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The healthcare industry is experiencing unprecedented change. New technologies in care management are now widely available to help healthcare payers streamline care delivery, improve operational efficiencies, and automate manual processes.

How are industry shifts impacting the requirements of effective training for care management staff?

Sontz-Morrison: There are several factors influencing the demand for more and accessible staff training opportunities in functional areas like care management. The first is, without a doubt, workforce shortages and high turnover rates. The World Health Organization (WHO) predicts a shortage of 10 million health workers by 2030. This ongoing workforce shortage across allied and behavioral health, long-term services, nursing, primary care, and women’s health is placing an immense pressure on clinicians and support staff to “do more with less.” Despite these constraints, maintaining quality care remains paramount.

Second, the regulatory environment in healthcare is constantly changing. Health plans must remain updated on Medicare and Medicaid regulations while also focusing on improving pricing transparency and healthcare access. Though it can put more administrative burden on care teams, staying up-to-date on new guidelines is essential to ensuring compliance and remaining competitive.

Lastly, the consumer demand for personalization is shaping how we need to develop our training. Modern consumers have come to expect personalized experiences in most aspects of their lives—including their healthcare. These expectations are pushing healthcare payers to adopt new technologies that are transformational. Training for any of these technologies, which can require staff behavioral changes and high adoption rates to be effective, must be fool proof.

The integration of new technologies, evolving regulations, and current workforce dynamics significantly impacts the requirements for technology onboarding and training at health plans. Health plan staff must enhance their knowledge and stay current with regulations to streamline their processes without adding extra layers or underutilizing talent. Without proper education, new tools can become cumbersome for users, causing issues like technology underutilization, administrative errors, missed regulatory deadlines, or missed opportunities to improve member outcomes.

What is GuidingCare University, and how can it support health plan staff?

GuidingCare® University (GCU) is a self-service learning and development solution designed to empower customers and end-users by giving them control over their success. GuidingCare® users even receive alerts before new training modules go live to improve visibility. With GCU, staff have access to comprehensive training on GuidingCare content, technology, optimization, and best practices.

GuidingCare University was designed to serve staff working in a variety of roles, including utilization management, nurses, medical directors, appeals and grievance staff, and population health professionals. By targeting all staff that utilize GuidingCare software, GCU ensures comprehensive training and knowledge sharing across teams. This leads to optimized solution usage, breakdown of internal siloes, and streamlined daily operations.

What are some of the benefits to leveraging GuidingCare University training?

• Continuous Learning: New courses are added quarterly and as needed based on product feature enhancements, ensuring that there are no delays due to a lack of instructors or updated information.
• Real-Time Updates: Training modules go live at the same time as product updates, providing insights and best practices whose value can be passed on to members.
• Increased Efficiency: Employees can access and revisit trainings at any time, reducing time spent searching for answers and getting stalled by not knowing who to ask.
• Improved Accessibility: Training modules are broken into “bite-sized” 5-20-minute segments, making them easy to watch and understand even with a busy schedule. This is particularly beneficial for care managers who balance training with patient care.
• Self-Empowerment: On-demand training modules ensure employees never have to feel like they don’t have enough training to perform their roles effectively. Trainings can also be used alongside organizational onboarding to give new users a comprehensive resource.

Which metrics do health plans use to measure the impact of on-demand training from GuidingCare University?

Key performance indicators (KPIs) play a crucial role in evaluating the effectiveness of training tools like GCU. In addition to tracking metrics like messaging and touchpoint volume, health plans can assess training effectiveness in other ways. Increasingly, organizations are using badge programs and certifications to demonstrate employee skills and understanding of a digital solution.

To help healthcare payers understand how their employees are using the modules and absorbing important information, GCU will be incorporating three new tools into the platform:

• Knowledge checks that pop up throughout training videos.
• Pre- and post-training quizzes to gauge understanding and identify areas for improvement.
• Reporting that tracks video engagement, including watch duration, completion rates, and most rewatched content.

Recently, a customer interview revealed that employees found GCU training streamlined their comfort with the GuidingCare solution. New employees also reported the GCU training modules enhanced their overall onboarding process and helped them feel empowered to fulfill their roles successfully.

The Bottom Line

Today’s healthcare environment demands a responsive and adaptive approach to staff training, especially when it comes to using new technologies. Effective training solutions are not just an option for health plans, but a necessity. By providing continuous learning opportunities and real-time updates, GuidingCare University ensures that staff are well-equipped to meet the dynamic demands of the healthcare industry—leading to better performance, improved member outcomes, and more efficient operations.

Read our brochure, “Empowering Health Plans to Advance Care Management with GuidingCare”

Digital care programs have emerged as a transformative tool to improve clinical outcomes and member engagement. From supporting maternity populations to managing chronic conditions like Diabetes, digital care programs can provide personalized support to members across the risk pyramid. However, the success of these programs hinges on meeting members where they are to keep them invested in improving their health.

Unlocking the Potential of Digital Care Programs

Digital care programs offer immense potential to improve clinical outcomes and member engagement. By implementing best practices such as omnichannel support, consistent communication, personalized information, and accessible language, health plans can enhance the member experience and increase care program completion rates.

The Wellframe solution makes it easier for members to take control of their health by providing information and support through a convenient digital app. Here, we’re sharing best practices to drive member engagement for digital care programs.

Omnichannel Support: Meeting Members Where They Are

Today’s healthcare consumers expect convenience. They need to be able to reach out to their health plans and care teams on their own time, using the channels they prefer. For many members, this goes beyond answering sporadic phone calls or waiting on hold.

Making care programs available to members via smartphone makes it easier for them to engage at their convenience. They can also engage in multiple ways, depending on their needs and preferences. Wellframe’s omnichannel support ensures that members can interact with their care programs via smartphone or tablet at any time of day, providing flexibility and accessibility.

Key Features:

• 1:1 HIPAA-Compliant Messaging: Members can send secure in-app communications to their care teams. Participants can also send attachments (like photos) and links to helpful information.
• Digital Assessments & Surveys: Instead of calling members and asking them dozens of questions over the phone, send a digital survey or assessment. Members can answer them discreetly, and care managers are alerted when they’ve been completed.
• On-Demand Educational Content: Clinically reviewed articles are written at or below a 4th-grade reading level. This information helps empower members with information they need when they need it.

By offering multiple ways for members to interact, Wellframe makes it easier for individuals to stay engaged and committed to their health and wellness goals.

Consistent Communication: Building Daily Habits

Consistency is key to forming healthy habits, and Wellframe leverages this by providing members with a personalized daily checklist of health-related tasks. Members can check in with the app daily to check messages from their care managers, track biometric data, complete medication reminders, and take other health actions. This consistent communication helps members integrate care activities into their daily routines, making it more manageable and sustainable.

Key Features:

• Personalized Checklists: Tailored tasks and recommended articles based on care program enrollment, medications, and health goals.
• Medication & Appointment Reminders: Keep members on track with the option to create in-app prompts for medications and doctors’ appointments.
• Biometrics Tracking: Encourage members to log biometrics such as weight, blood glucose, blood pressure, and step counts regularly to foster a sense of accomplishment.

By maintaining a steady flow of communication, Wellframe keeps members engaged and motivated to complete their care programs.

Personalized, Relevant Information: Enhancing Member Experience

One size does not fit all in healthcare. Wellframe ensures that each member receives personalized and relevant information tailored to their specific needs and health conditions. This personalization enhances the member experience by making educational content more applicable and engaging.

Key Features:

• Digital Care Programs: Clinicians enroll members in digital care programs based on diagnosis, condition, or health goals. Currently, Wellframe offers more than 70 care programs.
• Targeted Content: Members receive links to suggested articles on their daily checklists. Articles are related to the member’s current care program.

Providing personalized articles and information keeps members engaged and helps them feel understood and supported.

Steer Clear of Healthcare Jargon: Bridging the Health Literacy Gap

With only 12 percent of Americans having proficient health literacy skills, it is crucial to use accessible language in digital care programs. All Wellframe content is written at or below a 4th-grade reading level to ensure it is accessible to as many members as possible. But accessible language should go beyond educational health content—nearly 1 in 4 members said they are “often” or “always” confused by health plan communications.

Key Features:

• Simplified Language: Avoid healthcare industry jargon and use clear, straightforward vocabulary. Member communications should be written at or below a 4th grade reading level.
• Educational Resources: Healthcare information should be easy to understand and act upon.

By simplifying the language used in member-facing communications and articles, Wellframe makes healthcare more approachable and reduces barriers to engagement.

Leveraging Wellframe Solutions: A Comprehensive Approach

Wellframe offers robust solutions designed to enhance member engagement and improve clinical outcomes. Wellframe’s Digital Care Management and Clinical Advocacy services provide comprehensive support across the healthcare continuum.

Key Solutions:

• Digital Care Management: Streamlining care processes and improving member experience.
• Clinical Advocacy: Offering personalized support and guidance to members.

By leveraging Wellframe’s solutions, health plans can create a more connected, efficient, and effective care ecosystem.

The healthcare landscape is fiercely competitive, with both established payers and innovative disruptors vying to capture market share. Yet, in this rush, a crucial factor often gets overlooked: member engagement.

In our five-part blog series, HealthEdge Source™ Horizons, we demonstrate how our payment integrity solution empowers health plans to achieve compliance, expand market reach, and manage value-based care. In this blog, we will dive into how health plans can enhance payment accuracy and transparency, the cornerstones of member trust and engagement.

Read the entire series at the links below:

• Ensure Regulatory Compliance and Cost Transparency
• Improve Payment Accuracy and Efficiency with Advanced Automation
• How Payment Integrity Innovation Helps Expand New Business Opportunities
• Simplifying Value-Based Care Contracts & Reimbursements
• Increase Member Engagement & Build Trust with Cost Transparency

Why member engagement matters

Member engagement goes beyond profit; it directly impacts health outcomes. Engaged members take a more active role in their healthcare, leading to better health outcomes and lower long-term costs for your plan.  However, factors such as inaccurate payments, lack of transparency, and delays can erode trust and disengage members.

Our recent webinar, “Empowering Modern Health Care Consumers,” highlights the importance of member satisfaction. We emphasize the critical role of payment accuracy and transparency in building member engagement. By offering clear explanations of benefits, coverage details, and out-of-pocket expenses, you enable members to make well-informed healthcare decisions. This not only reduces anxiety about surprise bills but also fosters collaboration, leading to a stronger partnership and better health outcomes.

Increase health plan efficiency to improve member relationships and engagement

Reduce clinician burnout from administrative overload

Clinicians are drowning in administrative tasks, leading to burnout and less time spent with patients. Every minute spent on paperwork steals valuable time from direct patient care, hindering the ability to deliver personalized and attentive care.

HealthEdge Source alleviates this burden for clinicians, creating a ripple effect of positive outcomes. Our solution automates essential claims and payment processes, freeing up time for clinical decision-making. By streamlining routine tasks and simplifying complex processes, we eliminate the need for time-consuming manual reviews. This allows clinicians to refocus their energy on what matters most—delivering high-quality patient care.

With more time dedicated to patients, improved communication and a more positive patient experience naturally follow. And reduced clinician burnout leads to lower turnover rates, saving on costly recruitment and training expenses.

Offer pricing transparency and easy access to information for members

Transparency in healthcare costs and coverage is a top priority for both your members and regulatory agencies including the Centers for Medicare and Medicaid Services. Empowering your members with clear, accurate information is key to building trust and driving engagement.

Here’s how we help health plans achieve transparency:

• Eliminate Surprise Billing: Our cloud-based system ensures accurate estimates upfront, preventing surprise bills and fostering trust from the beginning.
• Real-Time Information Access: With 24/7 data access, your plan or any providers can proactively communicate coverage details and potential cost-saving options directly to members.

Cloud-based data delivery ensures that your plan has the most up-to-date and accurate content and regulatory updates, eliminating confusion and errors. Furthermore, cloud-based processing reduces wait times by streamlining claims and inquiries. Most importantly, the cloud provides a secure and scalable environment to protect member data and ensure smooth system performance even during peak demand.

Happy providers = Happy members

Building strong provider relationships is crucial for a health plan’s success. Happy providers lead to happy members, yielding better health outcomes and reducing long-term costs. Designed for true Payment Accountability, HealthEdge Source not only streamlines internal operations but also allows you to nurture these crucial relationships.

Traditional claim processing frustrates providers with errors and inconsistencies. Our Platform Access technology solves this issue by streamlining internal operations, ensuring accuracy, transparency, and comprehensive claims payments upstream in the adjudication process. Now you can transform your business, organize your data in a single place, address root cause issues, and pay claims right the first time.

With key features including:

• Editing Library with History: Access historical data, parameters, and exceptions for edits, allowing for informed decision-making.
• Custom Edit Builder: Tailor specific edits to meet your unique payment arrangements and cost-saving goals.
• Real-Time Analytics: Gain valuable insights into performance metrics and the impact of edits on your claims process.
• Monitor Mode: Test the impact of edits on your system before implementation, minimizing disruptions.
• Comprehensive Audit Trail: Track and view claim-level edit details for complete transparency.

Our platform seamlessly integrates with your existing systems, eliminating the need for disruptive rip-and-replace solutions. Regular updates ensure your system stays current, while the scalable design allows you to adapt to future needs.

By providing a single, streamlined platform for accurate and efficient claims processing, we can help you to build stronger relationships with your providers. This translates to a win-win for everyone: happier providers delivering better care, a more satisfied member base, and a healthier bottom line for your health plan.

Ready to learn more?

Explore our blog series, “HealthEdge Source™ Horizons,” to discover how our solution can help you achieve compliance, expand market reach, and manage value-based care.

Want to learn more about how your health plan can access valuable analytics while increasing payment accuracy and transparency? Read our blog, “The Shift to Payment Accountability®: An Enterprise Approach to Healthcare Payment Integrity.”

Has your health plan ever processed claims for the month, only to be hit with a new regulation or a provider contract update? This frustrating cycle of retroactive changes is a consistent pain point for healthcare payers, causing delays, errors, and wasted time. Don’t make your team backtrack, re-evaluate claims, and scramble to adjust payments. HealthEdge Source™ offers a retroactive change management tool that ensures all adjustments are accurately tracked and implemented.

Leveraging Retroactive Change Management to Improve Payment Accuracy

Retroactive change management refers to the process of adjusting previously completed healthcare claims transactions to correct errors or reflect new information. For healthcare payers, this is essential for maintaining accuracy and compliance. HealthEdge Source solution incorporates retroactive change capabilities, helping healthcare payers to manage discrepancies and avoid financial losses.

The Costs of Making Retroactive Payment Changes

Throughout 2024 alone, experts anticipate over 600 changes to fee schedules, edits, and pricing logic. Updates to guidelines and regulations come from various sources, including:

• Regulatory bodies (e.g., Center for Medicare and Medicaid Services (CMS) updates, Medicaid rate changes)
• Network contracts (e.g., modifications to provider agreements or payment policies)
• Internal configurations (e.g., changes in fee schedules or other system configurations)

Retroactive changes can impact a health plan’s bottom line in a few ways. Delays in enacting these changes may result in overpayments to providers, leading to financial losses. Conversely, underpayments can strain relationships with providers and pose administrative burdens for your team. Both overpayments and underpayments can damage your health plan’s reputation and expose you to potential regulatory penalties.

Implementing a solution with retroactive change management capabilities can help payers improve:

1. Accuracy: Ensures all payment adjustments are accurate and compliant.
2. Efficiency: Streamlines the process of managing retroactive changes.
3. Compliance: Keeps up with regulatory requirements by applying necessary changes retroactively.

Shift from a Reactive to Proactive Strategy

Manually managing retroactive changes is a time-consuming and error-prone process that diverts valuable resources away from other important tasks. The volume and complexity of retroactive changes can be overwhelming for staff. But health plans can mitigate manual roadblocks with a proactive approach to reimbursement management.

Here at HealthEdge, we understand the financial burden retroactive changes create. Our solution aims to reduce overpayments and underpayments and ensure claims are paid correctly—the first time. With our Retroactive Change Manager (RCM) tool, your team can spend less time finding, chasing, and collecting what’s already gone out the door.

HealthEdge Source™ Retroactive Change Manager

Last year, HealthEdge Source launched the first phase of the Retroactive Change Manager. The tool helps healthcare payers automate core tasks, such as flagging claims that will be automatically eligible for reconciliation upon delivery. Scheduled reviews save valuable time that would have been spent on manual searching.

Additionally, RCM users receive regular variance reports that detail all the claims impacted by retroactive changes, along with the exact adjustments needed. This comprehensive approach gives health plans a clear picture of financial exposure and eliminates guesswork. This initial rollout laid the foundation for a more proactive approach to managing reimbursements, saving time and money, and avoiding potential payment issues.

Latest Enhancements to the Retroactive Change Manager

The latest enhancements to the Retroactive Change Manager go beyond regulatory updates. They empower health plans with a range of features designed to streamline workflows and maximize financial security.

With new targeted analyses and streamlined operations, healthcare payers can:

• View configuration updates within specific timeframes to focus analysis on impacted claims related to provider types or edits.
• Receive timely email notifications and enhanced claim summary reports for a clear understanding of adjustments needed.
• Enhance the user experience with increased performance and stability for smoother operations.

Leveraging the RCM directly translates to a healthier financial bottom line for health plans in three primary ways. First, it automatically recovers overpayments that might have been missed before. Second, faster and more accurate payments to providers lead to stronger relationships and fewer disputes—which can save time and administrative costs. Finally, the RCM keeps claims data organized and readily available, ensuring health plans are always audit-ready. This peace of mind allows payers to focus on strategic initiatives that drive organizational growth.

By shifting from a reactive to a proactive claims management approach, health plans can leverage a single system to identify and address retroactive changes. Imagine complete data sets analyzed automatically, underpayments identified and addressed proactively, and overpayments recovered internally. This not only saves time and money, but also fosters stronger provider relationships and ensures compliance. With fully incorporated industry changes and provider configurations healthcare payers can finally move from reactive adjustments to proactive control.

For more information about how your health plan can leverage retroactive change management, watch our on-demand webinar, “Optimizing Retroactive Configuration Changes”.

Healthcare payer claims operations teams often face additional work and processing when working with multiple claims or data systems. Scattered processes and data lead to waste, inaccuracies, and friction within a health plan’s IT ecosystem that translates to the payer-provider relationship. 

Gain a Competitive Edge by Consolidating Your In-Network and Out-of-Network Pricing Management

Specifically designed to extend to third-party best-of-breed content solutions, HealthEdge Source™ uniquely addresses these challenges. With this integration, payers can seamlessly incorporate FAIR Health data into their workflow to streamline in-network and out-of-network pricing for Medicare parts A and B, or any line of business that utilizes FAIR Health. 

FAIR Health is a renowned third-party vendor that collects data for pricing management. It uses pricing benchmarks based on the region and zip code, as well as national averages, providing just the kind of data needed to streamline your operations and cut out wasteful processes.  

The Value of Integrating FAIR Health’s Data with HealthEdge Source

Utilizing FAIR Health’s robust data offerings and bringing them to Source is a significant step in providing our clients with more value. It enables Source members to deliver unique insights and analytics that could transform your claims operations – making them more efficient and cost-effective. 

The FAIR Health integration will not only resolve common issues you face but also potentially introduce UI changes based on client requests. This can include data reference views and new pricers connected to the FAIR Health fee schedule. The latter is similar to wrapper pricers and other third-party pricers presently in Source.  

Moreover, users can expect potential enhancements in configurations, unlocking even greater capacity for your operations. Our development teams are working behind the scenes on utilizing a data pipeline for file transformation to ensure this integration provides maximum advantages for your health plan operations. 

The End Goal: Smoother Workflow and Seamless Integration

Ultimately, the end goal is to facilitate a smoother workflow and a more seamless integration between multiple claims or data systems. The integration of FAIR Health content into HealthEdge Source opens up a myriad of opportunities for healthcare payer claims operations teams to streamline their processes and work more efficiently.