In early May, HealthEdge hosted the 2024 Clinical Leadership Forum in Boston, Massachusetts. This event brought together more than 50 health plan executives, clinicians, and other healthcare leaders, and served as a platform to address key concerns and opportunities in the industry.

The forum focused on the role of integrated digital health management solutions in driving efficiency, clinical outcomes, and organizational goals by making the most of the resources payers already have. Speakers also discussed the need to embrace the constant change and modernization of the healthcare industry. Health plans across the U.S. are being asked to improve experiences and outcomes without raising costs—and the right digital health solutions can help. In this article, we delve deeper into the discoveries and experiences shared during our exclusive event.

“We need to think about how technology will change our processes to add more value to businesses and customer experiences, and then we have to organize ourselves to change those processes.”

-Steve Krupa, CEO, HealthEdge®

Key Takeaways: We’re being offered the opportunity to change everything we do

The pace of healthcare industry innovation continues to accelerate. Members expect a convenient and personalized experience, regulatory requirements keep shifting, and high-needs populations are growing. Three customer panels stood out for their emphasis on engaging members to improve health outcomes and the member experience.

Address Health Equity Using Digital Care Management

One of the forum’s highlights was a panel led by Dr. Sandhya Gardner, Chief Medical Officer at HealthEdge. Dr. Gardner facilitated a discussion between clinicians from three large regional health plans, who shared how they address health equity among their member populations using digital solutions.

This discussion underscored the benefits of offering digital health management tools to members and care managers. For care managers, integrated digital health tools help improve staff efficiency and make it easier for care managers to identify health equity challenges and social determinants of health. The insights care teams get from digital health solutions enables them to deliver more timely and relevant care that meets members where they are. Digital health tools can also improve the accessibility of healthcare services by giving members a single point of access where they can reach out to care teams, read relevant health and benefits information, and keep track of their health goals.

“What we’re really concerned about are the folks who are working but unavailable to us. They may be shift workers, they may be working overnight, or beyond the hours our regular care managers work. They may have a burner cell phone. All those things lead to disparities. So figuring out ways to reach people through other channels, whatever they may be, is critical to reducing disparities.”

-Vice President of Clinical Operations, Regional Health Plan

Combat Industry Pressure with Integrated Care Management

Healthcare payers are under a lot of pressure—trying to combat rising costs, satisfy regulatory requirements, and increase member satisfaction while trying to stay competitive. In a session with two statewide health plan executives, panelists discussed the role of integrated care management in empowering key member, care team, and health plan stakeholders to achieve their goals. The fusion of digital member engagement and hands-on care management empowers members to take control of their health and make more informed decisions.

Attendees were given an exclusive look into the ways connected care ecosystems enhance operational capacities and forge a more empathetic, responsive culture. A digitally enabled care management approach is particularly beneficial for high-risk populations, like maternity and Medicaid. Plus, demonstrations of the Care-Wellframe solution provided concrete examples of how this technology can be seamlessly integrated into existing workflows, offering a glimpse into a future where healthcare is both high-tech and high-touch.

“Instead of asking our staff to take on the additional cognitive burden of choosing which members to call, we can clearly identify exactly who the members are who have emerging risks. It also gives our members access to a repository of information that they can access 24/7, 365.”

-Chief Medical Officer, Regional Health Plan

Championing Change Management: Best Practices

In a rapidly evolving healthcare landscape, adaptability is key. In one session, leaders from three regional and national payers shared best practices based on their experience with change management throughout the digital implementation process. Earning buy-in from stakeholders and future users can be a challenge. One way to improve adoption and reduce pushback is to build trust with your internal team through transparent communication and early involvement.

Panelists also emphasized the importance of cultivating a company culture that not only adapts to digital innovations but thrives because of them. From workflow optimization to team engagement, the health plan leaders provided a comprehensive toolkit to support successful digital transitions. Most notably, this included the importance of transparency throughout the implementation process. When stakeholders and employees know the “why” behind a change, they’re more likely to feel involved in the solution.

“Once you have team members that understand the value of ‘why,’ and over-communicating the value of ‘why’ so it’s not just sitting with the clinical team, that’s how you gain some traction.” 

-Chief Medical Officer, National Health Plan 

Leveraging AI for Care Management

Discussions about the applications of AI are everywhere. But where can it have the greatest impact on health plan operations? Many AI solutions need more training before they can fully replace manual documentation. But digital health management platforms like GuidingCare® and Wellframe leverage AI algorithms to improve clinical decision-making and member outcomes.

An AI assistant helps improve staff productivity by suggesting message templates, flagging high-risk members, making engagement recommendations, and suggesting next best actions. HealthEdge views AI as a key component of helping our customers become digital payers through transformational consumer experiences and business agility enablement.

“What are you actually trying to use this technology to solve for? Are you trying to save people time, generate insights, proactively take something that took a lot of manual effort and uplevel their skills to work top-of-license? Those are all areas we think are core-value oriented.”

-SVP of Product Management, HealthEdge®

Looking Forward

The 2024 Clinical Leadership Forum was a testament to the power of collective insight and a shared commitment across the healthcare sector to drive positive change. The discussions and solution demonstrations highlighted not only the current capabilities of digital care management, but the possibilities for future innovations.

For health plan executives and healthcare leaders, the forum served as both a call to action and a way to build relationships with leaders at similar organizations. The Clinical Leadership Forum was a powerful reminder that the future we aspire to is not just a possibility but an inevitability if we continue to innovate, collaborate, and lead with empathy and vision.

Learn more about HealthEdge® digital health management and member engagement solutions, visit the GuidingCare® and Wellframe pages on our website.

To stay ahead in the constantly evolving healthcare sector, payers are adopting digital solutions that put automation and accuracy at the core of every workflow. It’s critical that your Core Administrative Processing System (CAPS) delivers the most up-to-date data available so you can improve automation rates and streamline processes. Our five-part blog series, titled HealthRules® Payer Horizons, demonstrates how our CAPS solution empowers payers to adapt to meet new market opportunities.

Read the entire series at the links below:

• Automating regulatory compliance and accuracy 
• Enabling automation with integration 
• Expanding new business opportunities
• Optimizing value-based care & reimbursement
• Delivering superior customer service

Take advantage of end-to-end automation with HealthRules® Payer

In today’s healthcare landscape, the pressure to reduce costs and simultaneously enhance operational efficiency is more intense than ever for health plan leaders. Amidst this complex industry, automation emerges not just as a solution but as a strategic imperative for health plans seeking to invest in. HealthRules Payer is a platform uniquely designed to leverage the power of end-to-end automation to streamline operations and improve efficiency.

By harnessing the automation capabilities of HealthRules Payer, health plans can dramatically reduce administrative burden, streamline redundant processes, and optimize resource utilization. Equally critical is maintaining regulatory compliance in a strict and shifting environment. Through regular, automated updates, HealthRules Payer ensures that health plans remain compliant—significantly mitigating the risk of costly resubmissions.

Leveraging advanced automation will also let your plan reallocate manual resources toward higher-value work.

For health plan executives, the message is clear: leveraging end-to-end automation with HealthRules Payer not only addresses the immediate challenge of cost pressures but also unlocks the potential for strategic growth and sustainability.

1. Improve operational efficiency  

Streamline workflows and create efficiencies by automating the claims adjudication process and saving manual reviews for what matters most. With HealthRules Payer, our health plan partners regularly achieve auto-adjudication rates over 90%, and claims accuracy of 99%.

For one metropolitan non-profit health plan, leveraging HealthRules Payer led to:

• 96% increase in auto-adjudication rate for Medicare claims processing
• 95% decrease in pending claims
• 0 claims aged over 15 days on a monthly basis

2. Increase productivity and transparency

By automating more of the claims review process, your health plan can reduce complexities and administrative burdens associated with manual reviews. Plus, the HealthRules Payer platform is regularly updated with the latest payment regulations to reduce repayments and adjustments—saving time and money. For one customer, automating key processes led to savings of more than $1.6M.

3. Leverage auto reprocessing capabilities

The HealthRules Manager feature within HealthRules Payer allows your health plan to make adjustments based on your specific criteria to reduce reprocessing times. HealthRules Manager also allows users to manage membership, providers, billing and commissions, pricing, cost estimators, pricing transparency, and integrations with care and utilization management tools.

4. Support remote operations with hyper-automation

Accelerate payment accuracy and advanced configurations with integrated end-to-end system automation—what we call hyper-automation. By bringing disparate systems together and controlling information processing this way, your health plan can adapt more easily to industry demands and shifting payment guidelines. HealthRules Payer can integrate with your existing technology suite, as well as HealthEdge Source™ for payment integrity, GuidingCare® for care management, and Wellframe for member engagement.

Do you want to learn more about how HealthRules Payer can lower production time, reduce errors, and easily build audits across claims environments? 

Read our Case Study, “HealthRules® Promote Empowers Medica Health Plan to Streamline Processes” to see how our solution empowers customers to drive efficiency and quality.”

HealthEdge’s Regulatory Compliance Manager Maggie Brown and VP of Sales Solutions Diane Pascot recently addressed a large audience of AHIP members on an AHIP webinar that focused specifically on the rapidly evolving regulations surrounding price transparency. The two industry veterans gave attendees a fresh perspective on the evolution of multiple regulations as well as practical guidance on what payers can do in 2024 to better navigate the changing CMS regulations as they come into sharp focus this year for many payers, including the more than 130 HealthEdge customers.

This blog serves as a summary of the webinar. To listen to the full webinar, visit the HealthEdge Resources section on the HealthEdge website.

A Regulatory Refresher

The Transparency in Coverage and No Surprises Acts have both passed, but the final ruling on how health plans must implement these Acts and how they will be enforced are still evolving. New rulings, such as the Mental Health Parity Act and Advancing Interoperability & Improving Prior Authorization Acts, have emerged, and CMS recently released FAQs to help clarify how health plans must provide personalized cost sharing information for ALL items and services.

The rapidly evolving regulations can feel like a complex puzzle for many health plan leaders. But when you step back and look at the evolution of healthcare policy as a whole, it starts to make a bit more sense. The big picture is all about seeking transparency in healthcare processes and pricing, consumer protection, digital access to information and care, and the different regulations tend to build upon each other.

While these regulations tend to build upon each other, everything is constantly evolving so health plans can no longer respond to individual rules just in time. They must understand where the policies are going and be prepared with the right technology and partners who can help them implement strategies that will support compliance long term.

What We Know: Regulatory Evolution

As regulations continue to be finalized, they seem overwhelming, but they are designed to build on one another, giving payers opportunity to leverage a stepped approach. If we approach them as building upon each other, leaving room for unexpected regulations, it optimizes the ability to successfully prepare, taking one step at a time.

4 Concrete Steps Plans Can Take Today to Ensure Readiness 

Concrete Step #1: Make sure you have the right technology, especially the right core administrative processing system (CAPS) in place and are focused on the right functions for existing and future rulings and implementation guidelines.

Your CAPS technology needs to have the structure that can pull together the right pieces of administrative data and the flexibility to support compliance as guidelines evolve. For example, with the new interoperability regulations, health plans will eventually have to show how many times each patient uses an access API in a year.

To achieve compliance with this reporting requirement, you need to start with a CAPS and a technology partner that can help you thoughtfully set up the access and structure to gather the meaningful data about individual and aggregated patient access. This must be done in a way that can be configured for any required audience or requirement.

1. Benefits administration and member management

1. Ensuringmembers are associated with the right benefits package
2. Properly tracking member accumulators so cost-sharing information is accurate and up-to-date

2. Provider network configuration and management

• Seeking negotiated rates with all providers
• Establishing processes for out-of-network providers so members aren’t surprised
• Maintaining up to date provider directories with complete and accurate information

3. Billing and Data

• Automated billing practices to ensure that members are held harmless under NSA criteria
• Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) application programming interfaces (APIs) to improve the electronic exchange of health care data and streamline prior authorization processes
• Cost-sharing data for all items and services available online

4. Claims Processing

• Processes to avoid, and handle provider disputes
• Processes that build on existing claims workflows, but can generate claims information for AEOBs for members – without triggering a bill or a payment

Compliance can get a bad reputation, because the regulations and changes can lead to burdensome manualized processes. In fact, many CAPS systems require payers to pend claims. But, when you leverage flexibility and configurability within the right structures, you can retain automated processes, minimize pending, pay your providers on time, and remain compliant. Well thought out reporting and analytics can be used to monitor trends, identify trends, reduce access to care issues and ultimately improve outcomes.

Concrete Plan #2: Web-based Price Comparison Tool

According to the No Surprises Act that builds on the Transparency in Coverage Act, health plans must provide web-based and personalized cost information, allowing members to compare prices for different providers and find out what their cost-sharing responsibility will be with respect to current accumulators.

Your CAPS system should have some kind of flexible claims functionality. With HealthRules® Payer, for example, plans can call for current accurate data into basically a ‘practice’ claim without triggering an adjudication.

This is a big deal, because in most claims processes, going through the process of pulling provider and member data together would automatically trigger a payment process. And, if plans try to work-around NOT using the claims system, they can’t get the same level of up-to-date accuracy. This is important because not only does provider pricing change, but member accumulators change every time they contribute to their deductible or out of pocket max.

While the regulations relating to this requirement were passed quite a while ago, just last month, in February, more detail was released.

This is another example of how plans can take a phased approach for evolving regulations by establishing and auditing this type of a tool also gives a good opportunity to see if there are any billing/benefits changes needed for your plan to meet parity guidelines, i.e., mental health co-pays are equivalent to physical health.

Similarly, interoperability and the prior authorization enhancements will rely not only on accurate data, but the ability to assemble the data into a meaningful story.

Price Transparency Snapshot

Challenge: Provide a web-based service for members to compare pricing for specific providers with respect to their current plan and accumulators

Solution: A CAPS system with flexible claims functionality will help health plans produce accurate claim adjudication details that include member responsibilities regarding:

1. Provider-specific payment/contract terms and fee schedules
2. Member benefit plan data
3. Member cost sharing based on accumulators at the time of trial claim adjudication

With the right technology, health plans can aggregate member-specific, provider, and service details according to accurate (not estimated) claims data. There is also CAPS technology available to connect this data to web-based member tools (e.g., member portals) so members can access cost information at any time and platforms through which customer service representatives can provide member-specific price comparisons to support member price comparison questions via phone.

Concrete Step #3: Advanced Explanations of Benefits (AEOB)

The Advanced Explanations of Benefits (AEOB), a key requirement introduced by the Consolidate Appropriations Act of 2021, is still pending. Guidelines are in development, with an RFI concluding last year. The AEOB will be triggered when a provider notifies the health plan that services have been scheduled, using a good faith estimate. Health plans must be able to respond with cost sharing based on that good faith estimate, which will include estimates from all providers involved in the scheduled service or procedure.

Payers need to make sure their CAPS system is prepared to meet regulations using a trial feature merged with existing EOB processes. The key piece here, again, is that they can use existing platform functionality and up-to-date, accurate information without triggering a payment.

If the scheduled service is with an out-of-network provider or facility, the EOB will note that and use qualified payment amounts to provide the anticipated cost. Plans may also have to recommend an in-network alternative to members on the AEOB.

AEOB Snapshot

Challenge: Prepare to meet AEOB requirements according to forthcoming rulemaking and implementation guidelines

Solution: A CAPS system with flexible claims functionality will help health plans aggregate details related to service codes and provider types, including:

1. Individual services costs
2. Episodes of care costs
3. Individual member-level details, including current accumulator data

With the right technology, health plans can generate anticipated claims payment detail in advance of a scheduled service. A full claims adjudication process takes advantage of all configuration details, calculating accurate – and not estimated – costs without triggering a payment.

Existing CAPS features generate EOBs for configurable and automated distribution that can be combined with the detail generated by the trial claim.

Concrete Step #4: Payer to Payer Data Exchange

Health plans using HealthRules Payer already meet the required relevant standards for this regulation, including:

• United States Core Data for Interoperability (USCDI)​
• HL7® Fast Healthcare Interoperability Resources (FHIR®) Release 4.0.1​
• HL7 FHIR US Core Implementation Guide (IG) Standard for Trial Use (STU) 3.1.1​
• HL7 SMART Application Launch Framework Implementation Guide Release 1.0.0​
• FHIR Bulk Data Access (Flat FHIR) (v1.0.0: STU 1)​
• OpenID Connect Core 1.0

Because we focus on regulation all day every day, we are also prepared with recommended implementation guidelines, such as:  ​

• HL7 FHIR CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) IG Version STU 2.0.0
• HL7 SMART App Launch IG Release 2.0.0 to support Backend Services Authorization

These implementation guidelines will also help health plans prepare for the upcoming prior authorization, such as:

• HL7 FHIR Da Vinci Documentation Templates and Rules (DTR) IG Version STU 2.0.0​
• HL7 FHIR Da Vinci Prior Authorization Support (PAS) IG Version STU 2.0.1​

Payer to Payer Data Exchange 

Challenge: Payer to Payer Data Exchange has been expanded. The original set of requirements were deferred, and now there are structure and implementation guides for January 2027. This criteria includes HL7 and specific implementation guides.

Solution: A CAPS system and technical partner with the expertise to apply implementation guides for meaningful results

1. Leverages existing technology for new Payer to Payer Data Exchange meeting Required Standards with the expertise to recommend the right implementation guidelines
2. Creates meaningful information by sending and receiving the right data elements in the right configuration to ensure transparency and continuity of care for members

Key Takeaways

Regulations require us to understand the compliance requirements and the intention of each rule, how it relates to the current state of the business process, and how it impacts both the upstream and downstream processes. Each rule dives into the “why,” and health plans should seek to collaborate with technology partners to create solutions that support the requirement.

1. New regulations build on recently passed regulations; a stepped approach will help payers stay on top of the evolution. Stay on top of all types of communication such as changing enforcement dates, FAQs, guidelines, etc., not just final rulings.
2. Cost transparency and the proposed mental health parity regulations build toward consumer protections and updated data exchange methods. Make sure you have the data and analytics established to report on pricing for the Parity regulations. Be sure to pull your reports well in advance of the January 2025 enforcement date so you can identify and adjust any non-compliant pricing issues.
3. The right CAPS will have the structure and configurability that help health plans prepare for and adapt to ever-evolving regulations. Make sure you have the right CAPS technology and are focused on the right functions for existing and future rulings and implementation guidelines. Your CAPS needs to have the structure that can pull together the right pieces of administrative data and the flexibility to support compliance as guidelines evolve. Plans will not be able to meet the evolving regulations without technology that can ensure compliance and automation.
4. Keep the big picture in mind and look for the next-best step that works for your health plan. Make sure your CAPS technology meets required standards for upcoming interoperability and prior authorization regulations. Ensure you have a good technology partner who can help you start to plan your implementation guidelines and start planning now.

To learn more about how HealthEdge solutions can help your organization navigate the evolving CMS regulations, visit www.healthedge.com.

To remain competitive, payers are increasingly adopting integrated digital technologies that help improve efficiency and reduce costs. Make sure your Core Administrative Processing System (CAPS) is providing the real-time information your health plan needs to maintain accuracy and compliance. This 5-part blog series, entitled HealthRules® Payer Horizons, highlights a few of the key ways our CAPS solution is empowering payers to take full advantage of market opportunities.

Read the entire series at the links below:

• Automating regulatory compliance and accuracy
• Enabling automation with integration – coming soon
• Expanding new business opportunities – coming soon
• Optimizing value-based care & reimbursement – coming soon
• Delivering superior customer service – coming soon

Simplify regulatory compliance with HealthRules® Payer

Healthcare payers are facing pressure from all sides, with high member expectations, regulatory changes, staffing shortages, and rising costs among the top challenges. Many health plans are turning to digital transformation to gain a competitive advantage and better serve their members. A Core Administrative Processing System (CAPS) that meets these needs is one of the most significant investments your health plan can make.

HealthRules® Payer (HRP) is a modern CAPS solution that automates compliance regulation, enabling you to streamline existing workflows and respond to new opportunities in real-time. Using HealthRules Payer, your teams will spend less time manually adjusting payments—streamlining the claims editing process and making it easier to save money on retroactive changes. Regulatory compliance can also improve Star ratings, with 4.5-star health plans having a 5% revenue advantage over 3.5-star plans.

As an organization, HealthEdge® is dedicated to simplifying regulatory compliance and transparency through innovative solutions. For HealthRules Payer, that includes features payers need to maintain efficiency while satisfying the demands of members, providers, and regulators.

1. State and federal legislation monitoring 

HealthRules Payer continually monitors federal and state-level legislation across Medicare, Medicaid, and Commercial lines of business. This information is automatically updated within the system to ensure regulatory compliance and reduce the need for manual editing and resubmission. HRP customers regularly achieve auto-adjudication rates of more than 90%—and financial accuracy up to 99%.

Healthcare payers rely on HRP to automate regulatory compliance so they can focus on larger organizational goals.

2. Compliance-based strategic planning 

The intentional design of HealthRules Payer makes it easy for users to access the information they need to develop a comprehensive strategy. Customers can leverage controlled and comprehensive modeling of new product designs and provider pricing methodologies based on specific business rules and compliance programs. With HRP, health plans can establish modeling during employer negotiations, leading to quicker turnaround of new product offerings, better customer service, and increased sales.

3. Reliable collaboration and support 

Customers working with HealthRules Payer receive personalized support. Health plans can vet their support strategies with the HRP Steering Committee, as well as hold monthly meetings to assess progress toward key business goals.

For the third year in a row, HealthRules Payer was named “Best in KLAS®” for Claims & Administration Platforms. In the KLAS survey of existing HRP customers, 100% of respondents said HealthEdge solutions are part of their long-term plans.

4. Cloud-based delivery model 

A cloud-based repository makes it possible for health plans to communicate strategy and compliance artifacts within HealthRules Payer while tracking an annual+ roadmap of compliance initiatives. Cloud-based solutions also facilitate real-time integrations with third-party systems, leading to more cost-effective and lower-risk IT ecosystem maintenance. In addition, they offer continuous monitoring, remediation, and patching to free internal IT teams to focus on higher-value objectives.

Companies using cloud services are held to rigorous security and confidentiality standards, meaning member protected health information (PHI) and sensitive payer data are guarded.

Do you want to learn more about how HealthRules Payer can help your health plan stay compliant with the No Surprises Act and other regulations? 

Read our data sheet, “Navigating the No Surprises Act: The Right Tools for Health Plan Success” to see how our solution empowers customers to increase auto-adjudication, give members personalized cost-sharing information, easily configure out-of-network services, and more.