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Healthcare in the United States is one of the most highly regulated industries, where healthcare providers and payers must stay on top of a myriad of ever-changing rules and regulations that can have a massive impact on their financial future. The constant evolution of these regulations demands adaptability and efficiency in administrative processes and technology systems.

The Complex World of Health Insurance Regulations

For decades, health plans of all types and sizes have struggled to keep pace with ever-changing government regulations that occur at both the federal and state levels. While it may seem that federal changes would be easier to manage, the truth is that any regulatory shift is inherently difficult to administer mainly because these changes encompass a wide range of aspects, from timelines to benefit levels, and even provider contracts. Some regulatory changes are actually retroactive, forcing insurers to go back through claims and payments to make sure they remain compliant with government mandates.

Adding to the complexity, regulatory requirements can change over time as they are implemented. Payers are often given a three-year window to adapt to new programs, only to see mid-course alterations, sometimes for the better, but still demanding for payers to constantly respond and adjust course.

This constant state of flux has created a challenging environment that shows no signs of slowing down. In fact, it is expected to become even more frequent and command higher fines for non-compliance in the coming years. The pace at which CMS issues regulatory changes can be influenced by various factors:

• Annual Changes: CMS typically releases an annual cycle of regulatory changes, which often coincide with the calendar year or fiscal year. These changes can encompass updates to payment rates, coding systems, quality measures, and program requirements. Health insurance payers can anticipate these annual updates and plan accordingly.
• Legislative Mandates: Significant regulatory changes may be prompted by new healthcare-related legislation. When Congress passes laws related to healthcare, CMS is tasked with implementing and regulating these new requirements. The pace of change in this regard can vary depending on when new legislation is enacted.
• Administrative Updates: CMS may issue administrative updates and clarifications as needed to address immediate concerns or ambiguities in existing regulations. These updates can occur throughout the year and may be issued more frequently when there are rapid shifts in healthcare policy.
• Response to Public Input: CMS often seeks public input through the notice-and-comment rulemaking process. This involves publishing proposed regulations and allowing stakeholders to provide feedback. The time it takes to finalize regulations can vary depending on the complexity of the issues and the volume of public comments received.
• Market and Healthcare Trends: Regulatory changes can also be influenced by emerging trends in healthcare, such as changes in technology, care delivery models, and public health priorities. CMS may adjust regulations to accommodate these evolving trends.
• Political and Administrative Changes: The pace of regulatory changes can be affected by changes in presidential administrations and leadership at CMS. Different administrations may have different healthcare policy priorities, leading to shifts in the regulatory landscape.
• Emergency Regulations: In response to public health emergencies or crises, CMS may issue emergency regulations to address immediate needs. These changes can be rapid and may not follow the typical rulemaking process.

In a recent Modern Healthcare article that summarizes the 2024 state legislative changes across 20 different states, “Health providers and insurers will have to navigate a bevy of state laws that took effect with the new year, covering key issues such as reproductive care, patient documentation, wages and reimbursement.”

For example, in Oregon, individual and fully insured group health insurance plans must cover three primary care visits per covered individual per year. Insurers also must cap the copay, waive the deductible for the visits and assign a primary care provider to the individual within 90 days of enrollment, if a member has not selected one within that period. In Pennsylvania, insurers are required to have an electronic communications network that allows prior authorization requests to be submitted and returned electronically. In Texas, payers are required to create and maintain a website where providers can verify if patients are covered by the issuer and see a patient’s potential deductible, copayment or coinsurance. Many of these state regulations mirror or complement federal regulations, such as the CMS Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule.

The Role of Modern, Flexible Systems

To help navigate this ever-evolving regulatory landscape, health insurance payers need flexible technology systems that can handle both federal and state-specific requirements with ease. While most systems can support compliance with federal requirements at a broad level, it is equally important for payers who participate in state-specific programs to have the ability to support the wide range of state-specific changes as well.

Very few systems can support a large portion of the state changes and care programs, leaving the rest of the rules to be implemented by already-scarce IT resources or vendor engagement. This is where flexibility in system configuration becomes critical.

Whether it’s adapting to changes in benefits, claim systems, fee schedules, or state-specific care programs, the ability to administer these changes in an automated fashion is key. The systems must be capable of adapting and accommodating these shifts without manual intervention. This applies to healthcare organizations of all sizes, from large health plans to smaller providers.

The Law of Large Numbers Gain

The regulatory burden is a “law of large numbers” gain, meaning that having more health plans on a single solution can everyone help tackle the problem more efficiently. Even if two health plans come together through a common platform, they can collectively handle the workload more effectively than two separate entities. Therefore, collaboration and synergy across the industry are essential to addressing regulatory challenges.

How HealthEdge is Making a Difference

At HealthEdge, we understand the importance of payers having access to highly flexible, configurable technology systems that can support an organization’s ability react to regulatory changes and CMS mandates to avoid sanctions, potential fines, and remain competitive. That’s one of the many reasons more than 130 health plans rely on our solutions today and why HealthEdge solutions consistently rank Best in KLAS for multiple years in a row.

Our technology solutions automate access to real-time data, ensuring regulatory compliance so health plans can save time, resources and streamline internal processes. HealthEdge solutions not only help payers meet regulatory changes, but also provide them with a competitive advantage in an increasingly complex industry. Here are a few practical examples of how HealthEdge solutions help payers address regulatory challenges.

HealthRules^® Payer

• • Monitor federal and state level rules to identify rulemaking that impacts Payer Business Processes supported by HealthEdge
  • Develop business centric compliance requirements and use gap identification methods to develop a support strategy
  • Vet support strategy with the Steering Committee and collaborate with customers via monthly meetings
  • Communicate strategy and other compliance artifacts via a cloud-based repository, tracking over a year roadmap of compliance initiatives

HealthEdge Source™ payment integrity platform

• • Research, Policy, and Data experts actively monitor government and industry resources to develop, deliver and maintain the most up-to-date content
  • Full-service delivery of payment policies & edits every two weeks ensures tightly linked payment processes
  • Third-party ecosystem readily extends payment integrity capabilities

GuidingCare^® care management platform

• • Tracked changes and updates to state/federal program, reporting, and auditing requirements
  • OOB CMS-compliant Audit and Part C/D reports plus self-service custom reporting
  • Support for Regulatory audits/surveys, NCQA & URAC (utilization) review accreditation
  • NCQA Certified for HEDIS measures and Pre-Validated for Population Health Management since 2018

Wellframe member experience platform

• • Secure, HIPAA-compliant messaging between care managers and members
  • Configurable, customizable programs and assessments aligned with state requirements
  • Direct member access to NCQA-aligned health and risk assessments
  • Real-time insights and alerts help care teams effectively identify gaps in care and improve HEDIS performance

We encourage you to consider HealthEdge’s full suite of solutions can help your organization stay compliant with federal and state regulations while also growing margins. Visit www.healthedge.com.

 

 

Each year, HealthEdge conducts an extensive nationwide survey of the healthcare payer market in the United States. This survey serves as a valuable compass for health plan leaders, providing insights into the industry’s evolving challenges and opportunities.

The latest HealthEdge Annual Payer Market Report presents a fascinating picture of how technology is both the biggest challenge and the greatest ally for health plan leaders in the coming years. Let’s dive into the key findings from this report, shedding light on the role of technology in the healthcare payer landscape.

The Audience

This year’s survey garnered responses from over 350 health plan leaders and executives, representing diverse functional areas of the business and encompassing all types and sizes of health plans. Their collective insights offer a comprehensive view of the healthcare payer market.

The Dominant Themes

Throughout the survey, several dominant themes emerged, illustrating the impact of technology on the healthcare payer industry. These themes directly reflect the mounting pressures that payers are experiencing from multiple angles:

Evolving Regulatory Landscape:

Regulatory requirements are evolving at an unprecedented pace, aiming to address long-standing industry challenges such as cost, transparency, and value. Payers are required to adapt to these transformative regulations swiftly. To do so effectively, they must establish flexible and open technology systems.

Consumer Demand for Personalization:

Healthcare consumers today demand more personalized engagement and greater transparency, influenced by their modern retail experiences. Health plans must incorporate omnichannel communication capabilities to meet these consumer expectations.

Emerging Non-traditional Competitors:

Innovative, non-traditional competitors with tech-forward strategies continue to emerge, placing pressure on payers to excel in new member acquisition and member/provider satisfaction. System agility and high interoperability provide payers with a competitive advantage in this ever-changing landscape.

Workforce Challenges:

Workforce shortages and high turnover rates compel payers to automate their business processes further, empowering their current staff to achieve more with less. Modern solutions facilitate ease of use and higher levels of automation, ultimately reducing dependencies on manual resources.

Growing Complexity in Payment Models:

Changing payment models, such as value-based care and risk-sharing arrangements, contribute to the growing complexity of claims processing, performance measures, and plan configurations. Modern technology is pivotal in navigating these complexities efficiently.

Cost Management:

Managing costs has consistently been a top challenge for health plan leaders; this year is no exception. As business complexities increase, so do administrative costs. Leaders are focusing on strategies such as improving the financial accuracy of claims and increasing auto-adjudication rates to minimize costs.

Three Key Findings

1. A notable 62% of health plan leaders consider investing in modern technology for digital transformation as the number one way to achieve organizational goals in the new year.
2. Increasing interoperability across the healthcare ecosystem stands out as a promising strategy to reduce administrative costs, emphasizing the importance of seamless data sharing and efficient workflows.
3. Achieving alignment between IT and business ranks as the most significant challenge for health plan leaders, necessitating the adoption of modern solutions that support business agility. Other top challenges include:
   • Addressing workforce shortages and burnout
   • Facilitating business growth through membership growth, acquisitions, and market expansion
   • Managing costs by improving the financial accuracy of claims and increasing auto-adjudication rates to reduce administrative expenses
   • Improving member satisfaction by providing personalized communication capabilities in a landscape of expanding consumer choices
   • Ensuring provider satisfaction through stronger payer-provider collaboration to successfully implement value-based care models

The Changing Role of Technology in the Healthcare Payer Market

Given the growing complexities and the industry-wide shift towards digital transformation, it comes as no surprise that health plan leaders unanimously agree on the pivotal role of modern technology in addressing their major challenges in the new year.

As leaders search for new technology solutions, the survey highlights the top criteria for evaluating and finding the right solution, listed in order of importance:

Modern technology capabilities:

Modern technology can better support the future needs of organizations, enabling payers to be flexible and agile and do more with fewer resources as the market evolves.

Access to real-time data and analytics:

Health plan leaders need seamless access to up-to-the-minute information through robust APIs. Real-time data and analytics empower them to adopt value-based care payment models confidently, strengthen member-provider relations, and meet regulatory requirements.

Ease of doing business and customer service:

Modern technology companies should demonstrate flexibility in their product offerings, contracting processes, and support services to truly become partners rather than just vendors, enhancing the ease of doing business and elevating customer service to new heights.

Hassle-free configuration, upgrades, and implementation:

Every payer organization has its unique digital transformation journey, business processes, and growth plans. Modern technology platforms offer greater flexibility and faster deployment of new features, making it easier for payers to adopt innovations. This ensures that the system can accommodate each payer’s unique configuration requirements.

Automation and efficiency:

Vendors should be able to demonstrate how their technology can facilitate end-to-end process automation. Operational efficiency becomes even more crucial as payers’ requirements continue to rise.

Looking Ahead in the Healthcare Payer Market

The HealthEdge Annual Payer Market Report clearly shows the healthcare payer industry’s transformation driven by technology. As the industry continues to evolve, payers recognize the critical need for flexible, responsive, and highly interoperable solutions to thrive in this dynamic and competitive market. Technology is not just an enabler; it is becoming a mission-critical growth driver for healthcare payers in the future.

Download the full HealthEdge Annual Payer Market Report to learn more about these findings and gain insights from industry leaders.

 

 

In today’s ever-evolving healthcare landscape, payers are constantly searching for the right balance of providing exceptional care while keeping costs in check. Care management platforms have emerged as a solution to address both sides of this equation. However, measuring the return on investment (ROI) associated with care management solutions is not easy, given the complexity of healthcare operations and the multifaceted nature of care management.

Care management teams are given a tall order: Provide the highest-risk members with the most complete, whole-person care plans possible, all with the expectation that these members will adhere to their care plan and experience better health outcomes at a lower cost of care. Care managers are feeling pressure from every angle, struggling to balance the expectations of all stakeholders, including providers and care team staff, member families, government entities, and the health plan that employs them.

The reality is that care management is hard work. Care managers often work with the most complex and challenging members who are often hard to reach. These populations are multidimensional, meaning psycho-social factors and social determinants of health are almost always in play. In order to deliver whole-person care successfully, they have to build trusting relationships with these members, which is easier to do with access to the right data or the right technology solutions that can bridge communication gaps.

From an operational perspective, coordinating care across multiple, siloed care settings and community services is also difficult since most systems don’t talk to each other, and care managers have to log into multiple disparate systems to find the information they need. These outdated care management solutions hinder care manager productivity and efficiencies as caseloads continue to rise.

The Role of Modern Care Management Solutions

Modern care management solutions like GuidingCare can address these challenges and help health plans quickly see a return on their investment through extreme operational efficiencies and total cost of care savings. Here’s how it works:

1. Enhancing Care Manager Efficiencies:

GuidingCare streamlines care management processes by automating routine tasks, enabling care managers to focus on high-value activities and reach more at-risk members. With real-time data access and intelligent workflows, care managers are always equipped with the most up-to-date information to make informed decisions. The result? Improved care manager efficiency, reduced administrative overhead, and measurable time savings.

2. Cost Reduction and Expense Management:

GuidingCare’s predictive analytics and care coordination capabilities help payers proactively identify at-risk members, supporting early interventions and reducing expensive hospitalizations and emergency room visits. The care management solution provides transparent cost tracking, making it easier for payers to accurately quantify cost reductions and expense management achievements.

3. Optimal Allocation of Services:

GuidingCare’s data-driven approach ensures that services are allocated based on individual member needs. Payers can now measure the direct impact of their care management efforts on quality of care and member satisfaction.

Achieving Meaningful ROI with GuidingCare

In conclusion, GuidingCare represents more than just a care management solution; it is a strategic investment that empowers payers to successfully navigate the complexities of healthcare. By delivering measurable results, GuidingCare is the key to achieving better healthcare outcomes and effectively managing costs.

To learn more about how GuidingCare care management solutions can help your organization improve care quality while reducing costs, visit www.healthedge.com.

A few decades ago, change management success boiled down to phrases like, “Just do it!” or “Tough it out!” This kind of energy may have worked for short-term motivation, but it lacks the ability to inspire ongoing effort and address employee concerns. People want to know what’s in it for them when it comes to new workflows and expectations.

Today, change management is about effective listening and communication with your team—a strategy popularized by GE’s Change Acceleration Process. In times of change, employees are likely worried about job security or status and may not see why the change is necessary. Helping your team move from the current state to the improved future state requires managerial and structural support.

There are two questions your organization needs to answer before enacting change management:

1. Have we listened to employees and understood their pain points?
2. How will we communicate what we need each team to do?

This process doesn’t happen automatically—it needs to be proactive and intentional. We’ve identified 6 strategies that are essential for change management success.

1. Engage senior leadership.

One key indicator of effective change management is engagement from senior leadership. This is especially true when implementing new workflow technology or replacing a core administrative system. But what does it mean for leadership to be engaged?

To start, company leaders should be talking about the coming changes. Employees need to know why the changes are strategically important. Sharing this information helps them understand why adapting is worth the effort and gives them a sense of purpose beyond simply being told to adapt.

An objective way to measure engagement is by using the “calendar test.” Are executives attending project steering committee or other informative meetings? If not, it’s important to make sure they start. They should be able to speak about the ongoing project and understand how the implementation is progressing. This is also beneficial so senior leaders can see and appreciate the hard work middle managers and other employees are doing to ensure change management success.

2. Outline why change is necessary.

A common misstep that health plans make is assuming that employees know why you’re making this change. Many people won’t understand the need for new technologies or workflows when the original way seemed to work just fine. Your company leaders should be able to articulate the impacts in a way that helps employees feel involved in the decision-making process.

In what areas do you anticipate the most benefit from new systems? That could be paying claims faster or more accurately, complying with state audits, or modernizing legacy systems. Sometimes, the existing technology just isn’t viable any longer and can’t be properly maintained over time. Your employees want to work toward solving an important problem—so give them the information and motivation they need to do so.

3. Communicate the company vision.

Now that your employees and executives understand why change is necessary for your health plan, what is the vision for your organization over the next few years? Paint your team a compelling picture of the future state and where the company is headed. Ideally, your vision contains wording that speaks to both your team’s minds (i.e. intellect) and their hearts (i.e. emotion).

Make sure your team knows that with new technologies comes a chance to improve individual skills and maximize what they’re able to accomplish. In the case of HealthRules Payer, for example, the platform automatically handles adjudication and reviews for errors. This vastly reduces the need for manual reviews, giving employees time to focus on more complex, impactful tasks only they can do.

4. Gain internal commitment.

Encouraging your employees to commit to the change process is about more than education and passive acceptance. Identifying early adopters and internal influencers can be vital for gaining widespread support. These individuals already support the new adoption, which makes it easier for them to be engaged early in the project . They can then become a resource for other employees who have questions or need support during the process.

It is also beneficial to identify who might be resistant to change within your organization. Generally, areas of resistance fall into three categories: technical, political, and cultural. You don’t necessarily need to convert them into supporters, but it’s important to know why they might be hesitant and address their concerns so they’re not constantly pumping the brakes.

To help convince resisters why the change is important, turn to the three D’s:

1. Data: Use data, such as higher payment accuracy rates, to explain why the new system will be better.
2. Demonstrate: Show the new solution and share how other groups best utilize the platform.
3. Demand: Share regulatory requirements and customer expectations that convey why the new technologies are needed.

You do not need everyone at your health plan to be on board. In reality, when approximately one-third of your employees are supportive, the rest will follow and accept the coming change.

5. Adapt underlying systems and structures.

With new tools come new processes. So how can you encourage the change and not force the change?

First, have a plan for how processes will change with the new system and communicate it clearly to your employees. It is possible that the new tools will alter team structure and reporting, leaving some individuals without the support they’re used to. Knowing how they will be expected to work moving forward will help mitigate some of their apprehension.

Changing employee incentives can help with this process. Certain employees might have different goals because the organization can now sell to larger companies with bigger contracts. For others, it may be as simple as removing access to the legacy system and encouraging them to sign in to the modern user-friendly system. Once your team understands the structure of work, they can be more creative and accepting with how they get there.

6. Monitor progress with data.

What gets measured gets done, and what gets rewarded gets repeated. How is your organization measuring progress? What are the key milestones to reaching your goals? Your timeline will be unique based on your company goals, but it’s vital to add checkpoints along the way. Get comfortable with the idea of designing, building, and validating your processes before you go live—and then review and reiterate.

You will also need to know your leading and lagging indicators of project success, as well as how to break them down for iterative measurement. Once the project metrics are agreed on and in place, you can better align your employees to meet them.

Conclusion

Throughout this process, it’s important to remember: if you aren’t adapting and growing, you’re falling behind. Working with the right professional services team can support your organization in defining what change management success means for your organization. This includes steps like project planning to identify scope and milestones, meeting with senior executives to determine measures of success, establishing a steering committee, and enabling your team to continue building toward your objectives.

For more information about the HealthEdge Professional Services team and how it can impact your organization, click here.