Finding New Ways to Deliver Care, While Controlling Costs

Existing fee-for-service payment models are not scalable. Across the industry, there is an increasing emphasis on finding ways to deliver quality care while controlling costs. Health plans are transitioning from those older arrangements to new types of value-based reimbursement. There is a wide variety of effective value-based arrangements; this shift requires health plans to have the flexibility to negotiate, test, and implement a variety of payment models with more science and data behind them.

Especially on the national level, we’re seeing a conversion to using Medicare as a benchmark to make more informed decisions because it has one of the most robust data sets. For example, a health plan may use that as a reference point and decide to pay a specific percentage of Medicare, and then create some additional benefits for maternity care, different types of rehab, or cover more dental services or vaccines, among other things.

National payers need access to real-time data to find the best way to structure agreements that support their goal of providing quality care while keeping costs low. They require technology with the business intelligence tools to model and forecast different pricing scenarios, customizations, and edits to see the best way to transition from fee-for-service to value-based care reimbursement.

When taking a value-based approach, it’s crucial for health plans to have all of the information up-front and understand the impact of specific determinations on their providers. The ability to model arrangements using existing claims and run reports before putting them into place allows health plans to make informed business decisions and have better conversations and negotiations with their provider network.

The shift to new reimbursement models does not have to be contentious and can benefit all stakeholders. We’ve worked with several clients to transition to new arrangements where they can realize the cost savings while also still doing right by their providers.

Cloud-Based Solutions Improve Efficiency

Industry consolidation is one of the biggest trends in the payer space right now. National health plans might acquire other regional plans or enter a new line of business, resulting in multiple claims systems and different point solutions. The challenge is, how do they serve their core mission with technology that isn’t necessarily made to work together?

There are dozens of steps in the claims processing workflow, and they may all use different software solutions. Suppose a health plan uses a specific solution for pricing, another for grouping and another for editing. In that case, all those applications could update at various times and communicate results differently, putting strain on internal resources to manage the workflow. And if something goes wrong, it’s incredibly challenging to pinpoint where the error occurred.

Health plans want to improve operational efficiency, but they will not get the desired outcomes with different point solutions and applications from separate vendors.

Health plans need a single solution with real-time data and analytics that provides cloud-based delivery of regular updates to ensure they have all the correct information. Take Medicare and Medicaid, for example; at any given time, something is updating somewhere in the country. Health plans need to be aware of the changes and have those codes up to date across all of their solutions.

Without a cloud-based solution, health plans need to figure out all of these changes independently, manually make updates, and manage the software on their own.

Cloud-based solutions, however, have the ability to remotely deliver updates to payment policies as they occur, arming health plans with the most up-to-date information needed to process claims accurately and efficiently. With a single instance of a solution that includes all the business rules on top of it, the entire health plan will have the updated information, no matter where they are calling it from across the whole ecosystem.

Partnerships that Drive Quality Care and Improve Patient Outcomes

Like any other organization, communication is crucial for health plans to serve their mission: deliver the best care for their members and improve health outcomes.

Every day, members with healthcare concerns work with their health plans; it is an incredibly personal, human interaction. While technology vendors like us do not interact directly with members, it’s important that we keep the human element at the forefront of our minds and focus our efforts on making the healthcare experience a better one.

One way we do this is by considering time as a critical factor when it comes to a member’s care. Health plans understand that they must treat health-related questions from their members with the same urgency their members feel. Working together, we help our payer customers leverage technology that can increase efficiencies, improve transparency with providers, and enable solutions that quickly meet a member’s healthcare needs.

As a technology partner for payers, it’s crucial that we’re precise and our documentation is clear. We also must communicate the right messages and information to the right people and always give notice of upcoming industry changes or other things that might impact our clients’ workflow. Sharing this knowledge allows health plans to prepare and make informed decisions for their business while providing efficient customer services that their members expect.

Our partnership approach was especially important over this past year when many people adjusted to working remotely, and regular communication became an additional challenge. Several of our clients, particularly in Q2 of last year, got pulled into different workgroups and tried to figure out how best to handle COVID-19, plan for additional changes, and keep the business moving forward amidst the chaos.

COVID-19 was just one example of how quickly things can change. While health plans grapple with becoming more agile, technology vendors, too, must anticipate change, adapt, and accommodate evolving customer needs. We value our client relationships and know that maintaining a strong, supportive partnership will ultimately help our health plan customers navigate uncertainty so that they can stay focused on their mission.