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Genetic testing was once only available to individuals with a family history of certain genetic conditions or those who were experiencing symptoms. In recent years however, advances in technology have made it easier and more affordable to analyze DNA, making genetic testing more accessible to the general public. And as health plans are constantly looking for novel ways to identify individuals that may benefit from early intervention programs, genetic testing is becoming a powerful tool in this effort to provide more personalized medicine.

As a result of these trends, the volume and complexity of the medical policy, coding, and utilization review surrounding genetic testing has skyrocketed:

• 150,000+ genetic tests are on the market, compared to 10,000 only 10 years ago
• 9 codes are billed to represent a single genetic test
• 1,000+ pages of medical policy for providers and payers to try to interpret

For many payers, processing genetic testing claims is a tedious, manual, and time-consuming process. There are several reasons for this:

• Complexity of genetic testing: Genetic testing can be complex, and the interpretation of test results may require specialized knowledge and expertise. In some cases, payers may need to consult with genetic counselors or other experts to ensure that claims are processed accurately.
• Lack of standardization: There is currently no standardized process for genetic testing, which can make it difficult for insurance companies to determine which tests are appropriate and what constitutes a medically necessary test. This can result in delays or denials of claims.
• Billing codes: The process of billing for genetic testing can also be complicated. Each test may have its own unique billing code, and the correct code must be used to ensure that the claim is processed accurately.

Health plans that rely on outdated approaches are experiencing a growing volume of prior authorizations, denials, reviews, and appeals – all made more complex by multi-gene panel tests with multiple billing codes. The result is waste, variable quality, and frustrated members, providers, and medical directors.

A Better Way Forward

To navigate these challenges and help payers reduce the manual labor and time associated with processing genetic testing claims more accurately, Source has partnered with Concert Genetics, an industry leader in genetic test payment accuracy.

Concert Genetics has developed proprietary content and technology that streamlines clinical policy maintenance, prior authorization, coverage determination and claims processing for genetic testing. Here’s how it works:

• Payment policies that clarify and enforce test identification and standard, predictable coding.
• Clinical Edits flag tests that typically aren’t covered by health plans, such as experimental tests; tests not supported by patient age or gender; and tests not supported by specific diagnosis codes.
• Coding Edits, such as invalid procedure codes, are based on the current procedure codes and the AMA’s coding guidelines.

The scope of claims addressed by the base package of edits includes:

• Molecular Pathology
• Genomic Sequencing Procedures and Other Molecular Multianalyte Assays
• Multianalyte Assays with Algorithmic Analyses
• Proprietary Laboratory Analyses (PLA) Codes

A Single Source for Genetic Test Edits and Policies

As a transformative payment integrity solution for payers, Source has developed partnerships with many different best-of-breed vendors, including Concert Genetics. As part of the Source ecosystem, Concert Genetics is able to leverage advanced APIs from Source to deliver pre-built integrations between the two systems.

This not only eliminates the IT burden for payers who want to use both solutions, but it also creates a more seamless user experience by giving users the ability to access the Concert Genetics rules and edits directly from within the Source interface.

To learn more about how Source + Concert Genetics and the entire Source ecosystem of third-party partners can help your organization increase accuracy and reduce waste when it comes to genetic testing claims, visit the Source third-party integrations page here.

It’s no secret that change is the only constant in today’s business world. As organizations pivot to navigate the ever-evolving needs of their employees, customers, and markets, leaders must be able to keep up with the pace and thrive amidst it. The most successful people managers understand that exhibiting versatility isn’t just a nice trait; it’s essential for sustained organizational success and maximum impact among their teams. In this blog post, we’ll explore why being versatile as a leader is so important and provide great leadership examples.

Flexibility

Versatile leaders are adaptable and can adjust their leadership styles to fit different situations. They are open-minded and can embrace change, new ideas, and challenges without compromising their vision and values. A great example of this is Indra Nooyi, former CEO of PepsiCo. Nooyi was known for her adaptive leadership style, which allowed her to navigate various challenges and lead PepsiCo through a period of significant growth and transformation. She encouraged her team to think creatively and take risks, and she fostered a culture of openness and transparency. She recognized the importance of teamwork and collaboration and worked closely with her senior leadership team to develop and implement the company’s strategy.

Cultural Awareness

Versatile leaders are culturally competent and can work effectively with diverse teams. They understand the nuances of different cultures, respect different beliefs and values, and create an inclusive environment that values diversity. One example of a culturally aware leader is Satya Nadella, CEO of Microsoft. Nadella was born and raised in India, and he brings a global perspective to his leadership role. He has made a concerted effort to promote diversity and inclusion at Microsoft, recognizing the importance of cultural awareness and sensitivity in a global company. Under Nadella’s leadership, Microsoft has implemented several initiatives to promote diversity and inclusion. For example, the company has established employee resource groups to support underrepresented groups, such as women, people of color, and the LGBTQ+ community.

Communication Skills

Versatile leaders have excellent communication skills and can effectively connect with different audiences. They can tailor their messages to different stakeholders and use different communication channels, such as face-to-face, virtual, or written communication, to convey their ideas. One example of a leader who can communicate effectively with different audiences is Barack Obama, former President of the United States. In his speech at the 50th anniversary of the Selma-to-Montgomery civil rights march, he was able to connect with both black and white Americans, while also addressing the historical significance of the march and the ongoing struggle for civil rights. He spoke about the need for continued activism and engagement in the political process, while also recognizing the progress that had been made.

Emotional Intelligence

Versatile leaders have high emotional intelligence and can understand and manage their own emotions and those of others. They can empathize with their team members, build strong relationships, and resolve conflicts effectively. Mary Barra, CEO of General Motors is a great example of a leader with a high EQ. She is known for her approachability and her willingness to listen to employees at all levels of the organization. She has implemented several initiatives to promote employee engagement and development, recognizing that a motivated and engaged workforce is essential to the success of the company. She has done this while also driving innovation and change.

Strategic Thinking

Versatile leaders are strategic thinkers who can see the big picture while paying attention to details. They can analyze complex problems, identify opportunities, and develop creative solutions that align with their vision and goals. Jeff Bezos, former CEO at Amazon is an example of a leader who demonstrates strategic thinking. He recognizes the potential of new technologies and business models and was willing to take risks and invest in long-term growth. At the same time, he was able to manage complexity and scale, recognizing the importance of building strong organizational systems and processes to support a rapidly growing and evolving company.

As a leader, you can embrace versatility to create a positive and productive work environment where everyone is valued and respected. With an increased emphasis on flexibility, communication, and collaboration, versatile leaders can foster an open-minded atmosphere and collaborate effectively with teams of diverse backgrounds. Through these strategies, versatile leaders have the potential to maximize team effectiveness while creating a long-term culture of mutual trust and respect in the workplace. Ultimately, success as a leader depends on the ability to recognize problems and adjust strategies accordingly; developing versatility is essential for any leader looking to remain successful in the ever-changing business world.

Which leadership trait are you going to work on today?

For many Health Plans, 2023 presents unique challenges and opportunities when it comes to addressing strategic initiatives. The healthcare payer ecosystem is becoming increasingly digital, and for good reason. Data and processes that were once siloed and handled at departmental levels, are increasingly becoming more interoperable and overseen at an enterprise level with strategic investments into digital platforms.

In fact, Gartner cites “Payers that implement enterprise payment integrity programs and solutions are on the path to reducing medical expenses by 10% or more, with even more potential for significant reductions in administrative expense.”[1]

When it comes to Payment Integrity processes, over the past several years I’ve witnessed a significant shift away from individual point solutions that address singular pain points to digital investments that provide transparent and interoperable data and services that empower health plans to leverage up-to-date industry content, in-source capabilities, and customize the tools as needed.

For payers looking to address digital initiatives in 2023 with their editing solutions, a well-rounded approach and evaluation includes the following three items: depth of content, agility to accommodate a health plan’s unique requirements, and an “open book” approach so health plans can address the root cause of recurring payment errors.

1. Unique Data Set

Q: How does Source provide a broad, unique data set?

A: Our depth of content

Source provides a unique depth of content that includes a wide range of Medicare payment policy edits, state-specific Medicaid payment policy edits, as well as Clinical, Cost-Containment, and Validation edits maintained by subject matter experts. Source is also designed to incorporate 3^rd party specialty content into our ecosystem seamlessly including specialty content from MediQuant, 3M, Concert Genetics and TruthMD, to augment policy standards and ensure claims are paid accurately. Without this depth of content, Payers must rely on multiple vendors, perform excessive manual claims reviews, and risk over- or under-paying claims.

Our unique data set includes:

• Hands-off, automatic delivery of government, clinical, billing, and validation edits to handle complex policies automatically across all lines of business
• User-driven interface for easy development of customized edits to mimic medical policies
• History-based capability to look across claims for comprehensive editing
• Optional third-party edit libraries natively integrated into the solution

2. Agility to accommodate a health plan’s unique requirements

Q: As more and more health plans look to better understand and control their data, how does Source enable plans to deploy their own algorithms?

A: Source was designed to be agile to address a health plan’s unique business rules

Source allows Plans to deploy their own algorithms through creation of custom edits in a flexible configuration layer, existing real-time integrations to commercial claims systems, and workflow management to map to your system’s disposition codes for appropriate adjudication decision-making.

Source deployment capabilities include:

• Use of our native content with health plan-specific customizations to standard policy
• Adapting a payer’s proprietary edits through a contemporary user interface or leverage our professional services team to assist in the process
• The ability to monitor the financial and utilization impacts of an edit before deploying it for production use
• Hierarchical structure to efficiently deploy edits enterprise-wide or to specific regions, products, providers, etc.
• The ability to allow deployment of an edit to act as informational, soft denial, or automatic denial
• Single instance of the software in the Azure cloud that connects to all health plan claims systems for streamlined maintenance and consistent editing
• No technical maintenance as Source is updated and maintained by experts on a continuous basis

3. An “open book” approach

Q: How does Source enable plan to in-source a portion of their payment integrity capabilities?

A: Our “open book” approach

With Source, we’ve taken a “Black box to Open book” approach to payment integrity—ensuring that health plans have insight into root-cause analysis and the tools to address payment integrity issues upstream in the adjudication process.

This approach empowers health plans in multiple ways, including:

• Participation in Payment Integrity health checks performed by our experts to identify new cost of care or administrative savings opportunities.
• Enabling Source edit libraries in addition to your own proprietary edits through the user interface.
• Understanding the impact of edits with the use of Monitor Mode to see “what if” utilization and financial impacts that show aggregated results before turning the edit on in production.
• Enabling the edit in production with flexible adjudication decisions based on your business needs.
• Discovering new opportunities through real-time dashboards and reports while assessing the savings impacts of edits already in production.

Source uniquely provides editing content and capabilities alongside reimbursement for a comprehensive and cohesive approach to payment integrity that enables health plans to finally achieve long-term, enterprise-wide goals. This comprehensive and holistic approach to payment integrity considers reimbursement, application of medical and payment policies, analytics, and contract configuration—not as separate aspects of adjudication—but as part of an ecosystem that needs to remain agile, interoperable, and coordinated. Learn more about Source here.

 

[1]  – Gartner, Fight Healthcare Fraud With Enterprise Payment Integrity for U.S. Payer CIOs, Mandi Bishop, Refreshed 9 October 2022, Published 4 May 2021

Here at HealthEdge, our cybersecurity strategy relies on a defense-in-depth approach, which means we rely on people, processes, and technology to ensure our security controls remain viable and constantly evolve. Of these three, the HealthEdge team, is the most formidable layer of cybersecurity. We count on our global workforce to stay informed, identify and report suspicious messages, and to understand and comply with our IT Security Policies. Our Chief Information Security Officer, Jerry Sto. Tomas says, “I am often asked how big our security team is. I respond with, ‘around 2,000 people.’ Each of us has a responsibility in security because the HealthEdge team is the first line of defense.”

The SAFE program aims to empower our team with:

• Regular newsletters providing education on industry threats and vulnerabilities.
• Cybersecurity alerts on real-time threats and how the workforce can help.
• Comprehensive IT security policies.
• Mechanisms to report suspicious messages.
• Monthly internal phishing simulation tests and just-in-time training.
• Annual training, role-based training, and continuous micro-training.
• Cybersecurity best practice tips to implement in the workplace and at home.

Preparing the Team

With regular information newsletters and real-time security alerts, our team is always kept up-to-date on cybersecurity, regardless of their role at HealthEdge. Newsletters are sent out bi-weekly with cybersecurity news, tips, trends and communications about new security practices. Newsletter content is tailored to our organization with the objective of improving overall cybersecurity awareness both at work and home.

Identifying and Reporting

The goal of SAFE is to ensure everyone is able to identify and quickly report suspicious messages or activities. The Security Operations team analyzes every message that is reported as suspicious and sends the results back to the reporter. Sending the analysis results back to the reporter provides the reporter with confirmation of their ability to identify malicious messages or spam. On a monthly basis, phishing tests are sent out that simulate current phishing campaigns used by threat actors. Campaign attack techniques include domain and popular brand spoofs, QR codes, and suspicious links with requests for information, oftentimes with topics based on global security trends, cultural events or “the events of the day”. In addition to maintaining a low fail rate, the objective is to increase identification and reporting of suspicious messages. Those who fail are provided subsequent training to increase future awareness.

Administrative and Technical Controls

In addition to IT security policies, HealthEdge implements technical controls that monitor and enforce password policies and multifactor authentication. Network access is controlled, and principles of least privilege are enforced. This means that even trusted users with authorized network access are limited to only the access required to do their job. When access is granted, logs are collected from across the environment, which gives us the ability to monitor changes that could impact preservation of confidentiality, integrity, or availability. Our team’s cybersecurity habits, and best practices strengthen our administrative and technical controls; each component is critical for cybersecurity maturity.

A Holistic Approach

Our team prides itself on keeping up with the latest cybersecurity news and updates. We follow industry best practices, monitor third-party intelligence, implement technical and administrative controls, and most importantly we keep the cybersecurity discussion going. Our holistic approach allows our team to be prepared to protect the HealthEdge workforce network as the first line of defense, and also empowers them to practice good cyber hygiene at home. Security awareness for everyone, every day, everywhere.

 

HealthEdge’s Core Administrative Processing Platform Earns #1 Ranking

 

HealthEdge Software, provider of the industry’s leading next-gen integrated solution suite for health insurers, is proud to share that HealthRules Payer® earned the 2023 “Best in KLAS” title for Claims & Administration Platforms for the second year in a row. Healthcare IT data and insights company KLAS Research awards the annual recognition to companies ranking #1 in their category. Rankings are based on the opinions of healthcare professionals and clinicians in 23,000 evaluations across more than 4,500 organizations.

Powering plans across all lines of business, HealthRules Payer is solving some of today’s biggest payer challenges. An advanced core administrative processing system (CAPS) with capabilities far beyond legacy systems of the past, HealthRules Payer provides a transformational, digital foundation for health plans of all types and sizes. The next-gen application gives plans the agility, flexibility and insights to grow their business, embrace change, and swiftly address new regulations and market opportunities. In addition, the user-friendly platform reduces manual processing, empowering payers to improve operational efficiency through automation.

“We’re honored by the growing number of health plans that trust HealthRules Payer as the foundation for their digital transformation journey,” said Sagnik Bhattacharya, Executive Vice President and General Manager of HealthRules Payer. “We look forward to further accelerating health plan digital automation, flexibility and agility as today’s healthcare economy demands.”

What do HealthEdge customers say?

KLAS evaluations give a glimpse into what users are saying about HealthEdge & HealthRules Payer:

“HealthRules Payer is a great product. The system is very configurable, and we experience a high automatic adjudication rate for our claims, and those are really positive things. There are very few things that we haven’t been able to do in the system. I would buy HealthRules Payer again because it is a solid product. HealthEdge has done a lot of work and implementations, and they have created the best practices to move from one system to the next.” – Health plan COO, September 22, 2022

“HealthEdge stands out as the one vendor we would want to expand the business relationship with. When their CEO ascended, there was a shift in the philosophy of the company, and it became much more customer-centric. There is a whole chain of really talented people on their team, they have never hesitated to reach out, and our technical teams meet regularly. It is definitely a relationship we value quite a bit, even despite some bumps.” – Health plan CIO, September 22, 2022

“HealthEdge is at the forefront of things when it comes to staying current with the direction that healthcare is moving in the United States. Some examples of that are the ways that the vendor does value-based payments and makes sure that the system is aligned with the work that it needs to be. The vendor also keeps up the trend of moving toward a digital world. HealthEdge is very good at partnering with and acquiring other vendors.” – Health plan VP, September 22, 2022

Good Relationships + Good Technology = Customer Success

“Our company vision is to innovate a world where healthcare can focus on people,” highlights Steve Krupa, chief executive officer at HealthEdge “We’re thrilled to receive the “Best in KLAS” award for the second year in a row, and more importantly, help our payer customers write the next chapter of their story.”

Our healthcare SaaS software provides payers with a digital foundation that enables them to deliver a transparent and consumer-centric experience at lower cost while offering higher quality and higher service levels to their members, providers and partners.

HealthEdge’s Source Shines Bright in KLAS ‘Emerging Solutions Spotlight’

Alongside the “Best in KLAS” title honoring HealthRules Payer, KLAS Research surfaced high scores for prospective payment integrity platform Source, an integral part of the HealthEdge ecosystem. In a 2023 “Emerging Solutions Spotlight” examining product performance, KLAS details Source’s strong customer satisfaction scores, with A grades for all key performance indicators and success in achieving customers’ expectations. The report references high points called out by customers, including the tool’s biweekly updates around pricing guidelines and real-time claims processing that gets prices right on the first pass. Payers in the report credit Source for increased savings, reduced agreement volumes and workflow automation. KLAS Research highlights customer comments commending the company for listening to customer needs, providing frequent updates to reflect changes in fee schedules, and enabling visibility into Medicare rates and pricing. “What sets HealthEdge apart from other vendors is the capability to look up the Medicare rates in the system,” said a health plan director. “If we have, for example, a provider that says that we didn’t price a claim correctly, we love the way that the audit tool can go in and look at the claim.”

“As an interoperable, cloud-based platform built from the ground up, Source enables health plans to identify and fix issues at the root cause,” said Ryan Mooney, Source’s executive vice president and general manager. “With true transparency and control over their payment integrity operations, healthcare payers can finally unlock the ability to pay claims accurately, quickly and comprehensively the first time.”

Learn more about HealthRules Payer and Source.

New York represents one of the country’s largest populations of Medicaid beneficiaries, according to Medicaid.gov. Keeping up with the payment and policy updates that the New York State Department of Health (NYSDOH) sets for Medicaid providers is no easy task for payers trying to successfully serve this growing population. In fact, in a 2022 survey of more than 400 payers offering Medicaid as a line of business, the three most popular challenges payers faced were all tied to staying compliant with all of the changes:

• 74% = staying compliant with changing reimbursement policies
• 62% = installing updates to the fee schedule in a timely manner
• 52% = keeping up with changing fee schedules

That same study revealed how manual-intensive it is for payers to keep their Medicaid program fee schedules and policies up-to-date, with 84% claiming that they do it “mostly manually.”

Due to the complex nature of Medicaid, payers have historically relied on a patchwork of disparate workflows and vendor solutions to provide pricing for their Medicaid lines of business. Today, Source is taking its expertise developed over decades of supporting Medicare reimbursement and applying that same depth and breadth of content to Medicaid. New York is the latest state supported by HealthEdge Source.

The uniqueness of state Medicaid programs is what makes it so challenging for many solutions to keep up. One size does not fit all, and change is constant. Each state has its own set of rules that payers must play by so there are very few common rules that can be applied. For example, in New York, the state doesn’t post nursing facility rates by NPI or Medicaid ID, but by operating certificate. Many states are still using grossly outdated Medicare guidelines and prices. And when you combine these unique complexities with those of the multiple Managed Care Organizations (MCOs), it can quickly become overwhelming to manage, resulting in non-compliance and inaccurate payments.

HealthEdge Source: How it Works

When it comes to payment integrity for Medicaid programs, the Source experts have payers covered with two dedicated teams – one for data research and new developments and a second for maintaining the Medicaid edits currently available. Armed with advanced web monitoring tools and seasoned research analysts, Source delivers updates to customers every two weeks. And because it is a cloud-based solution, those updates are automatically applied. That means IT teams are free to focus on strategic initiatives instead of trying to maintain complex pricing.

Many industry experts believe that state Medicaid programs will continue to become increasingly complex as the necessity of finding more cost-effective ways to deliver high quality care becomes more urgent due to rising costs. To learn more about how Source can help your organization stay on top of the ever-evolving New York Medicaid program requirements, visit Source Medicaid Reimbursement.