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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.

A health plan’s internal culture can make or break an implementation.

As a business consultant, I have worked on several different implementations throughout my career. Every internal culture is so vastly different from one project to the next.

My role requires me to ask the right questions to understand the company culture and quickly adapt to ensure a successful implementation. Whether a customer is switching to an entirely new system or performing an upgrade, the project will shift how the company operates to some degree.

When it comes to change, there will always be natural pushback, so it is an important step at the beginning of the project to understand why there may be hesitancy. Some clients are ecstatic; they’re ready for a better solution that will take care of the pain points they’re experiencing. On the other hand, some people are comfortable with their routine and not ready to change from the status quo.

In a recent Accenture Research global survey of business and IT leaders worldwide, 77% of executives said that their technology architecture is becoming critical to the organization’s overall success.

The Importance of Collaboration for Successful Health Plan Implementations

When it comes to significant initiatives to transform a health plan’s business, like a system migration, it requires buy-in from the executive level down to the teammates who will work on the new platform. Without buy-in and collaboration, the implementation process is always much more challenging for health plans.

I understand when plans are mindful of time and resources and say, for example, “I don’t think we need a technical person to join this part of the process.” However, if a project is understaffed from the onset, customers will spend more time and resources doing catch-up. Ramping down is always easier than ramping up mid-project. The entire process goes much smoother someone at the table can quickly solve an issue or answer a question to keep the project moving forward. Otherwise, clients will spend valuable time scrambling to find the right people and getting them up to speed.

The most successful projects I’ve worked on are those where the team includes expertise from all facets of the project. When health plans have everyone aligned―project managers, account executives, consultants, financial analysts, IT, etc.―from the beginning, they will achieve the best result.

Health plans face financial decisions every day that impact their bottom line. What terms will make a new provider contract more beneficial? How should a new payment policy be implemented for Medicare Advantage or Commercial business? To answer these questions well, health plans need solutions that enable them to overcome the limitations of their existing technology and leverage claims analytics insights for business decisions and negotiations.

But some health plans run on multiple core claims systems that use several disparate pricing, editing, and payment integrity point solutions to try to pay claims accurately. Claims administrators spend hours looking at data from disparate sources and compiling information.

Historically, claims analytics can be disjointed. A payer may need to export claims from multiple sources, then process them in multiple batches using a separate solution to get the analytical data they need. This back-and-forth process produces old information that cannot be relied on for accurate analysis. It causes delays for everyone involved, and if decision-makers do not have quality information in a timely manner, there is less confidence for those in medical management and contracting when they make crucial decisions for a health plan’s financial success.

How Claims Analytics Can Help CFOs

It is time for health plans to invest in integrated systems that allow data, and therefore analytics, to land in one centralized place. There is an opportunity to simplify the entire payment ecosystem and seamlessly connect to multiple claims systems and third-party solutions. Rather than connecting individually with different systems for Medicare and Medicaid pricing or specialty systems like genetic testing, the data should be available in a single location.

To gain a competitive edge in the evolving health care market, health plan CFOs need access to real-time claims analytics data and the ability to view and analyze all claims as they are processed. Imagine that you could look at scenarios quickly with accurate data and evaluate “what if” modeling to discover better ways to do business. This information can transform a business, delivering immense value — like predicting the potential savings from structuring a contract differently.

Financial decisionmakers need a modeling tool that can take claims from one provider and run those claims through another provider’s contract to see how they would have priced differently. Imagine heading to the negotiation table armed with this data. A simple payment term could hold up an agreement – on the surface, one might assume this would deliver a big financial hit, but what if the data said otherwise? What if the data showed that there would not be a significant impact? Then the payer and provider could quickly agree to a contract that satisfies all parties without a contentious debate.

With the right technology and business intelligence tools, payers can model and forecast different pricing scenarios. They can make customizations and edits to see how different pricing rules calculate down to the cent. Reliable, real-time, integrated analytics unlock new possibilities and enable complete business transformation.

How many resources does it take to run the core configuration of your enterprise?  What type of custom external tools are required to build and maintain the configuration?  What are the financial impacts associated between the complexity of the configuration in a system and the cost per member per month (PMPM) in healthcare or total cost of ownership (TCO) figures?

As we evolve into the next generation of core systems, these types of questions top the list for the potential vendors looking to modernize a core platform for a prospective health plan.  One thing is clear, as we continue forward in the market, the time of the core systems that require high administration costs in terms of the number of resources and custom solutions it takes to configure and maintain is coming to an end.

Currently, the savviest health plans in the market are shifting from the predominant solutions for configuring the system with offshore-based services and/or custom-developed utilities and toolsets to ones focused on out-of-the-box automation enabled by best-in-class configuration.

Can a system be both flexible and provide streamlined next-generation configuration capabilities?  Putting myself in the shoes of any given health plan in the market today for a core modernization and the surrounding ecosystem, one key focus would be on the core configuration and the level of automation that the system brings.

Is the system’s configuration overly complex, disparate, and requires custom external tools to build and maintain?  Can my current staff pick up the complexity of all the aspects of a system that need to be considered when implementing and maintaining my business?  Consequently, what does that ramp-up time look like?  The steeper the learning curve, the greater the chance staff will likely resist adopting the new technology, and the project suffers or fails outright.

In my career, I have seen far too many health plans that implemented their solutions 20 years ago and are faced with complete re-implementation of the existing platform.  Their current systems do not possess the flexibility nor the automation to provide the ability to implement enhancements to optimize existing configuration over time. The level of effort and analysis is simply too high when maintaining production states are the operational primary focus.

Historically, HealthEdge has focused on optimizing the transactional side of the payer business. As a core administrative solution provider, we touch all parts of our customers’ workflow, and this requires us to store and host volumes of data. By better understanding the data, we can use it to drive value for customers.

With a data lake, any kind of data, irrespective of structure and source, can quickly provide valuable insights that improve our customers’ business outcomes and operations.

With a traditional data warehouse, users must transform data into a well-defined schema before storing it in the warehouse.  In order to generate insights from the data, one is limited to the particular schema design. Furthermore, these traditional schemas face design challenges when new sources of data become available for ingestion.

With a data lake, there is no longer a barrier. The data does not need to be clean and perfect or come from a single source; it can come from anywhere. A data lake allows for the storage of data from core admin systems, pharma, EHRs, or other proprietary sources in its original format until it’s required for analysis. Furthermore, a data lake is scalable and can easily support large volumes of data at once or incrementally, enabling analysis that would not be possible with traditionally pre-defined hardware constraints. With the data lake’s distributed systems, a user can ask extremely complex questions as well as create computationally intensive predictive models.

For example, a model could be built to determine how to process claims more efficiently and improve auto adjudication rates using machine learning techniques. With a data lake, a user can perform complex data transformation of millions and millions of claims—including the claims history, adjustments, processing on reason codes, and more —and do it in a fraction of the time of a traditional SQL-based data warehouse.

A second example of leveraging data lake technologies for health plans is with predicting membership churn. Retaining members is a significant issue for health plans, but they can only compare the return rate versus the percentage of people leaving. With a data lake, there may be enough historical data to model member characteristics and behavior before they left the health plan in the past and use this knowledge to predict if current members will leave a plan in the future. With that information, health plans can adjust their offerings accordingly to improve retention rates.

This year, HealthEdge built a data science team that is currently pursuing these and other hypotheses. Through close collaboration with our customers and a series of near-term proofs-of-concept, we anticipate unlocking new types of value for the health insurance market not possible five years ago.

Batch processing of data has been the norm in the health insurance industry for decades. However, as the complexities and competition within the industry heat up, so do the pressures for the ability to access more timely and accurate data. Data that is a month old, or even a day old, is considered stale and useless in today’s fast-paced market.

The good news is that for many years, access to real-time data has been a guiding principle in the HealthEdge product investment strategy. In fact, all the HealthEdge applications are built with high-quality, highly available data in mind.

HealthRules Payer® contains valuable claims data shared via real-time APIs with other HealthEdge and third-party applications. HealthEdge Source incorporates payer edits and pricing content from other systems and updates its contents and rules every two weeks. GuidingCare® grants care managers access to important member benefits information so they can make smarter decisions on appropriate care plans for certain patient populations.

As we at HealthEdge help our customers aggressively pursue their digital transformation strategies, we consider access to real-time data the gateway to success in healthcare.

We acknowledge this access is critical to many constituents, including providers, members, and even brokers, who live outside of the four walls of the health plan. As such, we continue to actively invest in new ways to make more real-time data available to stakeholders who need it.

Why Real-Time Data Matters in Healthcare

As health plans seek to drive smarter clinical and operational decisions that result in better outcomes and greater efficiencies, access to real-time data is a must-have. In addition, regulatory bodies are consistently pressuring health plans to up their game when it comes to data access and transparency in recent years:

• The 21st Century CURES Act requires payers to provide access to all claims and clinical data, including care management data and certain documents within one day of having the information available in their system via FHIR-based APIs. It also sets new standards for the recency and accuracy of provider directories. Maintaining accurate provider data and exposing data to others is a significant challenge for many payers who operate on outdated, legacy systems.
• The No Surprises Act requires health plans and providers to make good-faith estimates for healthcare costs available to consumers and sets boundaries for out-of-network emergency care services. Information that is not available in real-time can misinform these estimates. This requires new levels of transparency and accuracy around pricing data.
• Implementation of the Consolidated Appropriates Act (CAA), as part of the Affordable Care Act, demands additional levels of pricing transparency, requiring plans to make certain pricing information publicly available to participants, beneficiaries, and enrollees via the internet and paper forms upon request.

In addition, consumers expect greater access to real-time data as they continue to play a bigger role in their health plan purchasing decisions. Providers expect greater access to data across their networks to help ease the administrative burdens associated with claims processing. And care managers expect greater access so they can provide more effective care plans that are appropriate for the different populations they serve.

The HealthEdge Plan to Enable Real-Time Data in Healthcare 

The HealthEdge approach to enabling greater access to real-time data centers on three main principles:

• Accurate data: We cannot talk about real-time data without also talking about data accuracy. The main idea is that more recent data is likely more accurate data. Not only does inaccurate data erode trust among providers and members who access it through portals or IVR systems, but it also can lead to higher operational costs when health plans have to chase down over-and under-payments. Our systems have data quality improvement capabilities within them to help minimize the burden of maintaining accurate data. For example, HealthEdge’s Source researches, manages, and maintains data (current and historical fee schedules, rates, payment policies, and provider-level data) and publishes updates every two weeks.
• Organized data: Making the real-time data accessible requires an easy-to-understand data structure. HealthEdge data closely models the real world, so the relationships of the data elements are more easily understood by other systems and provide more complete models for looking at providers, suppliers, subscribers, and members. This supports better network management and facilitates more informed contracting.
• Accessible data: APIs establish a common language by which disparate systems more easily share data with each other. As we recently announced at our annual customer conference, IMPACT 2021, we are continuing to expand access to all types of data through advancing our API framework. In addition, we are establishing an ecosystem of partners where our customers can be assured that the integration between our system and certain third-party systems, like EDI gateways, enrollment systems, member engagement, and analytic systems, will be fast, easy, and continuously supported by our team.

“Customers can be members, providers, brokers, whatever the constituent is. And the ability to surface the information and the needed response in real-time is the fundamental piece that outlines the success of what we do. Friday Health Plans has been able to leverage its claim system (HealthRules Payer) and underpinnings of technology and data to have a better customer experience.” Kevin Adams, CEO, UST HealthProof

To learn more about how we are working to give our customers, our applications, and our partners’ unprecedented access to real-time data, visit www.healthedge.com or contact us at [email protected].