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In the ever-evolving landscape of healthcare, one of the most challenging aspects for healthcare payers is keeping up with the constant changes in fee and policy schedules set by the Centers for Medicare & Medicaid Services (CMS). Each year, CMS makes numerous adjustments, amendments, and updates to these schedules that can create financial challenges and increase administrative burdens for payers.

The Frequency of CMS Updates 

CMS plays an important role in administering healthcare programs for more than 150M Americans according to CMS Fast Facts for CY 2022. As part of this responsibility, CMS continually reviews and revises its fee and policy schedules. The frequency of these updates can be daunting:

• Annually: CMS routinely publishes updates to various fee schedules and policies on an annual basis. These annual updates are eagerly anticipated by healthcare providers and payers, as they often involve significant changes to reimbursement rates and regulatory requirements.
• Quarterly: Beyond the annual updates, CMS also releases quarterly updates to fee schedules, which can include changes to payment rates, coding guidelines, and coverage policies. These quarterly updates are aimed at addressing emerging healthcare trends and issues.
• Ad Hoc Updates: In addition to the regularly scheduled updates, CMS may issue ad hoc updates in response to urgent healthcare needs or changes in legislation. These updates can have immediate and profound effects on the healthcare industry.

The Impact of CMS Updates on Payers

These updates encompass changes to reimbursement rates, policies, and regulations that directly influence how payers operate.

Reimbursement Rates:

One of the most significant aspects of CMS updates for healthcare payers is the adjustment of reimbursement rates. CMS sets rates for services covered under Medicare and Medicaid, which serve as benchmarks for many private payers. When CMS updates reimbursement rates, it affects the revenue that healthcare payers receive from government-sponsored plans and, subsequently, the rates they negotiate with providers.

Financial Sustainability:

CMS updates can pose financial challenges for healthcare payers. Reductions in reimbursement rates or changes in payment methodologies can impact the profitability of managing government-sponsored plans. Payers may need to adapt their cost structures, premium pricing, or network strategies to maintain financial sustainability.

Compliance Burden:

CMS updates often come with changes in documentation, coding, and billing requirements. Healthcare payers must invest in compliance efforts to ensure they meet the evolving regulatory standards. This can increase administrative costs and necessitate ongoing training and education for staff.

Network Management:

Changes in CMS policies can also impact payer-provider relationships. Negotiating contracts with providers may become more complex due to changes in reimbursement rates and performance-based incentives.

Member Services:

CMS updates can directly affect the services and benefits offered to members of government-sponsored plans. Changes in coverage policies, eligibility criteria, or access to certain treatments can influence member satisfaction and retention. Healthcare payers must communicate these changes effectively to members and provide support to navigate evolving plan options.

Care Coordination:

CMS emphasizes care coordination and value-based care models in its updates. Healthcare payers need to align their strategies with these priorities to improve patient outcomes and control costs.

Regulatory Compliance:

Staying compliant with CMS updates is paramount for healthcare payers. Non-compliance can lead to penalties, reputational damage, and potential legal issues. Payers must continually monitor CMS changes, update their policies and procedures, and ensure that staff members are well-versed in the evolving regulations.

Navigating CMS Changes 

One of the ways many payers are choosing to navigate all of these changes is through the use of modern technology. Payers who use HealthEdge’s core administrative processing system (CAPS), HealthRules® Payer, have the unique opportunity to leverage the company’s award-winning prospective payment integrity solution, HealthEdge Source™, as a secondary editing solution.

This productized integration, called Payer-Source, is now available as a secondary editor, which means claims can go through another layer of validation so inaccurate and inappropriate claims are more likely to be caught before they are paid. This not only reduces the risks of overpayments and underpayments, but it also helps minimize provider abrasion.

And the good news is, there is no need for payers to replace or change their primary editing solution, which can be HealthRules Payer or other primary editing vendors, to take advantage of this new capability. It simply slips in the payment workflow after the primary editor but before the claim has been fully adjudicated. Users have complete flexibility and control over whether they want to accept the Source recommendations or not.

Powerful Savings Identified 

The Source Data Study team recently completed several data studies with payers, using the Payer-Source integrated solution as a secondary editor, and the savings opportunities the solution identified were significant:

• A national health plan was able to generate $8.7M, or 1.1% in incremental savings, on 5.1M claims, representing $790M in spend from its Medicaid and Dual-Eligible populations
• A regional health plan was able to generate $9.1M, or 1.6% in incremental savings, on 2.1M claims, representing $571M in spend
• A mid-sized regional health plan was able to generate $11.1M, or 1.6% in incremental savings, on 1.7M claims, representing $684M spend

Learn more about how payers can future-proof their claims editing for real savings here.

 

The volume of changes CMS makes to its policies and pricing schedules every year is staggering, with over 600 retroactive changes anticipated for 2023 alone, making it challenging for payers who depend on outdated technology to keep up. To capture the changes, Payers must comb through manuals, fee schedules, bulletins, and news flashes. Once the changes are identified, IT resources typically have to upload them into the payer’s ecosystem in multiple places.

For example, if a new modifier is posted for Medicare, teams must figure out which claims are impacted and what impact those changes may have. Then, they must determine what actions should be taken: overpayments that may require recoupments or underpayments that may surface during a CMS audit or spark a series of calls from providers, all contributing to provider abrasion. And the same process must be followed for changes at the state Medicaid level, which can be even more taxing and time-consuming since each state is unique.

Managing CMS policy and fee schedule changes is an enormous burden on everyone. Most payers have entire teams of business and technical resources dedicated to reacting to these changes.

However, at HealthEdge Source™, we are actively working with our customers to solve this problem using modern, prospective payment integrity solutions. We’re enabling payers to take a proactive approach to retroactive changes with Source Retroactive Change Manager.

Because the pricing and editing data is in a single instance, Source can automatically identify and assess which claims are impacted by the changes and capture the price/policy used when the claim was processed. Knowing the new price/policy, the system can then analyze the impact of the retroactive changes and help business leaders easily understand potential risks for over/under payments.

The Results Speak for Themselves

The Source Data Study team recently completed a study with a regional plan with home and host capabilities. The Source Retroactive Change Manager evaluated 67,916 claims from Q1 2023 and identified $2.67M in overpayments. The health plan was also able to use the solution to reduce several administrative burdens and costs, including:

• Automate timely identification, repricing, and reporting of retroactive changes
• Remove contingency vendors
• Ease provider abrasion
• Improve compliance
• Reduce waste

A separate regional health plan with 200K+ members was looking to strengthen confidence in its pricing accuracy, compliance, and readiness for external audits. In a 90-day study, Source Retroactive Change Manager identified 95,830 claims with pricing changes, resulting in over/underpayments totaling $20,921,901.

For more information on how Source can help your organization take a proactive approach to retroactive changes to CMS policies and prices, listen to this webinar, “Preparing for CMS Updates and Retroactive Changes,” presented by Jared Lorinsky, chief strategy officer, and Carl Anderson, senior product manager for HealthEdge Source.

For all the talk about value-based care models, few payers have actually discovered the secret to successfully deploying these types of arrangements with a significant portion of their provider network partners.

However, several payers, including Independent Health, a New York-based not-for-profit health plan with 387,000 members that leverages HealthRules^® Payer as its core administrative processing system (CAPS), appear to have discovered the secrets to success. In fact, Independent Health now has 98% of its primary care practice members in full capitation contracts, with solid alignment of goals with its provider network.

So, what’s the secret?

According to Dave Mika, Vice President, Enterprise Core System Operations at Independent Health, it comes down to the flexibility and power of technology.

“When we give providers data that shows how they are performing relative to required or recommended services for members within various demographics and disease states, we’re doing so with the ability to drill down to the individual patient level.

When we understand where a single patient stands relative to utilization of inpatient and outpatient services, we can offer clarity into everything from who needs to be more active in managing their own care to how cost calculators and digital health tools can be better utilized – by providers and their patients.”

The Role of HealthRules Payer

With HealthRules Payer, health plans can quickly address market opportunities and stay in front of competition. All this while achieving high levels of customer satisfaction and transparency by providing accurate, real-time information to everyone involved in the care continuum. HealthRules Payer has also significantly lowered administrative costs for our customers by simultaneously automating critical manual business processes, resulting in an enhanced bottom line.

“HealthEdge allows us to achieve speed to market with our products in the rapidly changing healthcare environment, with the capability to configure and implement products quickly and on the fly,” says Mika. “The solution also gives us the capability to drive alternative reimbursement models for our customers, now and in the future, as evolving needs – and regulations – dictate.”

With results like this, it’s no wonder that HealthRules Payer has been named “Best in KLAS” by KLAS Research for Claims & Administration Platforms for the past two years.

Finding the Value in Value-Based Care Contracts

As the healthcare industry continues to undergo transformation away from fee-for-service models to value-based payment models, digital health plans have a unique opportunity make this transition highly successfully for all stakeholders: payers, providers, and patients. They can do so by leveraging the advanced automation capabilities and real-time data insights that are readily available in modern CAPS like HealthRules Payer. With the right CAPS in place, the value of value-based contracts becomes crystal clear:

• Cost Control: Value-based care models can help health plans control costs over the long term by focusing on preventive care and early intervention
• Improved Member Health: By promoting healthier lifestyles and proactive healthcare management, value-based care can lead to improved health outcomes among members. This not only enhances members satisfaction but also reduces the financial burden on payers.
• Competitive Advantage: Payers that embrace value-based care early gain a competitive edge. They can attract providers and members who appreciate the benefits of this approach.

By harnessing the power of automation and aligning incentives with value-based care, health insurance companies can play a pivotal role in transforming the way healthcare is delivered and financed, ultimately benefiting both patients and the industry as a whole.

To learn more about how HealthRules Payer helped Independent Health, read the full case study today, and reach out to see how HealthEdge can help your organization embrace value-based care contracting by visiting www.healthedge.com.

With hundreds of health plans depending on HealthEdge’s HealthRules^® Payer core administrative processing system (CAPS) every day, members of the Customer Operations team have their work cut out for them.

How HealthEdge Customer Operations Team Supports Health Plans

This team is comprised of four different groups that work cohesively together to ensure customers have the best possible experience:

1. The infrastructure operations team ensures the company’s private cloud, networks, and operational spaces are secure and available.
2. The technical support services team manages the response to all inbound customer product inquiries and support tickets by coordinating with customers and product team members to facilitate fast responses and resolutions to any issues that may arise.
3. The customer success management team is ultimately responsible for understanding the current and future needs of HealthRules Payer customers and prioritizing the work for the rest of the organization. They are the customer “captains” who understand each customer end-to-end from an operations perspective.
4. The business intelligence team works with the data to enable the rest of the team and customers to gain actionable insights so they can proactively address opportunities for improvement.

Although much of this work sounds technical, the “north star” for this group of hard-working, seasoned professionals is all about helping HealthEdge customers give their members access to the healthcare benefits and services they need when they need them.

The internal tagline of being “Customer Obsessed” is ever-present among all team members who constantly strive to learn more about their customers’ business to provide a more personalized experience.

Equally important is the team leaders’ focus on humanizing the healthcare technology experience for employees. The work is more than just solving a technical problem. It’s about making sure that the eligibility file goes through correctly so that the mother gets access to the medications her sick child needs or the grandmother can get the medical procedure she needs to experience the joys of playing with her grandchild.

These scenarios remind the HealthRules Payer customer operations team members of their purpose: to always do what is best and suitable for their customers so their customers, in turn, can do what is best and ideal for their members.

The Future is Bright

As the HealthEdge customer community continues to expand, the customer operations leadership team is also looking to improve the lives and experiences of their employees. By establishing more standardized processes and proactively addressing the demand for unplanned work items, they are giving employees more time to focus on discovering innovative ways to support the growing customer base – all for the betterment of HealthEdge customers.

In addition, the team is working toward more standardized processes and a more integrated experience for customers of multiple HealthEdge solutions, including GuidingCare^® for care management, Source for payment integrity, and Wellframe^® for digital member engagement. As more integration points across these solutions become available, customers will have a more seamless experience working with HealthEdge.

Finally, as the organization encourages and enables health plans to become digital payers, HealthEdge is adopting more digital-centric capabilities that automate repetitive, manual tasks and improve productivity. Modern technologies that proactively monitor and adjust server capacity are also being implemented to benefit team members and customers alike.

The HealthEdge Customer Operations team is more than just a group of engineers and technical resources who support clients. They are members of a dedicated group focused on making a difference in people’s lives by enabling high-quality healthcare at the right time and the right place.

To learn more about the HealthEdge customer experience, visit www.healthedge.com.

As the U.S. healthcare system is undergoing rapid transformation, many health plans are looking to modernize their core administrative processing systems (CAPS). In fact, according to the 2023 Gartner® How U.S. Healthcare Payer CIOs Can Future-Proof Claims Editing report¹, “Increasing member expectations and operational demands are pushing payer CIOs to modernize their core administration systems.” A recent Gartner survey shows that:

• 60% of respondents are moving their core administration system from on-premises to the cloud.
• 34% are consolidating to a common platform.
• 26% are replacing proprietary solutions with commercial off-the-shelf (COTS) solutions.
• 17% are re-platforming to a modern architecture.”

However, the report also warns that the business goals associated with transitioning to more real-time claims processing are in jeopardy if CIOs do not simultaneously consider the capabilities of their claims editing solutions.

“With the modernization of claims administrative processing systems (CAPS), new business requirements and a heightened focus on real-time operations and interoperability, you need to reevaluate your claims editor’s performance.”¹

This report provides detailed questions CIOs should use to evaluate claims editing solutions and ensure they can be prepared for the future. The Source team offers these answers in response to the Gartner proposed evaluation criteria.

Modern Claims Editing Solution

Core Capabilities of Source Editing Solution

• Supports all lines of business in a single platform,
• Seamlessly integrates with virtually every major CAP system and offers complete interoperability with its sister product, HealthRules Payer (Payer-Source).
• Cloud-based solution means all maintenance and support costs are included in the monthly subscription fee, and all pricing and policy updates are proactively applied every two weeks, reducing IT and administrative burdens.
• Clients average a 30+% increase in first-pass adjudications.
• Clients find cost savings through many different edits, including validation, reimbursement, payment and billing guidelines, and medical necessity.
• Supports 39 months of claims history to help identify improper payments.
• Clients can easily customize any existing edit in Source libraries or build a custom edit in minutes.
• And much more!

Advanced Capabilities of Source Editing Solution to Support Future-Proof Initiatives

• By design, Source includes a real-time Analytics module that models claims after the editing, pricing, and audit processes occur for our client’s core claims adjudication. Source real-time analytics are run continuously and automatically.
• Source features a centralized advanced audit trail with rich data and reporting to provide complete transparency for audit and provider relations teams.
• Source allows users to set an edit to Monitor Mode to review its impact before it is put into production.
• All new edits/policies are delivered to the non-production environment where they can be tested, promoted to production in the “off” mode, and then instantaneously turned on through the system and published by the end user as needed for their required timelines.
• And much more!

Claims editing solutions’ critical role in enabling a real-time claims processing environment cannot be overstated. But even if organizations are not undergoing massive system transformations, the Source Editing solution can deliver powerful savings without changing anything in the existing editing stack.

For example, in recent data studies conducted by the Source team, millions of dollars in savings were identified when Source was placed in front of third-party editing solutions.

• 7M Medicare Advantage claims spend $648M, resulting in a $11.1M savings opportunity for a mid-size regional health plan
• 1M Medicaid claims spend $571M, resulting in a $9.1M savings opportunity for a large regional health plan
• 1M Medicaid and Dual Eligible claims spend $790M, resulting in a $8.7M savings opportunity for a national health plan

To read more about the Gartner recommendations on future-proofing your claims editing, click here for complimentary access to this report.

¹ Source: Gartner, How U.S. Healthcare Payer CIOs Can Future-Proof Claims Editing. Austynn Eubank, 20 April 2023. GARTNER is a registered trademark and service mark of Gartner, Inc. or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved. Gartner does not endorse any vendor, product, or service depicted in its research publications and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner’s research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

The healthcare landscape is in a constant state of evolution, with technology innovations serving as a guiding force for payers striving for efficiency, accuracy, and enhanced operations. In this journey, the Gartner Hype Cycle for U.S. Healthcare Payers 2023¹ report delivers insight into the maturity levels and adoption rates of 28 different innovations. In this report, one of the innovation mentioned is next-generation core administrative processing solutions (CAPS).

For the 13^th consecutive year, HealthEdge, has been recognized as a Sample Vendor in the report, under the category next-generation core administrative processing solutions (CAPS).

We believe this recognition underscores HealthEdge’s commitment to innovation, excellence, and its unwavering pursuit of transformative solutions.

The Power of HealthRules Payer

HealthRules Payer is more than just a solution; it’s a catalyst for transformation in the healthcare payer domain. Its unparalleled flexibility empowers health plans to embrace new business models, adapt to changing regulations, and expand into new markets seamlessly.

Elevating Business Impact

Next-generation CAPS like HealthRules Payer can have substantial influence across multiple facets of the healthcare insurance industry, including:

• Efficiency Enhancement: HealthRules Payer reduces transaction costs, improves access to real-time data, and streamlines operations, ushering in a new era of operational efficiency.
• Modern Architecture: HealthRules Payer supports real-time data and transaction processing through its modern architecture, bolstering the agility and responsiveness of health plans.
• Adapting to Change: With HealthRules Payer, health plans can now embrace new business models, such as value-based payment arrangements, and capitalize on cloud technology’s economies of scale and security.
• Simplified Integration: HealthRules Payer supports multiple interfaces that are configurable and user-friendly to ease the integration process with both payer and third-party applications.
• Reducing IT Dependence: HealthRules Payer’s cloud-based infrastructure and advanced automation minimizes the reliance on IT resources, resulting in increased autonomy and operational efficiency.

Recommendations

In the report, Gartner analysts provide user recommendations to payers about considerations they should make when selecting a next-generation CAPS. These recommendations include:

• Prioritize strategic versus commodity CAPS capabilities to evaluate investment decisions. The former include FHIR enablement, real-time processing or effective-now configuration to accommodate scenarios such as the Dobbs decision’s regulatory fragmentation.
• Analyze whether licensed applications, SaaS or business process outsourcing (BPO and BPaaS) solutions for each CAPS capability are best.
• Evaluate new versions of CAPS as greenfield. Old CAPS versions are not representative. However, weigh prior experience with vendor delivery heavily.
• Search for modular CAPS components that allow a partial or phased implementation and prioritize solutions that offer configurable interfaces.
• Validate the vendor’s primary market. Some CAPS have their most significant footprint in a segment like provider-led health plans, third-party administrators or dental. Consider whether influencing a vendor’s product roadmap outweighs the early adopter risk.
• Address the diminishing resource pool available to support legacy systems. Updated technologies will entice job candidates.

A Brighter Future

To us, HealthEdge’s recognition in the Gartner Hype Cycle for U.S. Healthcare Payers, 2023 under the category next-generation CAPS reflects its dedication to shaping the future of healthcare payer operations. As the industry marches towards next-generation CAPS adoption, HealthRules Payer will undoubtedly continue to serve as a benchmark for excellence, innovation, and transformative solutions in the health insurance industry.

To learn more about how HealthRules Payer can help your organization adopt a next-generation CAPS, visit www.healthedge.com.

¹ Source: Gartner, Hype Cycle for U.S. Healthcare Payers, 2023. Mandi Bishop, Connie Salgy, Austynn Eubank, 10 July 2023. GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally, HYPE CYCLE is a registered trademark of Gartner, Inc. and/or its affiliates and are used herein with permission. All rights reserved.. Gartner does not endorse any vendor, product, or service depicted in its research publications and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner’s research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.