Author: HealthEdge

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

 

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.

 

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.