Author: Michael Dignan

The next-generation core administrative processing system (CAPS) from HealthEdge, HealthRules® Payer, delivers transformational capabilities that allow health plans to compete more effectively and adapt faster to changing business models, market needs, and regulatory dynamics. The system’s powerful flexibility allows for an endless variety of configurations that can be designed to meet the dynamic needs of virtually any health plan and any line of business.

To help HealthRules Payer customers optimize system configurations and ensure further optimized business performance, the HealthEdge Global Professional Services team offers specialized services for HealthRules Payer configuration. Both new and existing customers can leverage our expert team complemented by an optimized mix of global resources, when appropriate, to accelerate the time-to-value during new implementations or system expansions into new lines of business or geographies.

Overcoming Industry Challenges

• Workforce shortages on both the IT and business fronts make it challenging for some health plans to move at the pace required to remain competitive in today’s rapidly changing market. HealthRules Payer experts ensure health plans have the resources they need when they need them to adapt and meet their ever-changing landscape.
• Technology innovations and new features are constantly being made available by HealthEdge and its partners. The Professional Services team of experts helps customers quickly embrace and implement these advancements to gain competitive advantage and optimize efficiencies.
• As health plans grow, so does the complexity of the systems that support the growth. HealthEdge experts help health plans identify new ways HealthRules Payer can enable, accelerate growth strategies, and support peak performance of both the system and the organization.

Unmatched Expertise in the Industry

HealthEdge Configuration as a Service is powered by the healthcare innovation experts at HealthEdge. The combination of HealthEdge’s technology, strategic leadership, best practices, and its experienced configuration teams and optimized U.S./global resource model, ensure health plans can achieve their goals in a timely and cost-effective manner.

• In-depth knowledge of the HealthRules Payer solution capabilities and architecture
• Expertise gained through hundreds of HealthRules Payer implementations
• Instant connections to HealthRules Payer software architects and developers

For projects where it is appropriate, additional resources can be sourced from global locations, giving payers extreme flexibility and cost savings while benefiting from workforces in multiple time zones that expedite time-to-value. A key attribute of these services is our ability to dynamically flex to a hybrid model of onshore and global resources to best support the project’s requirements, timeline, and budget while maximizing both quality and timeliness.

Health Plan Configuration as a Service

HealthRules Payer configuration often drives the cost and timeline of implementations, upgrades, expansions, or support projects. As a result, health plans may reduce the scope, preventing the organization from realizing the full possibilities of their CAPS system. Configuration as a Service provides expert resources and services to enable health plans to reduce delivery risk, increase quality, and maximize the cost-efficiency of projects associated with implementing, maintaining, and expanding the use of HealthRules Payer.

Configuration as a Service Features:

• Implementation services
• Line of business expansions
• New services
• Expanded capabilities
• Upgrades
• Migrations
• Other growth needs

Health Plan Benefits

Providing deep HealthRules Payer expertise in a cost-effective model, the Configuration as a Service delivers powerful assurances:

• Successful configuration through a standardized, scalable, & mature process framework
• Minimize costs through strategically optimizing resources
• Shorten delivery times for implementations, upgrades, and line of business expansions
• Reduce risks associated with implementations and system expansion
• Improve outcomes to ensure health plans optimize HealthRules Payer functionality

To learn more about how HealthEdge Configuration as a Service can deliver predictable, cost-effective services for your organization, please reach out to your HealthEdge representative or email [email protected].

Health plans need to price and pay all claims accurately, even though not all of a health plan’s claims will come from contracted providers with negotiated payment rates. Source is a comprehensive payment integrity platform, able to support plans with everything from enterprise-wide payment integrity strategy to foundational pricing and reimbursement for participating and non-participating providers alike. The following case study highlights the ability of Source to help with the foundational, complex pricing for one plan’s non-participating provider claims.

Challenges of Non-Participating Provider Claims

A large, non-profit health plan has a robust network of contracted providers within the northeast region, facilitating local care access for their members. But, as health plan members seek care with non-contracted providers due to travel beyond the health plan region or for other logistic or personal reasons, the health plan receives claims from providers not contracted with their health plan. With multiple lines of business and almost four million members, these non-participating provider claims stack-up quickly and the health plan must be prepared to pay these claims accurately and efficiently, even without the benefit of contractually negotiated payment terms.

“We didn’t have many different pricing arrangements, but because of the differences in products and how those products wanted to message differently, it ended up being 75 different rate configurations for only six edit mapping rules.” – Health Plan Reimbursement Initiatives Manager

CMS Fee Schedules

The Centers for Medicare and Medicaid Services (CMS) maintains a fee schedule, which is a complete listing of maximum fees used to reimburse providers on a fee-for-service (FFS) basis. There are different fee schedules for:

• physicians
• ambulance service
• clinical laboratory services
• and more

Further, these fees can vary with modifications based on patient, provider and location factors; for example, urban, rural or low-density qualified areas.¹

CMS fee schedules are not only important for Medicare and other government lines of business – they are also important for commercial lines of business. These fee schedules are often used by non-participating providers who submit claims using a percent of CMS FFS. Using CMS fee schedules can simplify the number of payment arrangements across these different provider types, but as this northeast health plan well knows, they still need to develop claims configurations and claims-payment messaging to account for varied provider characteristics. Configurations and messaging must be aligned with modifiers for government and commercial providers and in-network and out of network status. Further, the Plan must be able to edit these configurations to comply with ongoing policy updates, including retroactive change mandates.

“CMS pricing is not just a simple fee schedule. There are many different ways that CMS prices different types of claims, providers, bonuses, outliers and new technology payments. It’s very complicated and [to get claims right, we have to] understand the nuance.” – Health Plan Reimbursement Initiatives Manager

Solution = Source

Source was specifically designed as a single instance that connects with any claims system. Today, Source offers existing integration with over 10 claims systems, ensuring that implementation isn’t waylaid by key technology integration challenges. Source also supports the Plan with hierarchical edit capabilities to structure the six different enterprise-level configurations overlaying mapping rules for the 75 different rate configurations for the Plan’s commercial and Medicare Advantage products and lines of business using a percent of CMS FFS schedules.

“It’s helpful that updates are deployed so quickly. It’s helpful that HealthEdge puts edits right in [to the Source platform], so the brunt of validation and testing is already done in advance. This is a big advantage over other experiences that were not as positive – that we’ve had with other vendors.” – Health Plan Reimbursement Initiatives Manager

The Plan also faces provider-specific arrangements with non-participating providers whose pricing does not follow a percent of CMS schedule. As a true tech partner, Source was also able to help the Plan navigate this additional complexity. The Plan’s Reimbursement Initiatives Manager described reaching out to Source representatives who were able to show her how to configure pricing for these unique provider payment arrangements – leaving her confident in her ability to make other such configurations in the future.

“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

Takeaways

Non-participating providers are a critical extension of any plan’s network – and accurate and efficient payment despite the lack of contracted pricing, is an important component of effective health plan operations.

• Non-participating providers play an important role in ensuring member care access in and out of their home region
• Many non-participating providers use a percent of CMS FFS pricing
• While CMS pricing offers a standardized base reducing the number of payment arrangements, plans still need a platform such as Source that facilitates many configurations and specific messaging based on provider type and other factors
• Investing in a platform whose pricing includes ongoing, automatic updates keeps plans on-top of policy changes without additional resource demands
• Choosing an industry-specific tech partner like HealthEdge gives plans the support they need to optimize automation and accuracy despite the complexity of provider arrangements

¹https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo

The good news: COVID-19 numbers across the country have gotten low enough (daily reported cases are down 92%[1]) that the Federal government feels the Public Health Emergency status issued in March 2020 that enabled the government to weather the worst of the virus, is no longer needed. The bad news for the American healthcare system: Estimates show up to 18 million Americans will lose their health insurance coverage through Medicaid within 14 months[2].

The Medicaid line of business grew more than 17% from February 2020 to September 2022 from an increase in the unemployment rate as well as the Continuous Enrollment Provision as part of the Public Health Emergency. That growth may now tumble downward as states begin to comply with CMS and State guidelines for Medicaid eligibility.

[3]

While the current Federal guidelines give states up to 14 months to resume normal income eligibility for Medicaid enrollees, many states can choose to do so more rapidly. What this all means for health insurers is a renewed need for outreach to potential Medicaid members who are in danger of being disenrolled to communicate options for Marketplace coverage. This can become increasingly complex for states with federally facilitated Marketplaces that can oftentimes operate in siloes.  Others losing Medicaid may become eligible for Medicaid Premium Assistance in the Employer Sponsored Insurance (ESI), but while employment levels nationally have returned to pre-pandemic levels, it can vary widely from state to state.

But amidst this looming unrest lies an opportunity for an often-broken healthcare system to work as it should. States are encouraged to partner with health plans, MCOs, community health centers, ancillary care providers, and other health care partners to reach out to enrollees to conduct their annual Medicaid renewal application. Each entity plays a role in ensuring the fewest number of Americans become uninsured. With HealthEdge’s family of products, modern health plans can operate Medicaid lines of business with maximum efficiency while staying compliant with state-specific frequently changing regulations. To learn more visit: https://healthedge.com/lines-of-business/government/medicaid/

 

[1] https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html

[2] https://www.urban.org/sites/default/files/2022-12/The%20Impact%20of%20the%20COVID-19%20Public%20Health%20Emergency%20Expiration%20on%20All%20Types%20of%20Health%20Coverage_0.pdf

[3] https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/