Month: March 2024

Change management is a complex process that involves stakeholders across an organization. It’s not just the technical aspects that matter, but how successfully health plan leaders educate and engage the teams that will be impacted by organizational change.

When it comes to implementing a technology solution, some leaders might overlook the human element—getting so caught up in the process and technological details that they forget about the people involved. Methods like the People Process Technology framework can help by encouraging health plans to identify the training, documentation, and skillsets the team will need to be successful. But there are other ways to set your health plan up for change management success.

To demonstrate effective change management, here are the stories of two different health plans as they implemented digital solutions.

What does change management success look like?

Our first example is a health plan that successfully implemented a digital solution and achieved a significant return on investment (ROI).

Health plan leaders identified their current processes and reviewed them alongside their employees to pinpoint opportunities to phase out manual, low-value tasks. To ensure they were making the best choice for their needs, stakeholders investigated multiple solutions. They included middle management in the decision-making process to ensure those who would use the system had a voice in its selection.

This health plan invested substantial effort into the design, testing, and training phases of their new systems. They went live on schedule, within scope, and on budget. This resulted in exceptionally high buy-in and an impressive return on investment.

What does unsuccessful change management look like?

The second example involves a health plan that did not achieve long-term adoption of their chosen digital solution.

In this case, a senior leader new to the organization selected a vendor based on their previous experience, and shared the expectation that the system would help cut costs and make their health plan more competitive. However, despite on-time and on-budget implementation, the project struggled to get buy-in and engagement from stakeholders. This lack of engagement led to an unwillingness to test the new platform and engage in training sessions.

Within two weeks of go-live, the system was abandoned because end users didn’t like the way the platform functioned or how it impacted workflows.

4 Steps to set your health plan up for change management success

There are a few key differences between the two health plans mentioned above. One plan focused on educating their internal teams and getting organizational buy-in, facilitating technology adoption and achieving ROI. The other plan allowed one person to take charge and implement changes from the top down without communicating or sharing information with their wider organization, resulting in low adoption and usage.

How can you develop a change management strategy that sets your health plan up for success? These are four recommendations based on experiences with our customer implementations.

1. Understand and support employees

Knowing the needs and capabilities of your team is crucial. Your health plan could find the perfect technological solution, but it won’t be successful unless you have organizational support. It is important to have clear, open channels of dialogue from the onset so stakeholders and users can understand the value of new technology solutions as well as what will be expected of them. This is a great opportunity to emphasize how the new technology can help automate low-value work and empower your team to accomplish higher-value tasks.

2. Focus on inclusion and transparency

Involve middle management in decision-making and foster transparency with regular updates and opportunities for participation. Getting buy-in from middle managers is essential to gaining widespread organizational support. Give your team an early overview and demonstration of the system as it’s being built and implemented—not when it’s fully formed. Showing the new solution to your team and engaging with them helps garner approval and improve adoption.

3. Answer the question, “What’s in it for me?”

Each member of your team needs to understand the personal benefits that the new solution will offer. By engaging with and educating employees on the new solution, you’re enabling them to have discussions about how they’ll be expected to use this new technology and the value it will bring to their roles. At HealthEdge, our Professional Services team can help facilitate transparency with our customers through continuous dialogue. We show your team how the new system functions and engage a larger group to understand the company’s perspective on the solution.

4. Establish a change management work stream

An important step is establishing a project work stream dedicated to change management. Doing so can help you understand where your health plan stands in onboarding and addressing challenges that surface along the way. It is important to engage with your employees and over-communicate. This can be achieved by using change management methodologies such as: engaging leadership, defining why change is necessary, communicating the vision, obtaining employee buy-in, and reporting progress. To be successful, your health plan must lean into change management—you know your organization best and can help set the trajectory for success.

Preparing for change in your organization

Change is an inevitable and necessary aspect of growth—especially in healthcare. We’ve seen which strategies work, and which don’t when it comes to implementing a new digital solution. Remember, the more you involve and support your team from the beginning, the more likely your digital solution will be adopted successfully.

Engage with your team, provide them with a clear understanding of what’s to come, and give them the resources they need to succeed, and you’ll have a team ready to leverage new digital tools and embrace digital transformation.

 

Medical claims go through a long process of pricing, editing, analytics, and payment. And it’s vital that health plans pay claims accurately, quickly, and comprehensively—the first time.

An integrated workflow management system like HealthEdge Source™ can centralize claims processing and facilitate payment accuracy by offering:

• Contract visibility
• Pricing tools and algorithms
• Analytics and benchmarking
• Custom and history-based editing
• Comprehensive audit trail
• Data modeling

The Data Reference module within HealthEdge Source brings editing and pricing capabilities together in one cloud-hosted platform. Payers get full-audit support and access to actionable insights that help improve payment integrity. Below are three ways a Data Reference tool can give your health plan a claims processing advantage.

Utilize clean, aggregated data from multiple sources

Keeping track of multiple payment schedules and maintaining their accuracy can be a challenge. The Data Reference feature within HealthEdge Source brings together the most up-to-date fee schedule information and is refreshed every two weeks—giving users one less manual task to remember and ensuring higher levels of accuracy. In 2023, the HealthEdge Source delivered more than 1,500 data updates to its users and made more than 350 updates to policy and pricing met—giving users one less manual task to remember and ensuring higher levels of accuracy. In 2023, the HealthEdge Source delivered more than 1,500 data updates to its users and made more than 350 updates to policy and pricing methodologies across all lines of business.

Data Reference delivers insights based on information such as:

• Medicare rates and prospective payment data
• CMS policies and statistics by provider, region, and system
• CMS provider rates and statistics
• ICD-9, ICD-10, and HCPCS codes

Adjust quickly to CMS updates and policies

Information about updated Centers for Medicare & Medicaid Services (CMS) policies and regulations is available in many formats and in multiple locations. Many of the documents containing key information are difficult to understand, and data is not easy to verify between documents. When it comes to provider rate data, for example, health plans have to cross-reference National Provider Identifier (NPI) and Online Survey Certification and Reporting (OSCAR) numbers to match providers and ensure accurate payments.

CMS is expected to make more than 600 changes throughout 2024. Make sure your health plan is ready to adapt to these changes right away. With the Data Reference tool, Source aggregates and aligns key data in a way that’s easier for payers to view, search, understand, and use.

Streamline fee schedule and contract management

When it comes to off-cycle payment updates, some health plans are forced to knowingly pay claims inaccurately because they don’t have the most updated payment information or internal resources to make timely updates. Prevent these issues from impacting your health plan by working with a payment integrity solution that gives you access to the most recent and accessible information—and see it all in one place.

Source users can update payment policy and pricing methodologies to improve fee schedule management, pricing transparency, and auditing. Instead of juggling multiple websites and documents, the information you need is gathered in a single view that allows users to sort data by region and other filters.

Adjust to policy changes, prevent payment delays, and improve provider relations at your health plan by using a payment integrity solution that gives you access to the most recent and accessible information. With the Data Reference tool, you can readily access essential payment information in an organized and searchable format.

 

No matter how much your health plan prepares for a new technology integration, unexpected changes often arise. Healthcare market dynamics are always shifting, and health plans must adapt with them. Developing risk mitigation strategies can save your health plan from falling behind in digital adoption and help you pivot to address changes faster.

It is critically important to leverage risk management best practices at the beginning of the process and throughout implementation to avoid and address potential risks. Based on my experiences with customer implementation, I’ve compiled a list of the most common risks health plans face—including successful risk management strategies we’ve applied.

1. Risk: Misaligned Expectations

Lack of engagement from key business & technology stakeholders may result in misaligned expectations.

Mitigation: Establish a formal Program Governance entity for the implementation to facilitate organizational and vendor communication.

Key executive stakeholders should be involved throughout the implementation and onboarding process—including provider representation. Engaging internal leaders helps to expedite decision-making and stay on schedule. If stakeholders are not part of the Program Governance group, your health plan runs the risk of losing organizational alignment.

Health plans can measure involvement and gauge buy-in by ensuring stakeholders are attending and participating in key strategic and educational meetings. How can your plan gain buy-in? Share the value the new solution will bring, and how it helps meet key performance indicators (KPIs). Establishing KPIs up front also helps your team understand how to best leverage the solution to meet their goals.

2. Risk: Delayed deliverables

Lack of scope management processes may result in scope-creep, delayed deliverable completion, missed business milestones, and increased costs to the overall program.

Mitigation: Implement a formal change control process, including a Change Control Board, to review and evaluate all proposed changes to assess their impact on the program timeline, budget, and business objectives.

Every step of the process should be directly tied to achieving key business goals. When a request arises, ask, “Is this a necessary capability, or is it a request based on a legacy concern?” Your plan can also provide a channel to help expedite and escalate critical changes requiring Program Governance reviews and approvals as needed. Implementing a new solution is complex—to keep the process manageable, start by solving the most widely applicable issues and fine tuning for new markets later.

3. Risk: Digital interoperability

Integration issues within the Enterprise ecosystem (such as system compatibility & readiness, solution selection, data quality & exchange, or missing capabilities) will impact end-to-end system verification and operational readiness.

Mitigation: Define integration requirements early in the planning phase and follow test-driven development practices with iterative delivery for early, ongoing cross-solution validation.

During program start-up, identify vendors and solutions that will work with and support the use of the enterprise ecosystem. Even with an integrated solution suite, your health plan will need to utilize third-party technology. Third-party testing and integration after implementation can cause delays and reduce functional efficiency. Reduce this risk by fully testing data exchange and other key digital interactions before go-live.

4. Risk: Undefined objectives

Lack of operational objectives without defined measurement will lead to competing or disconnected business stakeholders within the organization, leading to a failed implementation.

Mitigation: Define KPIs for your organization and the new solution at the beginning of the process so your organization knows what to aim for.

Once you’ve defined organizational objectives, regularly monitor your progress toward these new metrics. This makes it easier to identify when you’re getting off-track and adjust quickly to support your business objectives. As you implement the new ecosystem, continue to monitor KPIs for opportunities to optimize usage and performance to get the most value.

Risk management is a necessary part of implementation and is a dynamic process—risks change throughout the implementation and go-live process. To stay proactive, health plans must develop and maintain risk management strategies to stay on schedule and on budget.

Whether your health plan is replacing an existing CAPS solution or launching a new enterprise product to support an emerging market opportunity, implementation challenges will arise. By applying Risk Management best practices, like assessing potential enterprise blockers from the start and having documented mitigation plans, the chances of a successful implementation are in your favor.

 

 

 

 

 

“Healthcare organizations face increasing complexity in reimbursing care with value-based payments, self-funded business and more; however, claims-pricing software remains largely stagnant. U.S. healthcare payer CIOs need to procure claims-pricing software that addresses this complexity.”

— Gartner® “How U.S. Healthcare Payer CIOs Handle Effective Claims Pricing” Austynn Eubank, 5 December 2023

Complexity can be found everywhere you look in the healthcare industry today. But never before has there been so much pressure on payers to respond to providers’ rising expectations for timely and accurate payments while also addressing members’ rising expectations for more personalized and flexible benefit plans. 

When you combine these pressure points with the industry’s shift toward value-based care models, the growth in self-funded employer contracts, and evolving Medicare Advantage Star Ratings criteria, it’s easy to see how payers can become overwhelmed by the complexities of accurate and timely payments.   

In an attempt to address these challenges, payers have stacked claims editing and pricing solutions on top of each other, but many have found that their antiquated systems are creating more problems than solutions. In fact, in a HealthEdge research report, 90% of payers depend on two or more payment vendors. However, many of these systems do not afford the flexibility that is necessary to support payers’ ability to meet rapidly evolving provider and member demands.   

It’s Time to Reevaluate Claims Pricers 

“U.S. healthcare payer CIOs advancing healthcare digital optimization and modernization should: Build flexibility and efficiencies into the claims adjudication process by leveraging modular, cloud-native and API-first platforms for claims processing, pricing and editing that support members’ and providers’ needs.” — Gartner® “How U.S. Healthcare Payer CIOs Handle Effective Claims Pricing” Austynn Eubank, 5 December 2023 

Flexibility is the name of the game, especially for payers with multiple, state-managed Medicaid contracts, unique self-funded arrangements, or wide provider networks that require more flexibility and fee scheduling capabilities.  

HealthEdge Source™ (Source) delivers the flexibility today’s payers need to address complex provider contracts and multiple fee schedules, ensuring that payers can meet the needs of their providers while also optimizing operational efficiencies.  

How it Works 

With Source, payers can combine dynamic configuration capabilities with a smart hierarchy structure to reduce the overhead of maintaining and updating contracts. Source also automatically supports the consistency of terms across provider contracts without jeopardizing the unique requirements of each contract.  

Several health plans that have implemented Source have benefited from a 90% reduction in the number of managed configurations, leading to faster times to contract, more accurate payments, and less provider abrasion.  

A Flexible Future For Claims Pricing Solutions

As payers work to implement more flexible claims pricing solutions that can accommodate today’s fee schedule complexities and rising provider demands for more timely and accurate payments, Source delivers a modular, cloud-based solution supported by a robust set of APIs that can connect to any existing CAPS via a single instance. As a result, payers can develop more collaborative and trusting relationships with their provider networks that ultimately lead to better member outcomes and lower operating costs.  

To learn more about how HealthEdge Source can help your organization meet the evolving demands for more timely and accurate claims payments, visit www.healthedge.com.  

1Source: “How U.S. Healthcare Payer CIOs Handle Effective Claims Pricing” Austynn Eubank, 5 December 2023.  

GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved. Gartner does not endorse any vendor, product, or service depicted in its research publications and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner’s research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose. 

  

In a recent Becker’s podcast, Steve Krupa, CEO of HealthEdge, and Ryan Mooney, EVP and General Manager of Payment Integrity at HealthEdge, discussed the transformative role of technology and transparency in payment integrity practices. The leaders reviewed how traditional payment integrity solutions often operate retrospectively, identifying and recovering erroneous payments after they have been made. This reactive approach can lead to inefficiencies, provider friction, and higher costs.

In contrast, Krupa and Mooney revealed how HealthEdge’s prospective payment integrity solution, HealthEdge Source™, aims to correct errors before payments are made, emphasizing the importance of accuracy and efficiency from the outset. This forward-looking approach reduces the need for costly post-payment recoveries, minimizes provider abrasion, and improves payer-provider relationships.

From Black Box to Open Book

A key innovation of HealthEdge Source is its departure from the industry’s “black-box” methodology, where payment integrity processes are opaque, and solutions are proprietary, to an “open book” philosophy. This transparency lets payers see precisely where and how errors occur, facilitating root cause analysis.

The first solution to bring together contract configuration, reimbursement, editing, and analytics, HealthEdge Source provides the tools payers need to in-source capabilities to make real-time corrections—completing a virtuous cycle of payments.

This shift enhances operational efficiencies by empowering payers with the information they need to correct any process errors further upstream before the claim is paid. It also fosters a more collaborative environment between payers and providers, ultimately contributing to a more transparent and effective healthcare system.

The Payment Paradigm

• Post payment: You’ve already made a mistake, and the claim gets paid, leading to excessive recoupments and provider abrasion.
• Pre-payment: Let’s catch the mistake before it leaves the door, but its root cause is unknown.
• Prospective payment integrity: You can identify the root cause of the mistake and correct the issue to avoid the mistake entirely in the future.

The Solution to Payment Integrity: Payment Accountability®

Payment integrity transformation can inform various aspects of a payer’s organization enterprise wide. While traditional payment integrity solutions provide a quick fix to problems, HealthEdge Source delivers Payment Accountability with software that creates transparency to address root cause inaccuracies so payers can pay claims accurately, quickly, and comprehensively the first time.

With HealthEdge Source advanced analytics and machine learning algorithms, payers have the tools needed to identify and prevent payment errors. The cloud-based platform can quickly analyze large amounts of data from multiple sources to identify patterns and anomalies that may indicate payment errors and proactively correct them.

Here are a few examples of how HealthEdge Source also helps payers go beyond claims accuracy to gain greater insights and make more informed decisions.

• Retroactive change management identifies claims impacted by retroactive changes and reprocesses them, which helps improve provider satisfaction and performance during audits.
• Predictive Policy Modeling monitors any new payment policy edits before they are put into production to determine the impact prospectively. This enables health plans to make appropriate business decisions and improve provider-payer relationships.
• Contract Modeling enables a transparent analysis of the performance of contract changes or conversions to new contracted payment methodologies before implementation with a plan’s providers.

HealthEdge Source was recognized in the 2023 Gartner^®  Hype Cycle™ as a Representative Vendor for Prospective Payment Integrity Solution Category. From 2019 to 2021, HealthEdge was recognized as Burgess Group in the Gartner Hype Cycle for Payment Integrity (PPI) Solutions category. HealthEdge acquired Burgess Group in August 2020.

To learn more about how HealthEdge Source can help your organization get out of the black box and embrace an open-book approach to payment integrity, visit www.healthedge.com.

Gartner, Hype Cycle for U.S. Healthcare Payers, 2023, Mandi Bishop, Connie Salgy, Austynn Eubank, 10 July 2023

GARTNER and HYPE CYCLE are registered trademarks of Gartner, Inc. and/or its affiliates in the U.S. and internationally and are used herein with permission. All rights reserved. Gartner does not endorse any vendor, product or service depicted in its research publications, and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.