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Health plans are facing unprecedented challenges in accurately pricing claims due to a growing number of value-based payments and government regulatory requirements. As providers’ expectations for more efficient and accurate payments continue to rise, health plan leaders are turning to modern technology for help.  In the past, health plans used a traditional approach to solving these challenges. They relied on multiple business units and stacked third-party claims editing solutions—which resulted in a fractured approach that focused solely on measuring a percentage of recovered savings downstream. 

The future of payment integrity is shifting towards Payment Accountability®, an enterprise-wide approach that brings together different business units to increase focus on measuring cost avoidance instead of just recovery. Payment accountability emphasizes creating transparency to address root cause inaccuracies so that payers can pay claims accurately, quickly, and comprehensively the first time.  

Industry experts claim that this enterprise-wide approach can reduce medical expenses by 10% or more, with the potential for significant reductions in administrative expenses. An enterprise approach to claims adjudication can shift processes upstream, solve root-cause issues, increase accuracy, and reduce provider abrasion.  

The Source Approach to Payment Accountability 

HealthEdge Source™ (Source) was specifically designed and intentionally built to enable payers to allow health plans to insource more functionality, derive valuable analytics, and increase transparency and interoperability.  

The Source platform, to meet evolving market demands, is focused on the following core areas: 

• Real-time integration expansion: Seamless integrations with third party solutions that expand payment integrity and reimbursement offerings and reduce the administrative burden on clients using multiple vendors. 
• Continued content expansion: To deliver added automation, savings, and accuracy, including additional Medicaid, Medicare, Cost Containment, and other specialty edits and pricers. 
• Improved accuracy: By including additional validating datasets such as prescriptions, medical records, and others. 
• Adoption of AI/ML technologies: To automate and/or assist manual and tedious workflows. 
• Efficient workflow and best-in-class user experience: Through self-service tools like policy creation, implementation, and management. 
• Creating insights for data-driven decisions. 

But the team doesn’t stop there. Our product investment strategy includes a multi-year roadmap focused on enhancing the content, features, and technology to drive continuous improvement in the solutions we deliver. We’re currently piloting an AI-enabled chat bot that allows users to type questions in natural language regarding the Source edits, pricers, functionality, and other capabilities. This results in quick and accurate responses, freeing auditors or provider relations team members from scouring through multiple user guides, worksheets, and other materials. The chatbot can provide the necessary information in seconds.  

Additionally, Source is streamlining the process of managing configuration by utilizing APIs to create, manage, and publish edit changes to production. This process reduces the need for manual user intervention, allowing the payment integrity and configuration team members to focus on other critical business tasks. 

A Guiding Hand from the Payment Integrity Experts 

Source experts are available to participate in a Payment Integrity Health Check as part of the implementation process. This helps our team gain a better understanding of your current processes, data, and internal expertise so that we can work together efficiently and provide a solution that enhances your health plan’s strengths and aligns with the long-term payment integrity goals. Source experts will also work with our customers continually after go-live, to review data and identify areas that can add value to your payment integrity program. 

Post-implementation, Source maintains close partnerships with our clients. We gather feedback and input on our product roadmap in many ways, such as conducting 1:1 user research and design sessions with the product and engineering teams, monthly user groups, semi-annual customer advisory boards, regulatory steering committees, bi-annual virtual customer events, and annual client conferences.  

From Payment Integrity to Payment Accountability 

At Source, our solution aims to redefine payment integrity by shifting the industry from a black box to an open-book approach. Unlike traditional payment integrity solutions that often operate retrospectively and give limited intelligence to health plans, Source is designed to deliver transparency in editing solutions. Our goal is to empower payers with technology that enables them to gain control of their IT ecosystems, address root-cause issues, and reduce waste in the healthcare system.  

Source accomplishes this differentiation by providing the following unique features:  

• The ability to configure contract reimbursement terms, edit and price claims, and run analytics in a single call to Source. 
• Extensive editing and pricing content libraries that are out of the box and always up-to-date and accurate through our two-week update cycle. 
• Configurable and customizable edits to make pre-payment claim decisions based on a health plan’s intellectual property. 
• Real-time analytics to monitor utilization and financial impacts of edits prior to enabling their impact in the live adjudication workflow. 
• Claims pricing based on negotiated fee schedules, including CMS and Medicaid methodologies, to ensure edits and reimbursement are accurate prior to adjudicating the claim. 
• Continuous member claims history analysis by the Source team to recommend new edits that solve recurring post-payment issues.  
• Integrated third-party content within the solution to improve accuracy, promote higher and faster automation, simplify workflows and vendor contracting, and keep all data in a single location. 

To learn more about how Source can help your organization successfully make the shift to payment accountability, visit the Source webpage.  

Regulatory compliance and transparency are more than healthcare industry buzzwords: they’re key areas of focus for regulatory agencies and consumers. Staying compliant with shifting state and federal regulations can be a challenge, requiring efficient access to the most up-to-date information available. And pricing transparency has become an essential way for health plan members to make informed care decisions.

At HealthEdge®, we are committed to supporting our customers in achieving and maintaining compliance. Our mission is to empower your organization to become a digital payer, achieving key business goals—like improving the member experience and reducing costs—by leveraging innovative digital technology.

Introducing HealthRules® Machine Readable Files Suite

The HealthRules® Machine Readable Files Suite 3.x stands as a testament to our commitment to innovation, compliance, and transparency in the healthcare industry. Designed to address the requirements of the Transparency in Coverage final rule, our pioneering software solution offers a robust framework for generating machine readable files (MRFs) that detail negotiated rates for in-network providers and allowed amounts for out-of-network providers.

This initiative is not merely about complying with regulations; it’s about ushering in a new era of clarity and trust between health plans and their members.

3 Key benefits of using Machine Readable Files

Real-Time Reporting

Leveraging the power of cloud technology, our solution suite allows health plans to their own reports in real-time, ensuring your team has consistent access to the most up-to-date information.

Intuitive User Interface

The platform’s user interface was designed to make compliance as straightforward as possible and significantly reduce the complexity of generating machine readable files through the HealthRules solution.

Native Integration

As the only machine-readable file generation tool built natively into a Core Administration Platform Solution (CAPS), our MRF suite seamlessly integrates into your existing systems—minimizing disruptions and enhancing operational efficiency.

Key goals of offering an integrated MRF suite within the HealthRules solution are to clarify compliance needs, enhance transparency, and improve the member experience for our health plan customers. This innovative feature is just one representation of our dedication to not just meeting the needs of payers today but shaping the future of healthcare. Partnering with HealthRules can help your team work more efficiently to transform industry challenges and demands into opportunities.

Are you looking for more information on our advanced Core Administrative Processing System (CAPS) and how it can integrate with your health plan’s existing platforms? Visit the HealthRules® Solution Suite.

 

 

 

On January 17, 2024, CMS released the Advancing Interoperability and Prior Authorization Final Rule (CMS-0057-F), which aims to improve health information exchange for patients, providers, and payers—and improve prior authorization processes. These regulations have a significant impact on payers and how they approach interoperability from all aspects of their businesses. 

We recently sat down with Bobby Sherwood, VP of product development for the HealthEdge® care management platform, GuidingCare®. Sherwood offered his perspective on interoperability with GuidingCare and how his team is enabling HealthEdge customers to meet compliance requirements and thrive in this new environment of real-time data sharing across their ecosystems.  

Q: The topic of interoperability has been around for more than a decade. Why do you think it is now emerging as an urgent priority for many health plans?  

Sherwood: There are several factors that cause interoperability strategies to become a central issue for payers. First, CMS plays a big role in this by strongly encouraging a standard interface (HL7® FHIR®). While this has been in the works for several years, the final ruling on the Advancing Interoperability and Improving Prior Authorizations Act published earlier this year brought more clarity around the standards and what payers should expect. More aligned standards make it easier for stakeholders to connect and share information. 

Second, members play a role in pushing interoperability to the forefront of payers’ minds. As mentioned in the Healthcare Consumer Satisfaction Survey, members want more personalized interactions and digital communications. Today’s healthcare consumers expect more from their health insurance providers, and the availability of real-time data is key to supporting these expectations.

Lastly, there is a huge amount of data now available that enables payers to do more things, like embrace value-based care models, leverage AI and ML, and more. As the adoption of all things digital increases, so does the value of the data that supports these things. For example, with accurate and timely data, AI can dramatically reduce administrative burdens that payers have struggled to address for decades. These burdens drive up operational costs and limit a health plan’s ability to adapt to market dynamics.  

With greater access to data comes the opportunity to make better decisions faster and realize significant savings that can be applied to other areas of the business. When you add in the value that data can deliver to the clinical areas of the business—such as analyzing risks, developing more individualized care plans, and even interacting with members—interoperability quickly becomes a must-have for remaining competitive in today’s market.  

Q: What are some of the barriers you see health plans struggling with the most when it comes to enabling the exchange of healthcare data? 

Sherwood: One of the biggest challenges I see health plans struggling with is that it takes all stakeholders working together to exchange the data and extract the real value from their interoperability strategies. For example, a health plan must have the right systems to easily accept and share real-time data with providers and members. Your providers also must have systems in place, such as electronic health record (EHR) systems, that can push and pull data to and from your systems. That’s where standards like FHIR and initiatives like the Da Vinci Project that HealthEdge is participating in come into play. The Da Vinci Project specifically targets these challenges by establishing standards and resources available to all stakeholders so interoperability can happen on a much broader scale than ever before.  

Another barrier I see is the cost of making disparate systems actually exchange data. It takes work, time, and specialized technical resources (QA, development, etc.) to connect all of these systems—and not all payers have the resources available to embrace all that robust interoperability strategies can deliver. But, as we further define the standards and more use cases become available, I believe those costs will come down, and the workflows will become more attainable. The costs will never go to zero, but the ROI will continue to grow, and interoperability will become more accessible—and a more desirable lever for payers to pull. The use cases for interoperability are almost unlimited. Besides the penalties that will be incurred for not adhering to CMS regulations, the financial gain will become increasingly evident for use cases like improving care coordination, eliminating gaps in care, improving Star ratings, and driving member satisfaction.   

Q: Where do you think the health insurance market is on the maturity map of interoperability?  

Sherwood: The market is relatively mature from a technological standpoint. For example, at GuidingCare, we’ve been delivering highly interoperable solutions for years. We have over 75 pre-packaged integrations with other systems, and we’ve recently released native integrations with our HealthEdge solutions, HealthRules® Payer (Care-Payer) and Wellframe (Care-Wellframe).  

From a payer perspective, the maturity levels vary. With our larger customers, they are very advanced, most likely because they have more complex businesses, provider networks, vendor ecosystems, and IT departments. We’ve partnered with many of them for years to help them meet their interoperability goals. Some smaller payers may not have as much of a need or as many resources, so many are still in the early stages. That’s one of the great things about working with HealthEdge, though. We bring the expertise of working with larger payers and understand where the market will help payers of all shapes and sizes succeed. So, when their needs change, we are there to help them grow and mature in the most informed, efficient way.  

Q: What have you heard from health plans about their readiness for these new standards to be enforced?  

Sherwood: Our current customers are ready because our solutions are FHIR-ready. We’ve been working hard to keep them informed about the interoperability standards over the past several years. Since the final ruling came out a few months ago, every prospective customer we talk to wants to understand how we will support them and their ability to meet these regulations. They are starting to formulate their strategies and turning to solutions like HealthEdge because we have a strong reputation for market-readiness when it comes to all things regulatory.  

Q: How does GuidingCare support these emerging interoperability standards?  

Sherwood: We build, support, and maintain a variety of data exchange capabilities within HealthEdge and the GuidingCare platform because we want to meet our customers where they are along their digital transformation journey. For example, within GuidingCare, we: 

• Have a robust suite of more than 125 APIs that expose data entities so our customers can retrieve the data they need whenever they need it to interact with external vendors or their own data warehouses 
• Improve efficiency with modern event streaming 
• Support FHIR standards and address the CMS interoperability requirements, which makes it easier for health plans to connect to external vendor systems, like their provider network EHR systems 
• Are participating in the HL7® Da Vinci Project, a group of industry leaders and health IT technical experts working together to accelerate the adoption of HL7® FHIR® as the standard to support and integrate value-based care (VBC) data exchange 
• Partner with some of the nation’s largest health plans that help us all stay current with emerging interoperability rules and trends 

Our goal is to offer a broad range of interoperability solutions so that every customer can benefit from the real-time data exchange. 

Q: What value does a highly interoperable care management system bring to a health plan? 

Sherwood: All stakeholders in the care management workflow win when health plans use a highly interoperable care management system like GuidingCare.   

• Care managers: Interoperable solutions enable care managers to access a more complete picture of their members directly within their GuidingCare workflows. Access to this information at their fingertips enables care managers to make more informed decisions, such as which programs members should enroll in, what social services would be most helpful, what their medical history is, what medications they are currently using, and more. For example, suppose collecting and storing social determinants of health (SDOH) data is managed outside the care management platform. In that case, it can be difficult for care managers to identify and refer members to social services like transportation or meal services. More informed decisions lead to better outcomes and lower utilization costs.  
• Payers: By accessing both clinical data that exists in GuidingCare and operational data that exists in other systems, payers can get a more complete picture of their business, especially when it comes to managing value-based payment models. Plus, they can more easily identify operational efficiencies and better align care services with the needs of their members.  
• Members: When engaging with health plans, members often get frustrated with things like filling out the same forms for every medical interaction. It can be comforting for them to know that their care team has the information at their fingertips. By easily exchanging data between payers and providers, as well as other payers, members are more confident in their care plans. Plus, they have greater access to their health information, appointment scheduling, self-reported data, and more. The seamless flow of data supports better care coordination and better health outcomes.  

Q: Where do you think interoperability is going over the next 5-10 years? 

Sherwood: I think interoperability standards will continue to mature, and the number of use cases will expand. We will get higher adoption of the new real-time data exchange standards and move away from batch transactions over time. Real-time data exchange will be the norm, and data will likely become liquid and flow seamlessly through the system. We will see a premium placed on the volume and quality of data that supports further innovations, like AI in healthcare.  

Q: For those payers who do not have the right care management platforms in place today to support the interoperability standards, what should they be looking for in a new solution?  

Sherwood: The three most important things I believe payers should consider when evaluating a care management platform that can support both current and future CMS standards such as FHIR are: 

1. Look for the vendor to have a strong foundation of existing capabilities already delivering FHIR-ready solutions, so you are starting with someone who is already highly capable of taking your organization into the future. You want to find a vendor who is leaning into interoperability and focused not only on the now, but also on the ‘what’s next.’  

1. Look for a vendor who truly embraces a partnership approach to interoperability. Every payer is at a different point in their journey, and you want a partner who offers flexible options that meet your specific needs. 

1. Ensure you find a system that has a strong care management platform that sits on top of all of this real-time data so that it can be used effectively in executing those care management activities.  

To learn more about how GuidingCare can help your organization make the most out of your interoperability strategy, visit www.healthedge.com.