Becoming a Digital Payer: Enabling Business Transparency

10 becoming a digital payer enabling business transparency

HealthEdge has identified five key attributes that drive digital payers, enabling them to rise above the competition and lead the way to better outcomes across the entire healthcare delivery system.

Digital health payers focus on:

  1. Improving end-user and member centricity
  2. Achieving higher levels of quality
  3. Increasing transparency
  4. Advancing customer service
  5. Reducing transaction costs

In this five-part blog post series, we are diving deeper into each attribute, delivering resources, information, and insights to enable health plans to transform into digital health payers. As we continue the conversation around what it means to be a digital payer, this discussion focuses on embracing business transparency.

Embracing Business Transparency

Transparency is increasingly becoming a hot topic for health plans. Consumers are demanding more transparency in terms of benefits, costs, and care choices. Government mandates like the Transparency in Coverage Rule and the No Surprises Act are requiring payers to make more data available to more healthcare stakeholders. Everyone across the healthcare ecosystem including members, providers, and other partners need greater access to data as they attempt to improve health outcomes and financial decision making.

Digital health payers are embracing this new emphasis on transparency that is possible with modern claims processing, care management, payment, and member engagement technologies like those from HealthEdge. They are able to use their next-generation systems and automated processes to support better integration, break down silos across departments, and optimize the flow of information.

Consumer Demand for Transparency

Today’s more tech-savvy consumers have grown accustomed to having information at their fingertips. Digital giants like Amazon and Google make price and quality transparency simple for just about any product or service – delivering ease of comparison across multiple retailers and products.

However, consumers remain in the dark when it comes to cost and quality information to support their healthcare decisions. Patients visit doctors, schedule surgeries, or visit urgent cares with limited-to-no visibility into quality or costs to inform decisions and plan ahead.

According to McKinsey & Company, more than 60% of patients report they want more information when deciding where to get care. Digital payers are leading the way to meet this consumer demand for greater transparency by making plan pricing and information more accessible. Through member portals, digital tools, and integration with other systems requiring information for consumers, digital payers can help the healthcare industry make a giant leap forward when it comes to increasing transparency.

Transparency across the Healthcare Ecosystem

Access to real-time health data and benefits information can improve care decisions for providers, members, and other partners. Better cost and pricing transparency can also enable providers and patients to make better financial decisions. Health plans have an opportunity to lead the way in this transparency effort by improving the exchange of information across the healthcare ecosystem.

Digital payers make data more accessible to internal team members, including care mangers, customer services teams, and external stakeholders such as providers and caregivers, through fully integrated systems that optimize the flow of information. With the right information available across the ecosystem, healthcare organizations can improve care and financial outcomes for all.

Regulation-Driven Transparency

Transparency does not just benefit health plans, members, and providers. New rules require more transparency from health plans and enforce penalties for those who do not comply. According to CMS.gov, as of July 1, 2022, group health plans and issuers of group or individual health insurance are to begin posting pricing information for covered items and services. More requirements will go into effect starting on January 1, 2023 and January 1, 2024 as part of the Transparency in Coverage rule.2

In addition, the No Surprises Act implemented on January 1, 2022 is also driving the need for greater transparency and information sharing as health plans are now required to cover some out-of-network claims and apply in-network cost-sharing if their provider directories are not kept up to date, according to Kaiser Family Foundation.

To maintain compliance, digital payers are using modern technology that can support the flexibility and digital connectivity necessary to seamlessly exchange data with those needing access. Whether is it care managers needing faster access to benefit utilization numbers or prior authorizations, or members needing insight into care networks, digital payers are able to provide transparency across the ecosystem.

Enabling Transparency with HealthEdge

HealthEdge delivers next-generation solutions for health plans to transform transparency requirements into business advantages. With best-in-class solutions that seamlessly integrate and share data across the ecosystem, HealthEdge technology delivers the digital foundation that enables digital payers to use and exchange critical data in a way that is meaningful for members, providers, and other partners. Solutions including, HealthRules® Payor and GuidingCare® leverage the power of true integration capabilities to streamline data flow across all lines of business and functional departments as well as third-party systems. With HealthEdge, payers transform into digital payers, leading the way in delivering transparency in healthcare.

Learn more about how to become a digital payer and turn transparency into your business advantage by by visiting www.healthedge.com or emailing [email protected].

1 McKinsey & Company. Consumer decision making in healthcare: The role of information transparency. July 13, 2020

2 Centers for Medicare & Medicaid Services. Transparency in Coverage

3 Kaiser Family Foundation. No Surprises Act Implementation: What to Expect in 2022. December 21, 2021

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