increased quality
• Increased service levels
• Increased business transparency

HealthEdge: Healthcare Payer Digital Transformation and Professional Services

HealthEdge’s Professional services provides expertise and support to accelerate your digital transformation. To become a next-generation health plan, you need a digital foundation that enables you to provide a transparent and person-centric experience at lower cost, higher quality, and higher service levels. HealthEdge® solutions provide that foundation – and HealthEdge Professional Services deliver the expertise and support to make the process swift, sure, and effective.

Learn more about HealthEdge Professional Services.

We will be exploring these in depth through an upcoming healthcare payer digital transformation series:

• Healthcare Payer Digital Transformation: Prepare & Plan
• Healthcare Payer Digital Transformation: Design Excellence – coming soon!
• Healthcare Payer Digital Transformation: Execute – coming soon!
• Healthcare Payer Digital Transformation: 3 Critical KPIs – coming soon!
• Healthcare Payer Digital Transformation: Optimize – coming soon!

 

The next-generation core administrative processing system (CAPS) from HealthEdge, HealthRules® Payer, delivers transformational capabilities that allow health plans to compete more effectively and adapt faster to changing business models, market needs, and regulatory dynamics. The system’s powerful flexibility allows for an endless variety of configurations that can be designed to meet the dynamic needs of virtually any health plan and any line of business.

To help HealthRules Payer customers optimize system configurations and ensure further optimized business performance, the HealthEdge Global Professional Services team offers specialized services for HealthRules Payer configuration. Both new and existing customers can leverage our expert team complemented by an optimized mix of global resources, when appropriate, to accelerate the time-to-value during new implementations or system expansions into new lines of business or geographies.

Overcoming Industry Challenges

• Workforce shortages on both the IT and business fronts make it challenging for some health plans to move at the pace required to remain competitive in today’s rapidly changing market. HealthRules Payer experts ensure health plans have the resources they need when they need them to adapt and meet their ever-changing landscape.
• Technology innovations and new features are constantly being made available by HealthEdge and its partners. The Professional Services team of experts helps customers quickly embrace and implement these advancements to gain competitive advantage and optimize efficiencies.
• As health plans grow, so does the complexity of the systems that support the growth. HealthEdge experts help health plans identify new ways HealthRules Payer can enable, accelerate growth strategies, and support peak performance of both the system and the organization.

Unmatched Expertise in the Industry

HealthEdge Configuration as a Service is powered by the healthcare innovation experts at HealthEdge. The combination of HealthEdge’s technology, strategic leadership, best practices, and its experienced configuration teams and optimized U.S./global resource model, ensure health plans can achieve their goals in a timely and cost-effective manner.

• In-depth knowledge of the HealthRules Payer solution capabilities and architecture
• Expertise gained through hundreds of HealthRules Payer implementations
• Instant connections to HealthRules Payer software architects and developers

For projects where it is appropriate, additional resources can be sourced from global locations, giving payers extreme flexibility and cost savings while benefiting from workforces in multiple time zones that expedite time-to-value. A key attribute of these services is our ability to dynamically flex to a hybrid model of onshore and global resources to best support the project’s requirements, timeline, and budget while maximizing both quality and timeliness.

Health Plan Configuration as a Service

HealthRules Payer configuration often drives the cost and timeline of implementations, upgrades, expansions, or support projects. As a result, health plans may reduce the scope, preventing the organization from realizing the full possibilities of their CAPS system. Configuration as a Service provides expert resources and services to enable health plans to reduce delivery risk, increase quality, and maximize the cost-efficiency of projects associated with implementing, maintaining, and expanding the use of HealthRules Payer.

Configuration as a Service Features:

• Implementation services
• Line of business expansions
• New services
• Expanded capabilities
• Upgrades
• Migrations
• Other growth needs

Health Plan Benefits

Providing deep HealthRules Payer expertise in a cost-effective model, the Configuration as a Service delivers powerful assurances:

• Successful configuration through a standardized, scalable, & mature process framework
• Minimize costs through strategically optimizing resources
• Shorten delivery times for implementations, upgrades, and line of business expansions
• Reduce risks associated with implementations and system expansion
• Improve outcomes to ensure health plans optimize HealthRules Payer functionality

To learn more about how HealthEdge Configuration as a Service can deliver predictable, cost-effective services for your organization, please reach out to your HealthEdge representative or email [email protected].

Health plans need to price and pay all claims accurately, even though not all of a health plan’s claims will come from contracted providers with negotiated payment rates. Source is a comprehensive payment integrity platform, able to support plans with everything from enterprise-wide payment integrity strategy to foundational pricing and reimbursement for participating and non-participating providers alike. The following case study highlights the ability of Source to help with the foundational, complex pricing for one plan’s non-participating provider claims.

Challenges of Non-Participating Provider Claims

A large, non-profit health plan has a robust network of contracted providers within the northeast region, facilitating local care access for their members. But, as health plan members seek care with non-contracted providers due to travel beyond the health plan region or for other logistic or personal reasons, the health plan receives claims from providers not contracted with their health plan. With multiple lines of business and almost four million members, these non-participating provider claims stack-up quickly and the health plan must be prepared to pay these claims accurately and efficiently, even without the benefit of contractually negotiated payment terms.

“We didn’t have many different pricing arrangements, but because of the differences in products and how those products wanted to message differently, it ended up being 75 different rate configurations for only six edit mapping rules.” – Health Plan Reimbursement Initiatives Manager

CMS Fee Schedules

The Centers for Medicare and Medicaid Services (CMS) maintains a fee schedule, which is a complete listing of maximum fees used to reimburse providers on a fee-for-service (FFS) basis. There are different fee schedules for:

• physicians
• ambulance service
• clinical laboratory services
• and more

Further, these fees can vary with modifications based on patient, provider and location factors; for example, urban, rural or low-density qualified areas.¹

CMS fee schedules are not only important for Medicare and other government lines of business – they are also important for commercial lines of business. These fee schedules are often used by non-participating providers who submit claims using a percent of CMS FFS. Using CMS fee schedules can simplify the number of payment arrangements across these different provider types, but as this northeast health plan well knows, they still need to develop claims configurations and claims-payment messaging to account for varied provider characteristics. Configurations and messaging must be aligned with modifiers for government and commercial providers and in-network and out of network status. Further, the Plan must be able to edit these configurations to comply with ongoing policy updates, including retroactive change mandates.

“CMS pricing is not just a simple fee schedule. There are many different ways that CMS prices different types of claims, providers, bonuses, outliers and new technology payments. It’s very complicated and [to get claims right, we have to] understand the nuance.” – Health Plan Reimbursement Initiatives Manager

Solution = Source

Source was specifically designed as a single instance that connects with any claims system. Today, Source offers existing integration with over 10 claims systems, ensuring that implementation isn’t waylaid by key technology integration challenges. Source also supports the Plan with hierarchical edit capabilities to structure the six different enterprise-level configurations overlaying mapping rules for the 75 different rate configurations for the Plan’s commercial and Medicare Advantage products and lines of business using a percent of CMS FFS schedules.

“It’s helpful that updates are deployed so quickly. It’s helpful that HealthEdge puts edits right in [to the Source platform], so the brunt of validation and testing is already done in advance. This is a big advantage over other experiences that were not as positive – that we’ve had with other vendors.” – Health Plan Reimbursement Initiatives Manager

The Plan also faces provider-specific arrangements with non-participating providers whose pricing does not follow a percent of CMS schedule. As a true tech partner, Source was also able to help the Plan navigate this additional complexity. The Plan’s Reimbursement Initiatives Manager described reaching out to Source representatives who were able to show her how to configure pricing for these unique provider payment arrangements – leaving her confident in her ability to make other such configurations in the future.

“I have found the HealthEdge Source system to be very robust and flexible with regards to all of the different types of CMS and non-CMS based pricing methodologies that it offers.” – Health Plan Reimbursement Initiatives Manager

Takeaways

Non-participating providers are a critical extension of any plan’s network – and accurate and efficient payment despite the lack of contracted pricing, is an important component of effective health plan operations.

• Non-participating providers play an important role in ensuring member care access in and out of their home region
• Many non-participating providers use a percent of CMS FFS pricing
• While CMS pricing offers a standardized base reducing the number of payment arrangements, plans still need a platform such as Source that facilitates many configurations and specific messaging based on provider type and other factors
• Investing in a platform whose pricing includes ongoing, automatic updates keeps plans on-top of policy changes without additional resource demands
• Choosing an industry-specific tech partner like HealthEdge gives plans the support they need to optimize automation and accuracy despite the complexity of provider arrangements

¹https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo