4 Risk Management strategies to become a successful digital payer

No matter how much your health plan prepares for a new technology integration, unexpected changes often arise. Healthcare market dynamics are always shifting, and health plans must adapt with them. Developing risk mitigation strategies can save your health plan from falling behind in digital adoption and help you pivot to address changes faster.

It is critically important to leverage risk management best practices at the beginning of the process and throughout implementation to avoid and address potential risks. Based on my experiences with customer implementation, I’ve compiled a list of the most common risks health plans face—including successful risk management strategies we’ve applied.

1. Risk: Misaligned Expectations

Lack of engagement from key business & technology stakeholders may result in misaligned expectations.

Mitigation: Establish a formal Program Governance entity for the implementation to facilitate organizational and vendor communication.

Key executive stakeholders should be involved throughout the implementation and onboarding process—including provider representation. Engaging internal leaders helps to expedite decision-making and stay on schedule. If stakeholders are not part of the Program Governance group, your health plan runs the risk of losing organizational alignment.

Health plans can measure involvement and gauge buy-in by ensuring stakeholders are attending and participating in key strategic and educational meetings. How can your plan gain buy-in? Share the value the new solution will bring, and how it helps meet key performance indicators (KPIs). Establishing KPIs up front also helps your team understand how to best leverage the solution to meet their goals.

2. Risk: Delayed deliverables

Lack of scope management processes may result in scope-creep, delayed deliverable completion, missed business milestones, and increased costs to the overall program.

Mitigation: Implement a formal change control process, including a Change Control Board, to review and evaluate all proposed changes to assess their impact on the program timeline, budget, and business objectives.

Every step of the process should be directly tied to achieving key business goals. When a request arises, ask, “Is this a necessary capability, or is it a request based on a legacy concern?” Your plan can also provide a channel to help expedite and escalate critical changes requiring Program Governance reviews and approvals as needed. Implementing a new solution is complex—to keep the process manageable, start by solving the most widely applicable issues and fine tuning for new markets later.

3. Risk: Digital interoperability

Integration issues within the Enterprise ecosystem (such as system compatibility & readiness, solution selection, data quality & exchange, or missing capabilities) will impact end-to-end system verification and operational readiness.

Mitigation: Define integration requirements early in the planning phase and follow test-driven development practices with iterative delivery for early, ongoing cross-solution validation.

During program start-up, identify vendors and solutions that will work with and support the use of the enterprise ecosystem. Even with an integrated solution suite, your health plan will need to utilize third-party technology. Third-party testing and integration after implementation can cause delays and reduce functional efficiency. Reduce this risk by fully testing data exchange and other key digital interactions before go-live.

4. Risk: Undefined objectives

Lack of operational objectives without defined measurement will lead to competing or disconnected business stakeholders within the organization, leading to a failed implementation.

Mitigation: Define KPIs for your organization and the new solution at the beginning of the process so your organization knows what to aim for.

Once you’ve defined organizational objectives, regularly monitor your progress toward these new metrics. This makes it easier to identify when you’re getting off-track and adjust quickly to support your business objectives. As you implement the new ecosystem, continue to monitor KPIs for opportunities to optimize usage and performance to get the most value.

Risk management is a necessary part of implementation and is a dynamic process—risks change throughout the implementation and go-live process. To stay proactive, health plans must develop and maintain risk management strategies to stay on schedule and on budget.

Whether your health plan is replacing an existing CAPS solution or launching a new enterprise product to support an emerging market opportunity, implementation challenges will arise. By applying Risk Management best practices, like assessing potential enterprise blockers from the start and having documented mitigation plans, the chances of a successful implementation are in your favor.






Healthcare Payer Digital Transformation: Top 3 Planning Mistakes

The digital transformation shift for payers can represent a massive change. One of the keys to successfully navigating that change is through thorough planning and preparing. However, skipping, or skimping, on the planning phase can cause a ripple of negative outcomes.

Top 3 Most Common Digital Transformation Planning Mistakes


1. “Filling in the Blanks”

Insufficient information and lack of goal communication can cause people to make up information in the absence of details. Executive decisions can also be misunderstood by the project/operational teams without sufficient information and context. Proactively share information and bring people along on the journey. Always overcommunicate.

2. Scope Creep

Adding/changing scope without considering its impact to your goals and objectives can cause budget and operational consequences. Establish your scope based on your objectives and goals and stick to it.

3. Job Security Mindset

The fear of being replaced by technology is real for a lot of people. This can cause people to not share legacy information so that they can’t be replaced by technology.

Plan for the Digital Transformation

Don’t fall victim to the “Ready, Fire, Aim” approach. Slow down and build the plan, prepare to initiate the next phase, gather requirements, think about the organizational change that will need to occur, be mindful in your decisions, and build in mitigation plans for critical dependencies and dates. Comprehensive preparation empowers your team to pivot and keep going rather than losing even more time having to do that work later, or possibly redoing it.

Ensure your people, processes, and technology are fully aligned before the project commences. Include the following considerations:

Top 3 Digital Transformation Planning Best Practices: Goals, Objectives, and KPIs

In the words of Stephen Covey, begin with the end in mind. What do you want to achieve? Why do you want to achieve it? What will achieving it mean to your members, your staff, your organization?

Define why you have decided to do this, your business goals and objectives, the current KPIs, and what you expect to achieve after implementing this new solution.

1. Define the Why

What are the business and technology goals behind the decision?

2. Evaluate impact on decisions

What are your goals and objectives? Will this have a positive impact on them? How will this change impact your technology, process, and people?

3. Establish a communication plan

Transparency and communication support the change. Focus on building cascade, transparency, and consensus. Document and publish it. These goals and objectives should become core to how you make decisions about scope and changes throughout the implementation and ongoing management of the solution.

HealthEdge: Healthcare Payer Digital Transformation and Professional Services

HealthEdge’s Professional Services provides expertise and support to accelerate your digital transformation. To become a next-generation health plan, you need a digital foundation that enables you to provide a transparent and person-centric experience at lower cost, higher quality, and higher service levels. HealthEdge® solutions provide that foundation – and HealthEdge Professional Services deliver the expertise and support to make the process swift, sure, and effective.

Learn more about HealthEdge Professional Services.

Join us for the rest of the Healthcare Payer Digital Transformation series

  • Healthcare Payer Digital Transformation: Navigating Change Through Strategic Planning
  • Healthcare Payer Digital Transformation: Prepare & Plan
  • Healthcare Payer Digital Transformation: Design Excellence – coming soon!
  • Healthcare Payer Digital Transformation: Execute – coming soon!
  • Healthcare Payer Digital Transformation: 3 Critical KPIs – coming soon!
  • Healthcare Payer Digital Transformation: Optimize – coming soon!