Author: HealthEdge

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.

 

Each year, HealthEdge conducts an extensive nationwide survey of the healthcare payer market in the United States. This survey serves as a valuable compass for health plan leaders, providing insights into the industry’s evolving challenges and opportunities.

The latest HealthEdge Annual Payer Market Report presents a fascinating picture of how technology is both the biggest challenge and the greatest ally for health plan leaders in the coming years. Let’s dive into the key findings from this report, shedding light on the role of technology in the healthcare payer landscape.

The Audience

This year’s survey garnered responses from over 350 health plan leaders and executives, representing diverse functional areas of the business and encompassing all types and sizes of health plans. Their collective insights offer a comprehensive view of the healthcare payer market.

The Dominant Themes

Throughout the survey, several dominant themes emerged, illustrating the impact of technology on the healthcare payer industry. These themes directly reflect the mounting pressures that payers are experiencing from multiple angles:

Evolving Regulatory Landscape:

Regulatory requirements are evolving at an unprecedented pace, aiming to address long-standing industry challenges such as cost, transparency, and value. Payers are required to adapt to these transformative regulations swiftly. To do so effectively, they must establish flexible and open technology systems.

Consumer Demand for Personalization:

Healthcare consumers today demand more personalized engagement and greater transparency, influenced by their modern retail experiences. Health plans must incorporate omnichannel communication capabilities to meet these consumer expectations.

Emerging Non-traditional Competitors:

Innovative, non-traditional competitors with tech-forward strategies continue to emerge, placing pressure on payers to excel in new member acquisition and member/provider satisfaction. System agility and high interoperability provide payers with a competitive advantage in this ever-changing landscape.

Workforce Challenges:

Workforce shortages and high turnover rates compel payers to automate their business processes further, empowering their current staff to achieve more with less. Modern solutions facilitate ease of use and higher levels of automation, ultimately reducing dependencies on manual resources.

Growing Complexity in Payment Models:

Changing payment models, such as value-based care and risk-sharing arrangements, contribute to the growing complexity of claims processing, performance measures, and plan configurations. Modern technology is pivotal in navigating these complexities efficiently.

Cost Management:

Managing costs has consistently been a top challenge for health plan leaders; this year is no exception. As business complexities increase, so do administrative costs. Leaders are focusing on strategies such as improving the financial accuracy of claims and increasing auto-adjudication rates to minimize costs.

Three Key Findings

1. A notable 62% of health plan leaders consider investing in modern technology for digital transformation as the number one way to achieve organizational goals in the new year.
2. Increasing interoperability across the healthcare ecosystem stands out as a promising strategy to reduce administrative costs, emphasizing the importance of seamless data sharing and efficient workflows.
3. Achieving alignment between IT and business ranks as the most significant challenge for health plan leaders, necessitating the adoption of modern solutions that support business agility. Other top challenges include:
   • Addressing workforce shortages and burnout
   • Facilitating business growth through membership growth, acquisitions, and market expansion
   • Managing costs by improving the financial accuracy of claims and increasing auto-adjudication rates to reduce administrative expenses
   • Improving member satisfaction by providing personalized communication capabilities in a landscape of expanding consumer choices
   • Ensuring provider satisfaction through stronger payer-provider collaboration to successfully implement value-based care models

The Changing Role of Technology in the Healthcare Payer Market

Given the growing complexities and the industry-wide shift towards digital transformation, it comes as no surprise that health plan leaders unanimously agree on the pivotal role of modern technology in addressing their major challenges in the new year.

As leaders search for new technology solutions, the survey highlights the top criteria for evaluating and finding the right solution, listed in order of importance:

Modern technology capabilities:

Modern technology can better support the future needs of organizations, enabling payers to be flexible and agile and do more with fewer resources as the market evolves.

Access to real-time data and analytics:

Health plan leaders need seamless access to up-to-the-minute information through robust APIs. Real-time data and analytics empower them to adopt value-based care payment models confidently, strengthen member-provider relations, and meet regulatory requirements.

Ease of doing business and customer service:

Modern technology companies should demonstrate flexibility in their product offerings, contracting processes, and support services to truly become partners rather than just vendors, enhancing the ease of doing business and elevating customer service to new heights.

Hassle-free configuration, upgrades, and implementation:

Every payer organization has its unique digital transformation journey, business processes, and growth plans. Modern technology platforms offer greater flexibility and faster deployment of new features, making it easier for payers to adopt innovations. This ensures that the system can accommodate each payer’s unique configuration requirements.

Automation and efficiency:

Vendors should be able to demonstrate how their technology can facilitate end-to-end process automation. Operational efficiency becomes even more crucial as payers’ requirements continue to rise.

Looking Ahead in the Healthcare Payer Market

The HealthEdge Annual Payer Market Report clearly shows the healthcare payer industry’s transformation driven by technology. As the industry continues to evolve, payers recognize the critical need for flexible, responsive, and highly interoperable solutions to thrive in this dynamic and competitive market. Technology is not just an enabler; it is becoming a mission-critical growth driver for healthcare payers in the future.

Download the full HealthEdge Annual Payer Market Report to learn more about these findings and gain insights from industry leaders.

 

 

In today’s ever-evolving healthcare landscape, payers are constantly searching for the right balance of providing exceptional care while keeping costs in check. Care management platforms have emerged as a solution to address both sides of this equation. However, measuring the return on investment (ROI) associated with care management solutions is not easy, given the complexity of healthcare operations and the multifaceted nature of care management.

Care management teams are given a tall order: Provide the highest-risk members with the most complete, whole-person care plans possible, all with the expectation that these members will adhere to their care plan and experience better health outcomes at a lower cost of care. Care managers are feeling pressure from every angle, struggling to balance the expectations of all stakeholders, including providers and care team staff, member families, government entities, and the health plan that employs them.

The reality is that care management is hard work. Care managers often work with the most complex and challenging members who are often hard to reach. These populations are multidimensional, meaning psycho-social factors and social determinants of health are almost always in play. In order to deliver whole-person care successfully, they have to build trusting relationships with these members, which is easier to do with access to the right data or the right technology solutions that can bridge communication gaps.

From an operational perspective, coordinating care across multiple, siloed care settings and community services is also difficult since most systems don’t talk to each other, and care managers have to log into multiple disparate systems to find the information they need. These outdated care management solutions hinder care manager productivity and efficiencies as caseloads continue to rise.

The Role of Modern Care Management Solutions

Modern care management solutions like GuidingCare can address these challenges and help health plans quickly see a return on their investment through extreme operational efficiencies and total cost of care savings. Here’s how it works:

1. Enhancing Care Manager Efficiencies:

GuidingCare streamlines care management processes by automating routine tasks, enabling care managers to focus on high-value activities and reach more at-risk members. With real-time data access and intelligent workflows, care managers are always equipped with the most up-to-date information to make informed decisions. The result? Improved care manager efficiency, reduced administrative overhead, and measurable time savings.

2. Cost Reduction and Expense Management:

GuidingCare’s predictive analytics and care coordination capabilities help payers proactively identify at-risk members, supporting early interventions and reducing expensive hospitalizations and emergency room visits. The care management solution provides transparent cost tracking, making it easier for payers to accurately quantify cost reductions and expense management achievements.

3. Optimal Allocation of Services:

GuidingCare’s data-driven approach ensures that services are allocated based on individual member needs. Payers can now measure the direct impact of their care management efforts on quality of care and member satisfaction.

Achieving Meaningful ROI with GuidingCare

In conclusion, GuidingCare represents more than just a care management solution; it is a strategic investment that empowers payers to successfully navigate the complexities of healthcare. By delivering measurable results, GuidingCare is the key to achieving better healthcare outcomes and effectively managing costs.

To learn more about how GuidingCare care management solutions can help your organization improve care quality while reducing costs, visit www.healthedge.com.

Ensuring accurate claims payments can be difficult and fixing errors can be costly. And health plans face challenges throughout the payment process. Multiple rounds of editing, pricing, and review leave payment integrity pitfalls for your organization to fall into. A billion-dollar market has been built around detecting payment inaccuracies—and it continues to grow.

59% of organizations listed “in-sourcing payment integrity functionality” as a . While outsourcing aspects of payment integrity can help organizations scale their operations, it can also lead to loss of data visibility, increased operating costs, and reliance on contingency vendors.

How can your organization promote greater payment accuracy while reducing costs?

Here are three ways a payment integrity solution like HealthEdge Source™ can impact your health plan.

1. Combine pricing and editing capabilities in one place.

75% of organizations said it would be “very valuable” to Consolidating solutions can help improve efficiency by bringing key information together, rather than taking extra time gathering fee schedules from multiple locations.

HealthEdge Source users, for example, can leverage native content including CMS, Medicaid, and AMA policies in one place—without the need for additional integrations. Having third-party best-of-breed content available within a single resource enables health plans to gain greater visibility into the payment process and organizational inefficiencies.

2. Improve visibility and analytics

Enable analytics by bringing pricing and editing information—for claims across all lines of business—into one place. See top providers, DRGs, CPT codes, and other insights that make it easier to understand how new policies could impact your claims.

It can be easy to fall into a pattern of relying on a vendor to detect certain issues and patterns without diving deeper into why these errors occur. Leveraging a single solution can reduce administrative burden and reduce the opportunity for mistakes, such as inputting incorrect fee schedules. Instead of trying to pull data from multiple cap systems and present it together, your organization could gain visibility into the root causes of inaccurate payments.

3. Reduce IT burden

Some organizations have reported spending up to a week updating fee schedules in 6 or more places. Each of these platforms has different upload requirements and requires IT support. If IT can’t deliver help in time and there’s an error, then you’d have to rely on a vendor solution to catch it later in the workflow.

This is where bringing pricing and policies together is important. If your team is managing fewer solutions, they’re able to work more efficiently and with a deeper knowledge of the platforms they’re using. There will also be less demand for IT and other internal stakeholders to keep software and other technology up to date.

This is not to say contingency vendors can be beneficial. However, eliminating more straightforward issues like reoccurring overpayments can open the door for vendors to focus on solutions for new and more complex issues. Once your health plan has a single solution in place, your teams can identify leakage in the workflow, understand why it’s happening, and move that information upstream to the primary editing space to ensure more accurate reimbursements.

Shifting from multiple solutions to a single platform doesn’t have to happen all at once. To learn more about the HealthEdge Source payment integrity solution, visit our guide, “Beyond the Basics: The Modern Approach to Payment Integrity Vendors With HealthEdge Source.”

Read the guide