Accelerating the Drive Toward Value-Based Care

Through value-based care arrangements, health insurance companies have the opportunity to share the burden of care delivery costs and rewards of high-quality care with their provider networks, so it’s no surprise that many organizations are headed that way. However, due to disjointed systems and siloed data sources, most payers are still restricted to small pilot projects that are limited in scope and impact. Very few payers have been able to launch large-scale value-based initiatives that deliver on the promise of true value-based care.

The Journey to Value

One could argue that health insurance companies have been on a journey toward value-based care since the 1990s when capitated rates were first introduced. But as CMS motivated providers with federal incentives to digitize their operations and move to electronic health record (EHR) systems through the Affordable Care Act, massive amounts of clinical data became available. At the same time, electronic claims became more prevalent, and the stage was set for what we now call value-based care.

The vision of being able to leverage claims and clinical data to reduce the cost of care, improve patient outcomes, and increase member satisfaction was formed. However, most of the clinical data remained locked within the systems that generated it. Claims data also sat idle and stuck within the core claims administration systems that produced it. Plus, non-medical data, such as social, economic, and behavioral data was available but highly unstructured and therefore largely unavailable for inclusion and analysis.

Disparate data and disjointed systems presented significant barriers to health insurance companies’ ability to execute value-based, risk-sharing arrangements rapidly and successfully. For payers that are operating on outdated systems, those barriers still exist today and pose significant threats to their ability to compete in the future as the industry moves away from fee-for-service toward value-based care models.

Modern Technology Breaks Down Barriers

While progress has been made among the provider, payer, and vendor communities when it comes to exchanging data through standard interoperability protocols, those payers who are equipped with modern systems on modern architectures are better positioned to succeed in a value-based care environment. Why? Because to achieve true value for the payer, provider, and member, the claims management, care management, and member engagement systems must work together seamlessly.

With modern technology solutions like those from HealthEdge, exchanging insights and integrating workflows across the entire spectrum is possible. This vision of end-to-end automation with the exchange of real-time data that can equip care managers, providers, and plan administrators with the right information at the right time to make the right decisions form the basis of HealthEdge’s recent acquisitions and product investment strategies. In the HealthEdge ecosystem, best-of-breed systems share real-time data across functional business processes, no matter where the data or the system functionality originates.

A HealthEdge Example

One health plan that is making great strides with value-based care models is Independent Health, a New York-based, not-for-profit organization serving more than 375,000 members. The leadership team wanted to transition from the traditional fee-for-service (FFS) model to drive down soaring costs and positively impact patient outcomes, and they chose HealthRules Payor to help them make the transition.

The secret? Building strong relationships with their providers based on data, which could be easily shared from the system.

“When we give providers data that show how they are performing relative to required or recommended services for members within various demographics and disease states, we’re doing so with the ability to drill down to the individual patient level,” explains Dave Mika, vice president, Enterprise Core System Operations at Independent Health. “When we understand where a single patient stands relative to utilization of inpatient and outpatient services, we can offer clarity into everything from who needs to be more active in managing their own care to how cost calculators and digital health tools can be better utilized – by providers and their patients.

The results were impressive. In one use case, Independent Health targeted a series of approximately 5,000 patient encounters with the goal of reducing wasteful practices in a post-acute setting – including readmissions and avoidable admissions. The result: a savings of $14.8M, which represented a cost reduction of 10 percent.

Independent Health reports that 98 percent of primary care practice members are now in full capitation contracts, with solid alignment of goals between Independent Health and its providers. Pay for value has improved patient outcomes and lowered healthcare costs, all the while increasing customer satisfaction and overall health in the community.

Many Approaches. One Solution.

Payers are approaching value-based care in different ways, and different aspects of their businesses are typically further along than others. Whether the organization is focused on improving clinical care to improve member outcomes or more focused on containing costs through creative pricing programs, the HealthEdge portfolio of solutions can pave the way.

“Value-based care comes in many different forms, but it’s really based on how health plans reward providers for delivering good service and good care to the member. We are helping our customers take a more member-centric focus and contract with providers who share their common vision.”

– Steve Krupa, CEO HealthEdge, IMPACT 2021 Customer Conference

The HealthEdge integrated ecosystem of products and partners work together seamlessly to help health plans accelerate the pace by which they can create and implement successful value-based care programs. As plans seek to align with provider partners who can share the responsibilities of care delivery costs and high-quality care, now is the time to embrace modern technologies that can help bring true value to value-based care.

To learn more about how HealthEdge can help your organization embrace value-based care arrangements with greater confidence, visit www.healthedge.com or contact us at [email protected].

Download the rest of the series here: 

The Foundation: End-to-end Business Automation

The Digital Transformation Journey: Real-Time All of the Time

Opportunity is the Name of the Game in Today’s Health Insurance Market

Opportunity is the Name of the Game in Today’s Health Insurance Market

As the 2022 open enrollment period comes to a close, health insurance industry leaders are facing a year of unprecedented change. For some, these changes are being embraced and viewed as an opportunity for growth. For others, the rapidly changing market dynamics will have them falling further and further behind. The difference? It’s all in the technology. IT systems that combine best-of-breed solutions with modern technological advancements that facilitate easy integration, fast implementations, and effortless upgrades will separate those who thrive and those who barely survive in the new year.

Growth in the Midst of Chaos

According to AHIP, the health insurance industry is experiencing significant growth as we look to the new year:

  • 12.2 million Americans will buy coverage through the Affordable Care Act’s health insurance exchanges this year, the highest number of individuals since the program began.
  • 213 health insurance providers will participate in the federal exchange this year, an increase of 15% from the previous year.
  • 27 million Americans are now enrolled in Medicare Advantage plans, which represents the highest percentage of Medicare beneficiaries to date.
  • 180 million Americans now receive their health coverage through employer-based health plans.
  • 40 states have now chosen to partner with Medicaid MCOs and more than 75% of Medicaid enrollees are served by Medicaid managed care (MMC) programs.

In addition to evolving consumer behaviors, legislation regarding interoperability and transparency is gaining momentum. In 2022, payers will be required to focus on the implementation of foundational transparency requirements, such as the Machine Readable In Network and Allowed Amount Files, and the No Surprises Act consumer protections. Payers will also be required to collaborate on the method and standards for the Advanced Explanation of Benefits and Pricing Comparison Tools. The technology advancements required to ensure compliance may be leveraged, since the increased access to information and the implementation of standards provides new insights into member health, risk scoring, and health equity gaps.

Increased Choice = Increased Competition = Increased Opportunity

As the numbers above show, consumers now have more choices than ever before. As a result, health insurance providers now have more competition than ever before. For example, AHIP tells us that the average number of options individuals had to choose from in this year’s federal exchange was six to seven options, up from four to five just last year.

For those organizations that have embraced modern technologies, this competition is a welcome opportunity to gain market share and grow their lines of business. For those still burdened by legacy core claims, admin systems, and manual-dependent care management platforms, this competition creates new risks of being left behind in a market that appears to have no intention of slowing down.

Over the past several years, the complexities that health insurance business leaders must address have grown exponentially. From regulatory requirements embedded in the 21st Century Cures Act to consumer demand for greater transparency and more control, leaders now recognize the critical role their technology stacks play in the ability to keep pace with change.

At the same time, technology companies that have mastered automation in other industries such as financial services and manufacturing have set their sights on modernizing the healthcare industry. Companies like Microsoft, Amazon, and Apple have moved into healthcare, bringing with them powerful new data sources that legacy health systems cannot absorb and new approaches to solving age-old problems.

Modern systems, like those from HealthEdge’s next-generation solution suite, can help health plans embrace change and leverage the opportunity to become more nimble, more efficient, and more consumer-centric as they explore new markets and pursue new payment models with greater confidence.

Eric Decker, Senior Vice President of Information Technology and Chief Information Officer, Independent Health, noted, “About ten years ago, the Affordable Care Act created uncertainty as to whether our legacy [core claims administration] system could manage things like member-level benefits, or how it would perform and integrate with exchanges. We closely evaluated different products in the space at the time and immediately realized HealthRules® Payer enabled us to significantly cut down our new product development time. Now, what used to take weeks and months actually takes hours or days.”

Speed to Market Matters

With the right systems in place, health plans can not only better identify opportunities for growth and better member outcomes, but they are also able to act on those opportunities with greater speed and more precision.

For example, health insurance companies who leverage the integrated HealthEdge solutions, which include best-of-breed core claims processing, care management, payment integrity, and digital health management systems, are uniquely equipped to bring innovative plan designs and benefit configurations to market faster. HealthEdge customers can easily expand into new geographies and reach new populations with next-generation products that are highly configurable.

This new level of nimbleness that modern technology platforms bring to the table in 2022, will be the difference between those who grow and those who fall further behind.

How It Works

Organizations that use HealthEdge products can take advantage of flexible configurations, customizable workflows, and automated processes.

For example, the English-like language capabilities used in HealthRules Payer make it easier for health plans to design and bring new benefit products to market faster. That’s because it has been designed in a way that a benefits person thinks, not the way a core admin system works.

With HealthEdge Source®, health plans receive automatic updates on important data, such as fee schedule changes, rates, payment policies, and provider-level data, every two weeks instead of having to wait months to receive now-outdated information. GuidingCare®, HealthEdge’s care management platform, streamlines clinical workflows so care managers easily create care plans and ensure that members follow the plans for better outcomes.

“[With HealthRules Payer], we’re able to complete the solution design process as a series of benefit objects, so we don’t have to rebuild over and over again at the risk of increased costs and errors.”

– John Janney, Senior Vice President of Transformation at AmeriHealth Administrators

Lifting the IT Load

The features and configuration capabilities of the software system are only part of the speed equation. The ability to easily integrate best-of-breed solutions with other systems in a seamless manner eliminates the IT burden that often serves as a barrier to change among health plans with legacy claims processing and care management systems. The business can only move as fast as the systems can manage the changes.

Similarly, implementations of monolithic systems needed to support new lines of business or new markets can dramatically slow down the health plan’s ability to pursue new opportunities. Upgrades with new features create similar IT challenges and have the potential to disrupt business operations.

“[GuidingCare] was an incredible partner, great collaborator, and provided great teamwork. I have great appreciation for that. We have no regrets about choosing GuidingCare.”

– Clinical Director, 1M+ member health plan that was able to replace its legacy system with GuidingCare in three stages across its entire business in only nine months

With modern technology and proven processes, health plans have the opportunity to expand into new markets and drive new business opportunities without worrying about how to fit projects onto an already overloaded IT list.

“Adaptability in terms of the benefit configuration and allowing us to roll out new products without having to do massive coding projects is a big deal that we don’t have today (with HealthEdge).”

– Eric Decker, SVP of IT and CIO at Independent Health

Get Ready to Grow

Advancements in modern technology, like those from HealthEdge, are helping health insurance companies keep pace with the ever-growing demands from regulators and consumers. But the pace of change in 2022 will require health plans to accelerate their digital transformation journeys if they want to capitalize on growth opportunities.

Our product investment strategy at HealthEdge is focused on helping our customers migrate to more modern, interoperable, and composable systems that allow them to grow in the ways they want and when they want to.

To learn more about our best-of-breed solutions and how they work together with our broader ecosystem of solutions and partners, visit www.healthedge.com or contact us at  [email protected].

“HealthEdge allows us to achieve speed to market with our products in the rapidly changing healthcare environment, with the capability to configure and implement products quickly and on the fly.”

– Dave Mika, VP, Enterprise Core Systems Operations, at Independent Health and user of HealthRules Payer

The Digital Transformation Journey: Real-Time All of the Time

Batch processing of data has been the norm in the health insurance industry for decades. However, as the complexities and competition within the industry heat up, so do the pressures for the ability to access more timely and accurate data. Data that is a month old, or even a day old, is considered stale and useless in today’s fast-paced market.

The good news is that for many years, access to real-time data has been a guiding principle in the HealthEdge product investment strategy. In fact, all the HealthEdge applications are built with high-quality, highly available data in mind.

HealthRules Payer® contains valuable claims data shared via real-time APIs with other HealthEdge and third-party applications. HealthEdge Source incorporates payer edits and pricing content from other systems and updates its contents and rules every two weeks. GuidingCare® grants care managers access to important member benefits information so they can make smarter decisions on appropriate care plans for certain patient populations.

As we at HealthEdge help our customers aggressively pursue their digital transformation strategies, we consider access to real-time data the gateway to success.

We acknowledge this access is critical to many constituents, including providers, members, and even brokers, who live outside of the four walls of the health plan. As such, we continue to actively invest in new ways to make more real-time data available to stakeholders who need it.

The Driving Forces

As health plans seek to drive smarter clinical and operational decisions that result in better outcomes and greater efficiencies, access to real-time data is a must-have. In addition, regulatory bodies are consistently pressuring health plans to up their game when it comes to data access and transparency in recent years:

  • The 21st Century CURES Act requires payers to provide access to all claims and clinical data, including care management data and certain documents within one day of having the information available in their system via FHIR-based APIs. It also sets new standards for the recency and accuracy of provider directories. Maintaining accurate provider data and exposing data to others is a significant challenge for many payers who operate on outdated, legacy systems.
  • The No Surprises Act requires health plans and providers to make good-faith estimates for healthcare costs available to consumers and sets boundaries for out-of-network emergency care services. Information that is not available in real-time can misinform these estimates. This requires new levels of transparency and accuracy around pricing data.
  • Implementation of the Consolidated Appropriates Act (CAA), as part of the Affordable Care Act, demands additional levels of pricing transparency, requiring plans to make certain pricing information publicly available to participants, beneficiaries, and enrollees via the internet and paper forms upon request.

In addition, consumers expect greater access to real-time data as they continue to play a bigger role in their health plan purchasing decisions. Providers expect greater access to data across their networks to help ease the administrative burdens associated with claims processing. And care managers expect greater access so they can provide more effective care plans that are appropriate for the different populations they serve.

The HealthEdge Plan

The HealthEdge approach to enabling greater access to real-time data centers on three main principles:

  • Accurate data: We cannot talk about real-time data without also talking about data accuracy. The main idea is that more recent data is likely more accurate data. Not only does inaccurate data erode trust among providers and members who access it through portals or IVR systems, but it also can lead to higher operational costs when health plans have to chase down over-and under-payments. Our systems have data quality improvement capabilities within them to help minimize the burden of maintaining accurate data. For example, HealthEdge’s Source researches, manages, and maintains data (current and historical fee schedules, rates, payment policies, and provider-level data) and publishes updates every two weeks.
  • Organized data: Making the real-time data accessible requires an easy-to-understand data structure. HealthEdge data closely models the real world, so the relationships of the data elements are more easily understood by other systems and provide more complete models for looking at providers, suppliers, subscribers, and members. This supports better network management and facilitates more informed contracting.
  • Accessible data: APIs establish a common language by which disparate systems more easily share data with each other. As we recently announced at our annual customer conference, IMPACT 2021, we are continuing to expand access to all types of data through advancing our API framework. In addition, we are establishing an ecosystem of partners where our customers can be assured that the integration between our system and certain third-party systems, like EDI gateways, enrollment systems, member engagement, and analytic systems, will be fast, easy, and continuously supported by our team.

“Customers can be members, providers, brokers, whatever the constituent is. And the ability to surface the information and the needed response in real-time is the fundamental piece that outlines the success of what we do. Friday Health Plans has been able to leverage its claim system (HealthRules Payer) and underpinnings of technology and data to have a better customer experience.” Kevin Adams, CEO, UST HealthProof

To learn more about how we are working to give our customers, our applications, and our partners’ unprecedented access to real-time data, visit www.healthedge.com or contact us at [email protected].

The Foundation: End-to-end Business Automation

Health plans have historically struggled with high operational costs, often driven by a combination of complex business processes and manual-intensive workflows that require human intervention and decision-making. In an effort to reduce costs, most health plans have tried to implement software systems that automate repeatable processes. However, the automation remain confined to functional silos, and spreadsheet gymnastics remain the dominant way to share data between systems and lines of business. The many promises of business automation continue to fall short of expectations.

As the industry becomes increasingly complex and consumers play a larger role in the selection of their health insurance, payers are recognizing that their complex processes and manual-intensive workflows are no longer sustainable. Mountains of work that sit in a queue waiting for a human to move it to the next step is slow, expensive, and prone to error.

The time has come for payers to lean more heavily on their software system vendors and technology advancements to automate business processes from one end of their business to the other. This fundamental principle of end-to-end automation is a key component of HealthEdge’s product investment strategy today.

Everyone is Doing It

We need not look far to see how other industries are using technology to create end-to-end automation. Consider Amazon, whose transaction costs are in the micro-cents and whose customer experience is revolutionizing consumers’ purchasing expectations. Netflix upended the entertainment industry with its use of modern technology to deliver content directly to the homes of its 214 million active subscribers.

At HealthEdge, we consider disrupters like these to be role models. Why? Because they think differently about how to solve problems. They focus first on the consumer experience and work through the options from there. With healthcare, the problems are extremely complex, driven by ever-evolving, ever-growing regulations and consumer demands. Therefore, we have to think about things differently, too. We can’t keep applying the old fixes to the rapidly evolving problems of today. And that’s exactly what we’re focused on helping our customers do.

This is the type of first-principles thinking that drives us at HealthEdge. Instead of just thinking about the status of a claim in our core administration system, we think about how that data can be used to empower nurses in care management, how to expedite eligibility checks, or how to help members select the right benefit package prior to enrollment. Instead of trying to improve second-pass claims editing, let’s get it right the first time. Instead of looking down into the functional silos, we look across the whole business of healthcare and seek to automate every business process possible to reduce operational costs and improve accuracy.

Enabling End-to-End Automation

With all of a health plan’s primary business systems, including core claims administration, care management, payment integrity, and member engagement, under one roof at HealthEdge, we are able to think more holistically about solving problems and driving innovation faster across the entire spectrum.

While powerful as individual solutions, the integration of these best-of-breed solutions gives us the unique advantage to improve accuracy, timeliness, and accessibility of data across multiple touchpoints, which is necessary to drive smarter, more automated workflows. As more workflows are automated, we can layer in leading edge technology advancements like artificial intelligence (AI) decision-making and machine learning to accelerate the time-to-value our customers experience when working with all our solutions. We take a unified view of the business processes that achieve desired outcomes, a key enabler of digital experiences for members and providers.

Business processes such as prior authorizations, claims adjudication, eligibility checks, enrollment, and even member correspondence are driven automatically through rule-based workflows that require little to no manual intervention. Plus, our open API interfaces make it easy to embrace third party systems that depend on accurate and timely delivery as well.

Realizing the Benefits of End-to-End Automation

When payers move toward end-to-end automation, they are able to free more resources to focus on innovation while also dramatically reducing transaction costs associated with claims processing, care management, and member engagement.

In its December 2020 report entitled “Strategic Automation Decision Framework,” Gartner estimates the cost to rework a claim is equal to $25 per claim. By automating more of the claims payment processes, health plans have the opportunity to get it right the first time and significantly reduce claims processing costs.

“It won’t be long before end-to-end automation becomes an expectation, rather than an outlier, and digital is simply business.”

– Gartner Group, Strategic Automation Decision Framework report, Dec. 2020

End-to-end automation is also fundamental to improving the member experience. Empowering care managers with information about member-specific benefits directly from within the care manager’s interface will help them not only build more informed care plans, but also better guide members along their care journeys. Equally as important is the ability to empower members with engagement capabilities. Solutions such as HealthEdge’s Wellframe® digital member engagement platform give members the opportunity to engage more directly with their care managers, which typically results in better care plan adherence and member satisfaction.

Creating a frictionless provider experience will also be a by-product of end-to-end automation, as the accuracy and timeliness of the claims adjudication process improves. For example, one HealthEdge customer was able to save hundreds of thousands of dollars by completing accurate pricing and editing in a single pass with HealthEdge’s Source payment integrity solution. The ability to eliminate manual pricing processes results in a time savings of 25% and a 40% reduction in claims volume that require rekeying.

At HealthEdge, we remain committed to helping our customers automate more of their business processes so they can drive down transaction costs and drive-up member and provider satisfaction. To learn more about how we are enabling end-to-end automation for our customers, visit www.healthedge.com or email [email protected].

Healthcare Tech Execs Talk About Reimagining Care for Chronic Illnesses

In a recent interview, Stephen Krupa spoke with Lucienne Ide, MD, PhD, founder and CEO of Rimidi. Ide’s focus is on patients with chronic diseases. Episodic care is not working for them, she shared, and a once-a-year or once-a-quarter trip to the doctor feels more like being called to the principal’s office than a health-focused partnership.

“We try to keep that focus on empathy for the patient and for the end user and to be sort of obsessive about our customers and our customer experience,” she said. Her previous experience in venture capital convinced her that investors didn’t understand the actual experience of the doctor, the nurse, the patient, for whomever they were building the tech.

At Rimidi, Ide and her team are building sustainable progress by pushing healthcare past just digitizing data into genuine decision-support tools, innovating in care delivery and doing the “dirty work” of truly setting patients up for success. Rimidi provides a suite of solutions to healthcare delivery systems for big health systems and  independent practices, layering decision support on top of the electronic health record. EHRs, Ide notes, are the record of authority and aren’t going away. “But we’ve got to put the tools on top of them that make them usable and efficient,” she says.

Ide has strong opinions about tackling the pain points of shifting to value-based models and what the tech industry needs to build for doctors who only have three minutes to make a decision: “IT systems need to do what humans don’t do very well, which is to aggregate and analyze and curate and present the necessary data in a very efficient manner.”

In this podcast, Ide and Krupa talk about how entrepreneurs should approach their ventures. “I always encourage people at the beginning of the journey, that if you’re not bringing a personal experience to it, or even if you are, continue to listen,” Ide says. “Listen more than you talk.”

Listen to the full conversation here:

About Steve’s Guest

Lucienne Marie Ide founded Rimidi, a cloud-based software platform that enables personalized management of health conditions across populations. She brings diverse experiences in medicine, science, venture capital and technology to bear in leading Rimidi’s strategy and vision. Motivated by the belief that we can do so much better as individuals, in industry and society, Lucie left clinical medicine to join the ranks of healthcare entrepreneurs who are trying to revolutionize the industry.

IMPACT 2021: The Journey to Transforming Healthcare

Here at HealthEdge, we have a rich history of hosting highly interactive and engaging customer conferences. It’s always been one of my favorite things we do because it allows us to bring our HealthEdge community of customers and partners together to exchange ideas, share lessons learned and talk about where we see the future of healthcare going.

Due to the pandemic, this year we hosted a virtual customer conference, IMPACT 2021, and it was an amazing event. We welcomed nearly 200 customers, ranging from those who have been with us since our inception to those who recently joined the HealthEdge community through our acquisitions of Burgess and Altruista Health.

During the four-hour session, we shared our vision of leading the digital transformation of healthcare through best-in-class products and an integrated platform, and they shared with us their plans, challenges and hopes for the future.

The purpose of this article is to share with you some of the highlights from my keynote address and encourage customers and prospects to reach out to their account managers and engage with us. Together, we are transforming the business of healthcare. I invite you to join us on this incredible journey.

Our Community is Growing

As our customers expand into new markets with new lines of business, we too have expanded our scope of offerings. After finding the right capital partner, Blackstone, in 2020 to help support our ambitious growth plans, we were able to bring into the HealthEdge family two businesses, Burgess Group and Altruista Health.

These additions brought more than just powerful, best-in-class products in the areas of payment integrity and clinical care management. They brought incredible teams of talent, packed with innovative ideas and best practices from across the health plan industry.

Bringing these bright minds together to plot our course of how the solutions will work together to drive incremental value for our customers has been nothing short of amazing.

Since then, we’ve double the size of the company both in terms of revenue and employees.  Today, we work with 90 companies, including national and regional health plans, commercial and government plans, BlueCross BlueShield plans and specialty claims processing organizations. We cover more than 35 million lives and virtually every line of business.

Building a Bright Future: For our Customers, with Our Customers

Our mission is to empower our customers to drive higher levels of automation and efficiencies while also reaching higher levels of member and provider satisfaction… and ultimately achieving growth. We accomplish this by focusing on our five core principles:

  1. Optimizing business value for our customers and employees
  2. Facilitating cross-functional collaboration
  3. Driving continuous process improvement
  4. Following first-principles thinking
  5. Enabling engineering excellence on behalf of our customers.

In fact, everything we do is for our customers. We’ve built this company for our customers, and the collaborative culture we share with them has been the key to helping us all solve some of the biggest challenges facing healthcare today. And I believe if we continue to focus on these core principles, we are uniquely qualified to lead the transformation of healthcare together.

The Journey of Transforming Healthcare

As health plans expand into new markets and healthcare consumers demand more personalized services, the need for automation and transformation has never been greater. At HealthEdge, our overarching product strategy centers on two main themes: (1) deliver best-of-breed solutions across our customers’ businesses that can (2) easily integrate together accelerate time-to-value for our customers. Let’s take a closer look at what we mean by these two themes.

Deliver best-in-class, individually excellent solutions.

  • Offer the finest claim system that gives our customers flexibility and agility to run their business – that’s HealthRules® Payor. We’re expanding our capabilities to support things like value-based care, expanded benefits design, and advanced integrations.
  • Offer the best claims editing and pricing rules engines to facilitate more accurate claims and higher payment integrity – that’s Source®.  Our Burgess team does a phenomenal job of maintaining the most up-to-date payor rules and pricing engines.
  • Offer the best care management system that empowers clinical teams to provide optimum care in the most cost-effective manner – that’s GuidingCare®. Our Altruista team is obsessed with coming up with new ways for clinical teams to monitor the quality and utilization of care services to generate the best outcomes.

Deliver an integrated suite of solutions.

By having all three platforms under one roof and our solution teams working closely together, we can more quickly build seamless connections and workflows that can:

    • Share more data in real-time for better insights and informed decision making
    • Drive smarter business process that take the burden off administrators and clinical resources
    • Generate extreme efficiencies, better care and more satisfied members and providers.

A Look Ahead

With our wide range of customers, our solutions exist in a wide variety of ecosystems. But as we look ahead to our product strategy for the next few years, there are four common denominators that will guide our product investment decisions:

  1. The need for end-to-end automation. The manual-intensive business processes that exist across health plans and providers are placing undue cost burdens that threaten our ability to deliver quality care in the future. We’re rethinking every process and finding new ways to automate the business of healthcare.
  2. The demand for real-time data. Being able to make more informed administrative and clinical decisions is dependent on being able to access the right data at the right time. We will continue to expand access to all types of data through advancing our API framework.
  3. The move to expand into new markets. Helping our customers quickly and confidently move into new markets or grow their lines of business requires flexible solutions. We’re focused on increasing the configurability of our solutions so our customers can adapt faster to changing market conditions.
  4. The shift to value-based care. From setting up value-based arrangements to accurately pricing value-based claims, we’re focused on making it easier for our customers to compete and win in value-based and risk-sharing arrangements with greater access to the clinical and operational data they need.

Beyond the Highlights

Packing a 45-minute keynote address into one brief article is an impossible task. We have so many innovative things going on across our business and across our customer base. I hope that you will stay tuned for more posts in the coming weeks as I dig deeper into each component of our strategy and our product leaders lay out their respective roadmaps.

For now, please know that we are grateful for the level of energy and enthusiasm we receive from our customers every day, and we are encouraged by all of the innovative ways they are using our solutions to grow their organizations and make healthcare better for everyone. Thank you to every one of our customers, partners and team members who made IMPACT 2021 such as success.