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“Operating margin improvement is a top three critical outcome for digital investments in 2024 for 67% of U.S. healthcare payers.”
— Gartner®, Three Operational Excellence Best Practices to Optimize Costs for U.S. Healthcare Payers, 1 November 2023, Mandi Bishop 1 

Healthcare payers’ operating margins are being squeezed like never before. As many payers turn to technology and automation for answers, it is important to identify areas in the business where manual resources are being used to do work that modern technology can easily accommodate.  

According to the same Gartner report, “You and your IT team must rationalize applications, hyperautomate manual-intensive processes (such as provider data management) and improve business collaboration today. This will deliver meaningful positive effects on business outcomes, operating metrics and enterprise-wide effectiveness over the next 18 months.”  

Barriers to Margin Optimization 

The problem is that many payers are still dependent on legacy, outdated core administrative processing systems (CAPS), siloed claims pricing and editing solutions, and disjointed care management systems. These systems are not able to accommodate today’s: 

• Highly complex payment models, including value-based care 
• Ever-increasing demands from providers to get paid faster and more accurately with more customized contracts 
• Rising healthcare consumer expectations that are being shaped by their retail experiences. 

Again, referencing the Gartner report, “The prevalence of legacy IT systems and number of custom practices mean payers have significant human-involved processes.”  

As a leader in integrated digital payer solutions, HealthEdge has identified three main functional areas of the business where operational efficiencies can be gained to impact payer operating margins directly and positively.  

1. Claims Processing

Many payers are wasting valuable resources and time by manually reworking claims and reconciling inaccurate payments. In fact, according to a recent HealthEdge survey on the current state of payment integrity, the waste is pervasive:  

• • 90% of payers depend on two or more payment integrity vendors, which means multiple datasets, update schedules, and instances across lines of business. The IT burden and workflow complexities associated with this approach have become overwhelming for many health plans.  
  • 55% of payers report that more than 20% of their claims require rework due to inaccurate first-pass adjudication. Claims rework not only requires additional time and effort from the payment integrity team, but it also downstream work for other teams, such as provider relations. 

• • 70% of payers have more than 10 full-time employees (FTEs) dedicated to payment integrity, and 45% have more than 25 FTEs. When asked what the future looks like when it comes to dedicated resources, 56% say they expect that number to increase over the next one to two years, further compressing operating margins.

2. Contract Configuration

As healthcare providers attempt to manage many diverse contract types, the complexities continue to grow. This often requires hundreds of different configurations to be created, which results in additional manual oversight and administrative burdens to avoid compliance issues and payment inaccuracies. In the end, many payers find themselves wondering if these complex configurations are really worth the impact they have on operational efficiencies. 

3. Care Management

With rising healthcare consumer expectations for more personalized engagement and greater transparency, payers are struggling to assemble the right mix of digital solutions that support positive member experiences and compliance with new price transparency rules. According to the HealthEdge Annual Consumer Survey, only 55% of healthcare consumers are fully satisfied with their health insurance provider, leaving much room for improvement. And as CMS doubles the weight of the member experience when it comes to Star ratings for Medicare Advantage plans in the new year, it is more important than ever for payers to address the rising expectations. 

Striving for Operational Excellence 

There are modern, tightly integrated digital payer solutions on the market today that can help payers find new operational efficiencies in these three areas. As the only provider of integrated digital payer solutions, HealthEdge® offers payers the opportunity to identify these efficiencies through hyperautomation of manual process across multiple functions and lines of business.  

Here is a brief summary of those HealthEdge solutions and how they work together to help relieve some of the pressures on today’s health plan margins.  

• HealthEdge Source™ (Source), is HealthEdge’s prospective payment integrity solution. With Source, payers get one source of truth for payment accuracy and accountability across all lines of business. And because it is a cloud-based solution, fee schedules and policy changes are updated automatically every two weeks. Designed specifically to integrate through a single API to any core administrative processing system (CAPS) for improved speed and performance, Source helps minimize the IT burden of implementing, connecting, and maintaining multiple editing and pricing tools. Plus, with Source Platform Access, payers are finally able to identify the root cause of inaccurate payments and resolve issues upstream so the errors do not repeat month after month.  

“By investing in a prospective payment integrity solution that highlights inaccuracies before the payment is made, you can stop the costly retroactive repayment process that negatively impacts your providers and members through administrative costs.” 2 

• HealthRules® Payer is HealthEdge’s next-generation core administrative processing system (CAPS) that enables transformational outcomes and business agility for all types and sizes of health plans. Recognized as a Best in KLAS CAPS for the third year in a row, the platform helps payers unlock new efficiencies through a combination of modern technology and highly flexible solutions that support real-time automation of business processes, such as claims adjudication, enrollment, and billing. In addition, HealthRules Payer automates many of the workflows associated with rapidly emerging regulatory requirements and seamlessly integrates with other HealthEdge solutions through productized integrations like Payer-Source and Care-Payer, for improved transparency and interoperability. When it comes to contract modeling, the system allows health plans to easily configure and manage a wide range of contract types, including value-based care arrangements, bundled payments, and traditional fee-for-service contacts – for all lines of business in one system. 
• GuidingCare® offers comprehensive solution that bridges the gap between payer capabilities and member expectations by facilitating more personalized member engagement. The platform achieves this through a set of integrated solutions, including Population Health, Utilization Management, Appeals & Grievances, Authorization Portal, and Business Analytics. In addition, GuidingCare provides a robust set of tools that support the unique requirements and complexities of many different state Medicaid programs. GuidingCare also integrates seamlessly with HealthEdge’s HealthRules Payer (Care-Payer) to give utilization management staff and care managers seamless access to real-time benefits information.  
• Wellframe™ digital care management solutions offer care team members the ability to seamlessly connect with members through multiple channels to reduce inpatient admissions by an average of 17% and increase preventative medicine utilization by an average of 29%. Integrated with GuidingCare (Care-Wellframe) or used as a standalone application, the system delivers a framework for engaging members of target populations to help them get access to the support they need outside of traditional care delivery settings. Wellframe also supports self-service digital resources that empower members to proactively reach their health and wellness goals. With Care-Wellframe, care managers can work seamlessly within both systems to gain greater visibility into member benefit plans and utilization while also offering a closed-loop referral process for social care services. With greater member engagement, member satisfaction rates and outcomes increase while operating costs decrease.  

Looking Ahead 

When a series of integrated digital payer solutions, like those offered by HealthEdge, are in place, payers are able to achieve new levels of operational efficiencies and minimize administrative burdens of working with many different software vendors. These efficiencies relieve some of the pressure on payers so they can focus more on providing high-quality care and services to their members and develop collaborative relationships with their provider networks.  

Sources: 1 Gartner®, Three Operational Excellence Best Practices to Optimize Costs for U.S. Healthcare Payers, 1 November 2023, Mandi Bishop, GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved. 

To learn more ideas on how to navigate the growing pressures on payer operating margins, download this complementary Gartner Report or visit HealthEdge at www.healthedge.com.  

Being agile enough to adapt and grow in a competitive market is essential for health plan leaders. This includes enhancing member care through continuous innovation—be it updating validation policies, modifying fee schedules, restructuring benefit plans, or launching new lines of business. But constraints and back-and-forth with IT departments to translate your visionary business concepts into actionable products or services can drain valuable time and energy, hindering your mission.

To address this challenge, HealthEdge developed HealthRules Promote, a revolutionary tool designed to restore power directly into the hands of health plan leaders like you. This platform is a testament to our dedication to disruption, offering a solution that is not only innovative but also empathetic to the hurdles your organization faces. With HealthRules Promote, we’re eliminating the technical barriers, enabling anyone within your organization to create configurations effortlessly.

Transforming Challenges into Opportunities with HealthRules Promote

HealthRules Promote isn’t just about easing the configuration process; it’s a catalyst for significant cost savings and improving efficiency. Medium-sized health plans can save up to $750K per year. Moreover, a health plan managing over 1 million lives was able to configure 81 plans in just 10 days with a four-person team. These figures showcase the profound impact HealthRules Promote can have on your operations and bottom line.

Real-Time Response to Market Needs

In today’s fast-paced healthcare industry, the ability to respond in real-time to new opportunities and market demands is invaluable. HealthRules Promote empowers you to quickly take on new business regardless of complexity, ensuring you’re always a step ahead. This agility is critical—not only for growth, but for sustaining relevance in a competitive landscape.

Streamlining Operations

Automating and streamlining existing lines of business—including Individual & Family, Commercial Group, and Medicare—are at the core of HealthRules Promote. By eliminating costly manual processing, we’re  improving operational efficiency while also enhancing accuracy and reliability. This shift towards automation frees up your resources, allowing you to focus on strategic initiatives that drive member satisfaction and growth.

Elevating Customer Service

At the heart of HealthRules Promote is a commitment to superior customer service. The platform enables your representatives to answer customer queries correctly the first time, fostering trust and loyalty. This level of service excellence is not just beneficial for member satisfaction—it’s a competitive advantage that sets you apart in the healthcare industry.

In a sector where change is the only constant, we understand the challenges health plan leaders face and offer a solution that makes it easier to respond to industry changes. Our vision is clear: to equip you with the tools necessary for agile growth, enabling you to care for your members effectively and efficiently. Let us embark on this transformative journey together, shaping a healthcare ecosystem that thrives on agility, innovation, and uncompromised care.

Change management is a complex process that involves stakeholders across an organization. It’s not just the technical aspects that matter, but how successfully health plan leaders educate and engage the teams that will be impacted by organizational change.

When it comes to implementing a technology solution, some leaders might overlook the human element—getting so caught up in the process and technological details that they forget about the people involved. Methods like the People Process Technology framework can help by encouraging health plans to identify the training, documentation, and skillsets the team will need to be successful. But there are other ways to set your health plan up for change management success.

To demonstrate effective change management, here are the stories of two different health plans as they implemented digital solutions.

What does change management success look like?

Our first example is a health plan that successfully implemented a digital solution and achieved a significant return on investment (ROI).

Health plan leaders identified their current processes and reviewed them alongside their employees to pinpoint opportunities to phase out manual, low-value tasks. To ensure they were making the best choice for their needs, stakeholders investigated multiple solutions. They included middle management in the decision-making process to ensure those who would use the system had a voice in its selection.

This health plan invested substantial effort into the design, testing, and training phases of their new systems. They went live on schedule, within scope, and on budget. This resulted in exceptionally high buy-in and an impressive return on investment.

What does unsuccessful change management look like?

The second example involves a health plan that did not achieve long-term adoption of their chosen digital solution.

In this case, a senior leader new to the organization selected a vendor based on their previous experience, and shared the expectation that the system would help cut costs and make their health plan more competitive. However, despite on-time and on-budget implementation, the project struggled to get buy-in and engagement from stakeholders. This lack of engagement led to an unwillingness to test the new platform and engage in training sessions.

Within two weeks of go-live, the system was abandoned because end users didn’t like the way the platform functioned or how it impacted workflows.

4 Steps to set your health plan up for change management success

There are a few key differences between the two health plans mentioned above. One plan focused on educating their internal teams and getting organizational buy-in, facilitating technology adoption and achieving ROI. The other plan allowed one person to take charge and implement changes from the top down without communicating or sharing information with their wider organization, resulting in low adoption and usage.

How can you develop a change management strategy that sets your health plan up for success? These are four recommendations based on experiences with our customer implementations.

1. Understand and support employees

Knowing the needs and capabilities of your team is crucial. Your health plan could find the perfect technological solution, but it won’t be successful unless you have organizational support. It is important to have clear, open channels of dialogue from the onset so stakeholders and users can understand the value of new technology solutions as well as what will be expected of them. This is a great opportunity to emphasize how the new technology can help automate low-value work and empower your team to accomplish higher-value tasks.

2. Focus on inclusion and transparency

Involve middle management in decision-making and foster transparency with regular updates and opportunities for participation. Getting buy-in from middle managers is essential to gaining widespread organizational support. Give your team an early overview and demonstration of the system as it’s being built and implemented—not when it’s fully formed. Showing the new solution to your team and engaging with them helps garner approval and improve adoption.

3. Answer the question, “What’s in it for me?”

Each member of your team needs to understand the personal benefits that the new solution will offer. By engaging with and educating employees on the new solution, you’re enabling them to have discussions about how they’ll be expected to use this new technology and the value it will bring to their roles. At HealthEdge, our Professional Services team can help facilitate transparency with our customers through continuous dialogue. We show your team how the new system functions and engage a larger group to understand the company’s perspective on the solution.

4. Establish a change management work stream

An important step is establishing a project work stream dedicated to change management. Doing so can help you understand where your health plan stands in onboarding and addressing challenges that surface along the way. It is important to engage with your employees and over-communicate. This can be achieved by using change management methodologies such as: engaging leadership, defining why change is necessary, communicating the vision, obtaining employee buy-in, and reporting progress. To be successful, your health plan must lean into change management—you know your organization best and can help set the trajectory for success.

Preparing for change in your organization

Change is an inevitable and necessary aspect of growth—especially in healthcare. We’ve seen which strategies work, and which don’t when it comes to implementing a new digital solution. Remember, the more you involve and support your team from the beginning, the more likely your digital solution will be adopted successfully.

Engage with your team, provide them with a clear understanding of what’s to come, and give them the resources they need to succeed, and you’ll have a team ready to leverage new digital tools and embrace digital transformation.

Medical claims go through a long process of pricing, editing, analytics, and payment. And it’s vital that health plans pay claims accurately, quickly, and comprehensively—the first time.

An integrated workflow management system like HealthEdge Source™ can centralize claims processing and facilitate payment accuracy by offering:

• Contract visibility
• Pricing tools and algorithms
• Analytics and benchmarking
• Custom and history-based editing
• Comprehensive audit trail
• Data modeling

The Data Reference module within HealthEdge Source brings editing and pricing capabilities together in one cloud-hosted platform. Payers get full-audit support and access to actionable insights that help improve payment integrity. Below are three ways a Data Reference tool can give your health plan a claims processing advantage.

Utilize clean, aggregated data from multiple sources

Keeping track of multiple payment schedules and maintaining their accuracy can be a challenge. The Data Reference feature within HealthEdge Source brings together the most up-to-date fee schedule information and is refreshed every two weeks—giving users one less manual task to remember and ensuring higher levels of accuracy. In 2023, the HealthEdge Source delivered more than 1,500 data updates to its users and made more than 350 updates to policy and pricing met—giving users one less manual task to remember and ensuring higher levels of accuracy. In 2023, the HealthEdge Source delivered more than 1,500 data updates to its users and made more than 350 updates to policy and pricing methodologies across all lines of business.

Data Reference delivers insights based on information such as:

• Medicare rates and prospective payment data
• CMS policies and statistics by provider, region, and system
• CMS provider rates and statistics
• ICD-9, ICD-10, and HCPCS codes

Adjust quickly to CMS updates and policies

Information about updated Centers for Medicare & Medicaid Services (CMS) policies and regulations is available in many formats and in multiple locations. Many of the documents containing key information are difficult to understand, and data is not easy to verify between documents. When it comes to provider rate data, for example, health plans have to cross-reference National Provider Identifier (NPI) and Online Survey Certification and Reporting (OSCAR) numbers to match providers and ensure accurate payments.

CMS is expected to make more than 600 changes throughout 2024. Make sure your health plan is ready to adapt to these changes right away. With the Data Reference tool, Source aggregates and aligns key data in a way that’s easier for payers to view, search, understand, and use.

Streamline fee schedule and contract management

When it comes to off-cycle payment updates, some health plans are forced to knowingly pay claims inaccurately because they don’t have the most updated payment information or internal resources to make timely updates. Prevent these issues from impacting your health plan by working with a payment integrity solution that gives you access to the most recent and accessible information—and see it all in one place.

Source users can update payment policy and pricing methodologies to improve fee schedule management, pricing transparency, and auditing. Instead of juggling multiple websites and documents, the information you need is gathered in a single view that allows users to sort data by region and other filters.

Adjust to policy changes, prevent payment delays, and improve provider relations at your health plan by using a payment integrity solution that gives you access to the most recent and accessible information. With the Data Reference tool, you can readily access essential payment information in an organized and searchable format.