Author: HealthEdge

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.

 

Meet Janelle, a health plan member

Janelle has been struggling with knee pain ever since she sustained a basketball injury in college. Her finances are pretty tight, so when she finally decides to schedule a needed knee surgery, she is careful to make sure it is with a surgeon who is a participating provider in her health plan, YourHealth.

When it’s time for the surgery, Janelle checks in at Midtown Surgery Clinic, a participating facility and pays an expected co-pay. The surgery goes well and once the anesthesia wears off, she heads home to recover. Janelle does not anticipate any additional bills as she and her surgeon fulfilled all prerequisites of her coverage.

Prior to the No Surprises Act

Two months later, Janelle receives a $600 bill from Midtown Anesthesiology. After waiting on-hold with the clinic, then her health plan, Janelle finally speaks to customer service and learns that while her surgeon was in-network, the anesthesiologist was not. Now, she is responsible for a cost-sharing bill she can’t afford.

Behind the scenes, Janelle’s surgery results in multiple, separate claims to YourHealth. Midtown Surgery bills YourHealth for the surgery and Midtown Anesthesiology bills $600 for an anesthesiology service. During claim adjudication, YourHealth identifies the anesthesiologist as an out-of-network provider and processes the anesthesiology claim with out-of-network deductible and co-insurance responsibilities for Janelle, which results in her receiving the $600 bill.

This process takes over 60 days, leaving Janelle with a significant, unexpected bill that arrives months after a service she expected to be fully covered. The process leaves Janelle surprised, confused and angry with her health plan, the doctor, and the healthcare system in general.

She becomes disinclined to engage in the recommended follow-up services and may try to avoid everything but emergency services in the future.

After the No Surprises Act

Prior to the scheduled surgery, Janelle uses the price comparison tool through her member portal and easily confirms the cost of the surgery and what her cost sharing responsibilities will be.

Following the visit, the Midtown facility and physicians bill YourHealth for the surgery and a $600 anesthesiology service, minus the collected co-pay. The out-of-network anesthesiologist claim is processed applying in-network cost sharing, holding Janelle harmless from the higher out-of-network cost sharing amounts.

The facility and physicians who provided Janelle’s care send their service claims to her health plan. YourHealth, has prepared for No Surprises Act (NSA) compliance, leveraging the flexibility of HealthRules Payer to:

• Configure out-of-network claims using NSA criteria
• Auto-adjudicate the out-of-network claim appropriately using the Qualified Payment Amount for the service
• Populate price comparison tools with provider and member-specific details using HealthRules Payer’s Trial Claim Feature, so Janelle was able to get personalized cost information well before surgery.

Later that year, YourHealth negotiates a slightly higher contracted fee schedule with Midtown Anesthesiology–expanding their network and improving provider and member satisfaction. They continue to monitor evolving NSA rulings, knowing that with the flexibility of HealthRules Payer they can prepare for future rulings like those anticipated for advanced explanations of benefits (AEOBs)–using the Trial Claim Feature and existing explanation of benefits processes to generate individualized claims detail for anticipated services.

Janelle receives no additional bill and engages in important physical therapy follow-up. By continuing to engage in preventive healthcare and treatment, Janelle optimizes her health outcomes and reduces lifetime health costs to herself and her health plan.

No Surprises Act, Regulatory Compliance, & HealthRules Payer

HealthRules Payer from HealthEdge, is a modern core administrative processing system with existing features that support plans in maintaining regulatory compliance. Designed for easy configuration, HealthRules Payer gives health plans the tools and support they need to succeed, even as transparency regulations evolve.

Learn more about how HealthRules Payer gives plans the tools to succeed as the No Surprises Act and industry regulation evolves.

 

Health plans face complex and multifactored pricing and payment demands. With a robust and flexible platform like HealthEdge’s Source, plans can increase automation while working to optimize resource-intensive and manual processes like claims audits. This case study highlights one plan’s experience integrating Source with existing legacy technology and improving first-pass adjudication rates and efficiently managing claims audit and inquiry processes.

Challenges

HealthEdge® representatives recently talked to two members of the provider reimbursement team from a large non-profit health plan in the northeast. At the time of interview, the Plan was primarily using Source for pricing and reimbursement, leveraging the extensive library of pricing edits and bi-weekly updates that come standard with the Source platform. The conversation focused on two common and critical health plan challenges related to provider reimbursement. First, was the need for the Plan to replace an older tech platform while assuring the new platform would integrate with other legacy components of their tech stack. Second, was the need for the provider reimbursement team and other health plan system users to be able to audit claims and address ongoing retroactive claims inquiries from internal and external stakeholders.

Solution = HealthEdge Source

In 2021, the Plan began a phased implementation process, sunsetting an older payment and pricing platform and upgrading to Source. While Source is a modern payment integrity platform, the Plan was still working with a legacy core administration processing system (CAPS) and had concerns about platform integration especially given the significant complexity inherent in their hierarchical provider payment arrangements. Fortunately, Source has built-in integration with 10+ claims systems, ensuring that implementation wasn’t waylaid by key technology integration challenges. Source also offers hierarchical edit capabilities, enabling for example, the six different enterprise-level configurations overlaying mapping rules for 75 different rate configurations used just for one (Centers for Medicare and Medicaid; CMS) fee schedule at this particular health plan.

Not only was Source able to integrate with the Plan’s legacy CAPS system and accommodate complex hierarchical pricing configurations, but the integration and upgrade also led to a significant improvement in their first-pass claims adjudication rate. As noted by the Plan’s Reimbursement Initiatives Manager, prior to integrating their CAPS system with Source, their first-pass rate averaged about 80% and is now near 98% according to their CAPS measurement criteria. She noted that improvements are tied to both the Source product and the improved integration with their CAPS system, which has streamlined a variety of reimbursement processes.

“The overall end-to-end process was improved from the way it worked before, when we had to use robots, compared to how we’re using Source now… There are a lot of things we can do in Source now that we couldn’t do before.” – Health Plan Reimbursement Initiatives Manager

Retroactive claims inquiries and adjustments are another ongoing challenge for the Plan, particularly for providers who bill using a percentage of CMS fee schedules. CMS fee schedules are subject to ongoing policy updates and payment changes, but because only a small percentage of the Plan’s contracted providers use the CMS fee schedules, the Plan does not automatically make claims adjustments based on retroactive CMS change policies. Instead, issues usually come to their attention following a claims complaint or audit.

While the reimbursement team noted how helpful Source’s automated and bi-weekly updates are, they also noted that CMS release data gives limited information about when retroactive changes should impact reimbursement for specific types of providers. An example was when they received a complaint about 50 different claims payments across different hospital facilities that they contract with using the CMS fee schedules. In this situation, with multiple and dispersed claims issues, it was difficult to trace a payment change back to a specific CMS release.

The Reimbursement Initiatives Manager noted how critical Source’s audit feature is to address these types of provider complaints. It enables her to download relevant claims from the production to the pre-production environment and reprocess them, compare the two side-by-side, and identify changes like a capital payment amount or wage index change, that could drive such dispersed claims complaints.

“One of the best features of Source that I love is the ability to download a claim from one environment to another environment. That’s very handy.” – Health Plan Reimbursement Initiatives Manager

It is easy to see how this regional plan serves to benefit from this type of automation, and this addition may be a next step on their payment integrity journey. But Source is designed to support plans at all stages, and the audit feature (one of the Plan’s most widely used Source features) enables the Plan to meet their retroactive claims inquiries and audit needs manually. Source’s audit feature is critical for the Plan’s customer service team members who access claims detail to answer questions from providers and members, and for the audit team who hold claims audit responsibility. Further, the provider reimbursement team regularly uses the audit feature to respond to inquiries from Plan leaders.

For example, the Reimbursement Initiatives Manager was recently asked to explain to the Plan’s leadership team how ambulance services (a particularly expensive line-item for plans), are priced by CMS. It was easy for her to use Source’s audit feature to search for hospital outpatient provider type, filter by an ambulance code to narrow down the results, then find examples of claims that contained the ambulance code. With this information, she was able to provide a detailed response to Plan leadership about how CMS reimburses those ambulance services

Takeaways

• Pre-existing integration capabilities minimize challenges inherent in integrating new platforms with legacy tech stack components
• Optimizing automation will drive accuracy while minimizing resource-intensive and manual work and re-work for prospective and retroactive pricing changes
• Retroactive pricing updates aren’t going away; the right tool will enable plans to leverage robust audit features for inquiries and manual adjustments while considering more automated solutions
• Choosing an industry-specific tech partner like HealthEdge gives plans the support they need to optimize automation and accuracy despite the complexity of diverse pricing and provider arrangements

I have found the HealthEdge Source system to be very robust and flexible with regards to all of the different types of CMS and non-CMS based pricing methodologies that it offers.” – Health Plan Reimbursement Initiatives Manager

New data shows that states are struggling with the administrative components of redetermination. How did we get here, and how do we solve this problem?

Following the end of the COVID-19 public health emergency this spring, states began the process of redetermining which residents are eligible for Medicaid coverage. As of early this August, KFF reports that nearly 4 million Medicaid enrollees have been disenrolled based on data reported from 41 states and the District of Columbia. Further, the U.S. Department of Health and Human Services (HHS) projects that 15 million people will lose Medicaid coverage once redeterminations are complete.

As health plans adjust to this new reality, proactive measures must be taken to offset the reduction in Medicaid enrollment. The below list describes effective medicaid redetermination strategies that health plans can adopt to ensure continued coverage for vulnerable populations while maintaining their commitment to providing accessible healthcare services.

1. Enhanced Communication and Outreach

Engage in targeted communication campaigns to educate existing and potential enrollees about the importance of maintaining Medicaid coverage. Leveraging modern technology, such as HealthEdge^®’s Wellframe^® digital engagement platform, to take an omni-channel approach to beneficiary communications, can improve connectivity and effectiveness. In these communications, payers should highlight the array of benefits Medicaid offers and emphasize how it positively impacts their health and financial well-being.

2. Streamlined Enrollment Processes

Simplify the enrollment and renewal processes to minimize administrative burdens on beneficiaries. Provide user-friendly online platforms that guide enrollees through the application process. Utilize technology, such as HealthEdge’s HealthRules^® Payer core administrative processing system, to streamline enrollment and even pre-populate application forms and ease the documentation requirements, ensuring that the process remains as hassle-free as possible.

3. Collaboration with Community Organizations

Forge partnerships with community organizations, local clinics, and non-profits to increase awareness about Medicaid and support beneficiaries in navigating enrollment challenges. Community-based assistance can play a pivotal role in helping eligible individuals complete applications and renewals accurately. Payers who depend on HealthEdge’s GuidingCare modern care management platform are able to easily create and manage these partnerships with its extensive API services and more than 75+ pre-built integrations, including some with services for social determinants of health (SDOH).

4. Personalized Assistance

Offer personalized assistance through customer service representatives or enrollment specialists. Provide dedicated helplines to address enrollees’ questions and concerns, helping them navigate the complexities of the enrollment process.

5. Outreach to Lapsed Enrollees

Implement outreach strategies aimed at lapsed enrollees. Send reminder notifications about re-enrollment deadlines, emphasizing the potential risks of going without coverage and the ease of reinstating benefits. Once again, an omni-channel approach to beneficiary communications has the potential to drive higher levels of engagement.

6. Education on Benefits

Conduct education campaigns to inform beneficiaries about the range of benefits available through Medicaid. Highlight services such as preventive care, prescription medications, mental health support, and pediatric care. Demonstrating the value of these benefits can incentivize individuals to maintain their enrollment.

7. Data Analytics for Targeted Outreach

Utilize data analytics to identify trends and patterns in disenrollment. This data can guide the creation of targeted outreach efforts, focusing on areas or demographic groups that are experiencing higher disenrollment rates. For example, care management systems like GuidingCare – which have dynamic business intelligence capabilities – grant greater access to real-time data and analytics to make this process easy for care teams and business leaders.

The Medicaid disenrollment trend following the expiration of the Emergency Act presents a challenge that health plans must address with urgency and compassion. By implementing a combination of enhanced communication, simplified processes, community partnerships, personalized assistance, and targeted outreach efforts, health plans can offset the reduction in Medicaid enrollment. These strategies not only help maintain coverage for vulnerable populations but also underscore health plans’ commitment to ensuring access to quality healthcare services for all.

To learn more about how HealthEdge is helping health plans architect and execute their Medicaid redetermination strategies, visit www.healthedge.com.