Month: December 2023

As payers look into the healthcare landscape of 2024, they must consider the rapidly evolving and ever-increasing importance that the market is placing on interoperability from both a strategic and regulatory perspective. All arrows point toward the need and requirement for greater collaboration between:

• Patients and payers
• Providers and payers
• Payers and other payers

Interoperability is taking center stage like never before. With the rapid advancement of technology and the increasing importance of patient-centric care, the Centers for Medicare & Medicaid Services (CMS) has introduced a set of regulations and rulings that are set to transform how healthcare information is shared and utilized.

Let’s explore these regulations to understand better why interoperability is crucial for payers and the healthcare industry as a whole.

Understanding Interoperability Regulations

Interoperability refers to the ability of different healthcare systems and software applications to communicate, exchange data, and use the information that has been exchanged. In 2024, CMS is implementing a series of regulations aimed at enhancing interoperability, with the key components being:

• Patient Access: CMS mandates that payers provide patients with access to their health information through standardized application programming interfaces (APIs). APIs mean that patients can securely access their health data, including claims and clinical information, through mobile apps or web portals. HealthRules Payer makes it easy for payers to leverage its robust set of APIs to meet these mandates.
• Provider Directory: Payers are required to maintain and update a comprehensive provider directory, ensuring that patients have access to accurate and up-to-date information about healthcare providers in their network. This directory must be made available through APIs, enabling third-party applications to incorporate this data. HealthEdge recently delivered its Provider Data Management solution to help payers meet this challenge and ensure all provider directories stay up-to-date and remain compliant.
• Data Exchange: The CMS is promoting the use of Fast Healthcare Interoperability Resources (FHIR) standards for data exchange. This will facilitate the sharing of patient data across different healthcare systems and applications, improving care coordination and reducing administrative burden. HealthEdge APIs are all consistent with these new CMS standards for sharing data.

5 Reasons Why Interoperability Matters

1. Improved Patient Outcomes:

Interoperability ensures that healthcare providers have access to a patient’s complete medical history, enabling them to make more informed decisions about their care, leading to faster diagnosis, more effective treatment plans, and, ultimately, improved patient outcomes.

2. Enhanced Care Coordination:

With interoperable systems, different care settings and providers can seamlessly share information, reducing the risk of duplicative tests and treatments, leading to better-coordinated care and a more efficient healthcare system.

3. Empowering Patients:

The ability for patients to access their health data empowers them to take a more active role in their healthcare journey. It fosters transparency and allows patients to make informed decisions about their care, leading to better engagement and satisfaction.

4. Reduced Healthcare Costs:

Interoperability can significantly reduce administrative costs by streamlining data exchange and reducing paperwork, which translates to cost savings for payers, providers, and patients alike.

5. Regulatory Compliance:

Adhering to CMS interoperability regulations is not just a matter of compliance; it’s a strategic imperative. Payers who embrace interoperability early on will be better positioned to thrive in the evolving healthcare landscape.

Examples of Interoperability Success

HealthEdge^®, a leading enterprise solution provider for payers, is fully prepared to guide its more than 100 payers who depend on HealthEdge solutions, including HealthRules^® Payer (core administrative processing system), GuidingCare^® (care management), HealthEdge Source (prospective payment integrity), and Wellframe (digital member engagement), to not only be compliant with emerging interoperability regulations but also leverage its highly interoperable systems to improve member outcomes, reduce cost and administrative waste, as well as deliver exceptional member experiences.

Payers can use the HealthEdge solutions as standalone next-generation software or deploy them as an integrated platform of digital solutions. Here are a few examples of how HealthEdge solutions help payers leverage their highly interoperable systems to achieve considerable success.

The HealthRules Payer Core Administrative Processing System (CAPS):

Dramatically reduces costs and administrative waste by delivering 90%–97% first-pass auto-adjudication rates and 99%+ accuracy. It opens the door to new value-based reimbursement models, benefit plans, and provider contracts and provides business insights that improve outcomes, lower costs, and increase transparency.

GuidingCare:

With 75+ unique vendor integrations, 12 productized integrations, and 75 API endpoints, GuidingCare offers payers a comprehensive solution for achieving interoperability within care management and across the healthcare ecosystem. By embracing such platforms, health plans can bolster their care management strategies, align with evolving industry demands, and ultimately provide better experiences and outcomes for their members.

Care-Payer Integration:

This unique pre-integrated solution that combines the power of HealthRules Payer and GuidingCare provides the API-based integration that enables the continuous management of member care and core administrative processes, further demonstrating how interoperability plays a big role in successful care management strategies.

Payer-Source Integration:

The integration between HealthRules® Payer and HealthEdge Source creates operational efficiency and accuracy in claims pricing and editing, which improves payer-provider relations and member satisfaction. Source is the first digital prospective payment integrity solution to natively bring together claim payment automation with proactive business intelligence, enabling payers with Medicare, Medicaid, and commercial lines of business to have better relationships with providers, reduce waste, and improve their financial performance.

Looking Ahead

As we look ahead to 2024, providing transparency, reducing costs, creating seamless and efficient care coordination, and improving health outcomes are the backbone of the CMS Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P), requiring payers to continue to integrate system functions and coordinate across the healthcare ecosystem in 2024.

Those payers who embrace modern, highly interoperable solutions and a solid digital transformation platform, like HealthEdge, are uniquely positioned to succeed when it comes to interoperability mandates and delivering higher quality, member-centric care, and services.

To explore how HealthEdge® can help you create transformational consumer experiences, deliver payer business agility, and accelerate your digital health payer strategy, visit www.healthedge.com.

 

While 2023 marked one of the most active regulatory years in recent history for the healthcare industry, 2024 is shaping up to be equally as challenging as many of the recent changes impacting payers kick into full gear in the new year.

The driving force behind many of the regulatory changes is CMS’s push to accelerate the digital transformation of the health insurance industry, similar to what CMS did nearly 15 years ago with the acute and ambulatory provider segments with the Health Information Technology for Economic and Clinical Health (HITECH) Act. Let’s take a closer look at five major regulatory requirements that are sure to keep payers on their toes in 2024.

1. Transparency in Coverage

Originally announced in 2020, the Transparency in Coverage Act has continued to expand in scope and reach over the past several years. As of January 1, 2022, payers were required to make pricing data on all items and services, for both in-network and out-of-network providers, made available in a format that computers could read, called Machine Readable Files (MRFs) free of charge. In 2023, CMS mandated that cost-sharing information be made available. By January 1, 2024, payers must provide cost-sharing information for all items and services available to members.

Transparency in coverage was a heavy technical lift for many payers. But those who are on more modern core administrative processing systems (CAPS), like HealthRules^® Payer, have been able to leverage HealthEdge’s APIs and tools, such as the company’s Price Comparison Tool, to meet the regulatory requirements with ease.

Transparency in coverage was a heavy technical lift for many payers. But those who are on more modern core administrative processing systems (CAPS), like HealthRules^® Payer, have been able to leverage HealthEdge’s APIs and tools, such as the company’s Price Comparison Tool, to meet the regulatory requirements with ease.

Making pricing data available in a consumer-friendly format and driving engagement with members who want to “shop” can be viewed as both a challenge and an opportunity in 2024.

• The challenges center on making the data easy for the everyday person to search for and understand, and presenting an accurate, real-time picture of each specific member’s cost-sharing responsibilities. For example, the system needs to say, “You are covered, and because it is a screening service, there will be no cost to you,” or “Because this is a diagnostic procedure, and because you have not met your deductible, there will be a cost of $X to you. There is a huge potential for members to become confused and highly frustrated, driving more calls to the support centers and contributing negatively to member satisfaction. Payers who depend on HealthRules Payer and HealthEdge Source benefit from an integrated solution called Payer-Source that delivers higher levels of accuracy because the responses are based on the negotiated rate and the claims data instead of just the negotiated rate.
• For forward-thinking payers, this creates endless opportunities to strengthen member engagement with those coming to their websites and member portals to “shop.” In 2024, these payers will seek to optimize this online shopping experience to inform members of missed screenings and vaccinations, promote healthy behaviors, and encourage more member responsibilities, all contributing to HEDIS scores and Star ratings. HealthEdge products and services support the needs of the portal through the real-time ability to provide personalized cost-sharing data specific to the member’s benefit plan, benefits used, and provider(s) selected.

CMS Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule

While interoperability is not a new topic within the healthcare industry, a wave of proposed rules focused on facilitating the exchange of health data between patients, providers, and payers are proving to be formidable challenges for payers dependent on legacy or outdated technology. The proposed rule focuses on the following:

Establishing data exchange standards among patients, healthcare providers, and payers:

• • According to CMS, the proposed policies in this rule will enable improved access to health data, supporting higher-quality care for patients with fewer disruptions. These policies include expanding the current Patient Access API to include information about prior authorization decisions, allowing providers to access their patients’ data by requiring payers to build and maintain a Provider Access FHIR API, to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship; and creating longitudinal patient records by requiring payers to exchange patient data using a Payer-to-Payer FHIR API when a patient moves between payers or has concurrent payers.HealthRules Payer customers can use the advanced set of APIs from HealthEdge to comply with the final rule. Plus, for Medicare Advantage plans, advancing interoperability leads to visibility and exchange of data, which can result in strategies for better outcomes and lower costs, leading to improved Star Ratings.

Improving the prior authorization process through policies and technologies:

• • The rule requires payers to implement an electronic prior authorization process, which will shorten the time payers can take to respond to prior authorization requests and establish policies to make the prior authorization process more efficient and transparent. The rule also supports the development of standards that payers will follow when exchanging data, making it easier to ensure complete patient records are available when transitioning between payers.The mechanism the rule uses to enforce the mandate will be APIs. More specifically, the proposed rule will require health plans to use a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorizations. By providing standards that all health plans must use, it is likely that in the long run, the rule will be more effective. HealthEdge’s robust API enables payers to meet all the interoperability standards and facilitates adherence to emerging prior authorization requirements.

2. Advancing health equity and improving access to care:

CMS recently released an updated framework, called CMS Framework for Health Equity, for further advancing health equity, expanding coverage, and improving health outcomes for its more than 170 million individuals supported by CMS programs. The framework sets the foundation and priorities for CMS’s work, strengthening its infrastructure for assessment, creating synergies across the healthcare system to drive structural change, and identifying and working to eliminate barriers to CMS-supported benefits, services, and coverage. There are five health equity priorities that CMS has stated for this new framework that is focused on reducing health disparities:

• Expand the Collection, Reporting, and Analysis of Standardized Data
• Assess Causes of Disparities Within CMS Programs and Address Inequities in Policies and Operations to Close Gaps
• Build Capacity of Health Care Organizations and the Workforce to Reduce Health and Health Care Disparities
• Advance Language Access, Health Literacy, and the Provision of Culturally Tailored Services
• Increase All Forms of Accessibility to Health Care Services and Coverage:

Previously, the health detriments and outcomes data primarily included geography/zip code and gender. Now, requirements include capturing and measuring health equity data such as gender, race, ethnicity, sexual orientation, gender identity, social, economic, and geographic area.

CMS strives to improve its collection and use of comprehensive, interoperable, standardized individual-level demographic and social determinants of health (SDOH) data, including race, ethnicity, language, gender identity, sex, sexual orientation, disability status, and SDOH.

Payers who depend on HealthEdge’s GuidingCare care management platform are already capturing this information to get a more holistic view of their members. Others who are using outdated technology will continue to struggle.

3. No Surprises Act

Introduced in 2021, the No Surprises Act was designed to protect consumers against surprise medical bills from out-of-network providers and high health plan cost-sharing policies. It has evolved over the past several years, and that trend will continue in 2024. In fact, on October 27, 2023, a rule was released proposing new processes and policies related to the Federal independent dispute resolution (IDR) process operation. This proposed rule would serve to expedite the processing of disputes by certified IDR entities. Read the Federal IDR Process Operations Proposed Rule to learn more about the proposed requirements. A fundamental piece to avoiding surprise billing is the ability for payers to maintain complete and up-to-date provider data directories. HealthEdge is delivering on its commitment with its new Provider Data Management solution (PDM).

4. Changes in Star Ratings for Medicare Advantage Plans

According to a 2023 article in Modern Healthcare, “Earlier this year, the Centers for Medicare & Medicaid Services (CMS) announced several changes to Medicare Advantage that will take effect in 2023. The changes aim to advance CMS’s vision for health equity, drive comprehensive, person-centered care, and promote Medicare affordability and sustainability. They include updates to Medicare Advantage capitation rates, Part C and Part D payment policies, and Star Ratings.”

Changes in the way Star ratings are calculated are of particular interest to health plans because Star ratings are directly tied to CMS bonuses payments and incentives. They are designed to reflect the quality of care a health plan delivers, and a large portion also reflects a patients’ experiences with health plans. By doubling the weight placed on the member experience for Star ratings, CMS is encouraging payers to focus on improving the member experience.

Data collected in 2024/2025 will greatly impact 2027 Star Ratings. With HealthRules Payer, payers can run modeling in 2024 to project their 2027 outcomes and develop corrective adjustments. The combination of HealthRules Payer and Guiding Care, along with the open APIs on the HealthEdge platform, provides payers with a comprehensive platform that can help them identify necessary adjustments that must be made now before these new calculations take effect.

More details of the Star rating changes planned in 2024 can be found in this fact sheet posted on the CMS website.

The Bottom Line

Regulatory trends will continue to push payers to accelerate their digital transformation journeys in 2024. Modern technology solutions from HealthEdge, along with the company’s dedicated team of regulatory specialists, are helping more than 100 payers to prepare for and optimize these regulatory changes to create competitive advantage and greater business insights.

To learn more about HealthEdge, visit www.healthedge.com.

 

In today’s rapidly evolving healthcare landscape, payers face a multitude of challenges. From rising healthcare costs to the increasing complexity of managing diverse member populations, the need for effective solutions to optimize healthcare delivery and control costs has never been greater. Combine that with the growing demand for a more individualized, patient-centric approach and payers actively seek ways to find the right balance.

That’s where population health software solutions come in – powerful tools that help payers address these challenges head-on. When leveraging modern population health solutions, payers can expect the following seven business advantages:

1. Improved Data Management and Analysis:

One of the key advantages of population health software is its ability to aggregate and analyze vast amounts of healthcare data. Payers can harness this capability to gain deeper insights into their member populations, identifying trends, patterns, and risk factors. This comprehensive view of data allows payers to make informed decisions, such as developing targeted interventions, forecasting healthcare utilization, and allocating resources effectively. It also gives care managers the ability to deliver more personalized care plans that address the specific needs of members, especially those at risk for costly complications from chronic diseases.

2. Enhanced Care Coordination:

Effective care coordination is essential for improving patient outcomes and reducing costs. Population health solutions facilitate better communication and collaboration among healthcare providers, enabling seamless coordination of care plans. Payers can leverage this advantage to ensure their members receive the proper care at the right time, reducing unnecessary hospital admissions and readmissions. For example, the GuidingCare^® Population Health Management module incorporates gaps-in-care analytics that enable clinical staff to identify high-risk patients and potential health improvement opportunities.

3. Risk Stratification and Predictive Analytics:

Population health solutions employ advanced algorithms to stratify members based on their health risks and needs. By categorizing members into risk tiers, payers can prioritize interventions for high-risk individuals, ultimately reducing costs associated with chronic conditions and preventable hospitalizations. Predictive analytics can help payers anticipate future healthcare trends and allocate resources accordingly.

4. Enhanced Member Engagement:

Engaging members in their healthcare is critical to improving health outcomes. Population health software provides payers the tools to create personalized health plans, offer wellness programs, and send targeted health information to members. Modern population health solutions can easily exchange information with member engagement solutions. For example, the GuidingCare care management platform is enhanced with the capabilities of Wellframe, a digital member engagement platform also from HealthEdge. Payers earn members’ trust by delivering a more personalized and compelling member experience. They can amplify and scale member support, access real-time member insights, unify the member experience, and consolidate staff workflows.

5. Efficient Claims Processing:

Streamlining claims processing is essential for reducing administrative costs and improving overall efficiency. Population health solutions, like GuidingCare’s Population Health Management module, often integrate with existing claims management systems, enabling payers to identify potential billing errors, fraud, and waste more effectively. For example, Care-Payer, the productized data exchange between HealthEdge’s core administrative processing system, HealthRules® Payer, and its care management platform, GuidingCare, enables the continuous management of member care and core administrative processes between the platforms. Care-Payer gives staff, care managers, and providers unparalleled access to near-real-time benefits information. Upon submission of the authorization in GuidingCare, users are assured that the authorization will flow through HealthRules Payer without error.

6. Compliance and Reporting:

The healthcare industry is heavily regulated, with numerous reporting requirements and quality measures to meet. Business intelligence capabilities within modern population health solutions can automate tracking and reporting these measures, ensuring that payers remain in compliance with government and industry standards. This reduces the risk of penalties and demonstrates a commitment to quality care.

7. Cost Savings and Revenue Generation:

Ultimately, the goal of any payer is to control costs while maintaining or improving the quality of care and member experiences. Population health software solutions enable payers to identify cost-saving opportunities, such as reducing hospital readmissions, preventing unnecessary tests and procedures, and negotiating favorable contracts with healthcare providers. Additionally, by improving member satisfaction and engagement, payers can potentially attract new members and generate additional revenue.

Population health software solutions have become critical tools for payers seeking to navigate the complex healthcare landscape effectively. Payers can control costs and improve the health and well-being of their members by harnessing the power of data analytics, care coordination, risk stratification, and member engagement. As healthcare continues to evolve, population health software will remain a critical component of payer strategies for delivering high-quality care while maintaining financial sustainability.

To learn more about GuidingCare population health management solutions, visit www.healthedge.com.

 

Optimization: Go-Live is just the Beginning

It can be easy to implement a new platform and think, ‘Phew! Glad that’s over’. But in the world of digital transformation, it’s a journey, and Go-Live  is not the destination.

Build continuous optimization into your plan. We always recommend an annual optimization assessment where we have a team of SMEs sit with you and evaluate how you use the product. From that evaluation, we identify recommendations to improve workflows, take advantage of new features, and add integrations or automation to remove manual or time-consuming activities. In addition, planning for upgrades enables you to stay current on the platform, giving you more features to drive your business to continuous improvement.

Follow these optimization best practices and avoid these common pitfalls:

Optimization Top 3 Best Practices

1. Adopt a Strategic Operating Model

Plan to move from Project Governance to a Strategic Operating Model with your ecosystem partners. Share your roadmap with HealthEdge so that we can consider the best ways to support your success and ongoing growth plans.

2. Annual Optimization Assessment

Plan for an annual optimization assessment. Evaluate how you are using the solution and develop a set of recommendations designed to drive optimization. Software improves, business evolves, and your needs may change. Adopt a continuous improvement approach to the operation.

3. Quarterly Business Reviews

Conduct quarterly business reviews (cross functional with CSE, Services and Product leadership). Maintain tight alignment of business and product roadmaps, upgrades, enhancements, and support needs. Consider any blockers to your success and how we can help remove them in the upcoming quarter. Set partnership goals to ensure the best path to success.

3 Common Optimization Pitfalls

1. Disbanding the “Project”

The project completion is just the beginning. Don’t stop fostering partnerships and influencing roadmaps. Don’t adopt an implemented and “done” mentality. Continue to use our partnership to meet your goals through consulting or customization.

2. Diminishing Return on Investment

Don’t allow your investment value to decrease, your software to get outdated, or your teams to struggle. Be proactive rather than reactive.

3. Lagging Behind

Waiting too long to upgrade results in additional cost and effort. Don’t miss out on improvements requested by the customer base. Take advantage of our technical-only upgrades that can be completed in 4-5 months. Actively review release notes for features that may enhance your business and ask for help in identifying and implementing new features that fit your needs.

HealthEdge & Healthcare Payer Digital Transformation

By implementing the HealthEdge solutions you will transform your business and operations. Our solutions will automate your business workflows and seamlessly exchange  data in real-time across the ecosystem, allowing you to experience the business benefits of: 

• Improved End-User & Consumer Centricity
• Ever Reducing Transaction Costs
• Ever Increasing Quality
• Ever increasing service levels
• Business transparency

HealthEdge 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
• Healthcare Payer Digital Transformation: Optimize

 

Measuring your Success

Undertaking a healthcare payer digital transformation, such as migrating to a new CAPs or Care Management System is one of the biggest business transformations you might ever be involved in. With change and impact of this magnitude, it’s critical to constantly monitor the success of these changes.

This kind of change is a marathon, not a sprint. It requires ongoing measurement and optimization. Be prepared to measure your progress so you can quantify success and know when to pivot. To do this, organizations must identify what is important to them and set target goals.

Top 3 Measurement Metrics:

1. Legacy Benchmarks

Know your legacy KPIs. Consider initial KPIs to legacy such as transaction turnaround time, auto adjudication rates, authorization turnaround time, claims backlog, etc. Good questions to ask include:

• Are your auto adjudication rates better than your legacy rates?
• Are you getting better than average auto adjudication rates?
• Are you able to measure customer satisfaction and tie it back to specific improvements you’ve made? Such as faster access to information for your customer service teams or a better member portal.
• Have your authorization turnaround times improved?

2. Project Metrics During Implementation

Monitor project metrics weekly so that you can adjust proactively based on what your project is trying to achieve. Include KPIs to benchmark project metrics such as on time, on budget, in scope and employee satisfaction. If a project metric is go-live by end of year, that will affect project decisions such as adding additional scope or functionality that is not needed day 1.

3. Ongoing Quarterly Operational Metrics

Keep your metrics front and center. Use them to motivate the teams, adjust, and improve.

Top 3 Measurement Mistakes:

Don’t make these common mistakes:

1. Unable to prove it.

Take the emotion out of evaluating success. Stick to the facts. Don’t rely on ‘trusting your gut’. Determine how the metric will be calculated, how often and by whom.

2. Perception over Reality

Let the data tell the story, measure the project health and guide changes. If you miss the target, determine the reasons why and create an action plan to get you back on track.

3. Getting Complacent

Stay vigilant and adjust as needed. Your business will evolve – keep pace.

Sample Measurement Dashboard

Showcasing your KPIs on a dashboard is a quick and easy way to showcase your progress on your digital transformation journey and rally your team. Share it with the project team and wider organization to bring everyone along on the transformation journey.

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!