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Difficult care management implementations have led to the demise of many care management solution vendors. Sometimes success can be a vendor’s worst enemy. If they pick up too many customers and can’t implement them properly, word of that spreads quickly.

How We Help Our Customers Implement 

We’ve invested a lot in having a successful care management implementation team. We wanted to make sure that if we win new business, we implement the customers properly so they can stay focused on improving care for their members.

Every customer is assigned an executive sponsor for their implementation, someone on our senior leadership team responsible for the customer relationship and ensuring that we’re meeting their needs.

Each implementation also has a core team that includes a project manager, a business analyst, a clinical subject matter expert, and, most importantly, a solutions architect. The solutions architect looks at the health plan’s overall ecosystem and configures it in the best way for GuidingCare.

The role of the solutions architect is important because health plans today want to seamlessly connect their care management system to other entities in the ecosystem.

Take social determinants of health (SDOH), for example. Care managers need the ability to reach out to an SDOH vendor, such as Unite Us, Healthify or Aunt Bertha, make an appointment for the member on whatever it might be―housing, food, job― without leaving the care management system. Everything must be connected and documented so they can report against it. Or, during an appointment, a care manager may realize a member could benefit from receiving specific content related to their healthcare needs. Without leaving the system, the care manager should be able to reach out to a vendor like HealthWise through the care management platform, gather that information and send it to the member in their preferred format.

Our customers want more integrations, and we’re listening.

Today, we have a developer portal with hundreds of APIs and continue to make new ones every month.

Health plans want a care management platform that is brilliant at the basics and innovative for the future. From the beginning of the implementation, we want our customers to know we will always be there to run to any challenge, support their needs, and continually improve our product.

In the fast-paced landscape of the healthcare industry, adaptation and innovation are key to success. At HealthEdge^® Professional Services, this philosophy is not just a motto but a driving force behind the transformative efforts led by the Transformation Management Office. This office, spearheaded by professionals who have transitioned from service delivery teams, is dedicated to reshaping the way solutions and services are brought to market, driven by customer demands and operational challenges. Let’s delve into the journey of this evolution and the remarkable strides being made towards enhancing customer and employee experiences.

Empowering Change through Cross-Functional Synergy

For the HealthEdge Transformation Management Office, the primary objective is clear: to identify market needs, customer requests, and operational inefficiencies, and then design strategic solutions that drive growth and improvement. This involves the convergence of cross-functional teams, uniting departments that may have operated in silos in the past. An inspiring example of this approach is the Care-Payer initiative. This groundbreaking endeavor brings together claims processing and care management under the unified umbrella of One HealthEdge. It’s not just about technical integration; it’s about harmonizing product teams, consulting teams, and technical experts from different entities that were once separate.

The result? A more streamlined deployment process, enhanced training materials, and a simplified approach to understanding and mapping product hierarchies. This approach exemplifies how different components, once disjointed, can come together as a unified force to deliver a seamless experience. The key takeaway here is that while challenges exist, strategic collaboration can bridge gaps and pave the way for innovation.

Innovating for Customer-Centric Solutions

The commitment to innovation is not limited to internal processes. HealthEdge Professional Services is consistently expanding its range of offerings to cater to customer needs more comprehensively. An outstanding example of this is the EDGEcelerate™ solution that was launched earlier this year. Originally introduced to support health plans who use HealthRules^® Payer, EDGEcelerate has since evolved to embrace GuidingCare^® customers and more, exemplifying the adaptability and customer-centric mindset of the organization.

EDGEcelerate revolves around a master umbrella Statement of Work (MSOW) that provides a holistic view of services and features available to clients. This modular approach allows customers to choose and execute services as needed, providing flexibility and scalability. This approach is not about imposing predefined services; it’s about tailoring solutions to meet the unique needs and growth trajectories of each client. The underlying principle is clear: customers are not just clients; they are partners in growth and innovation.

Digital Transformation for Enhanced Visibility

Enhancing customer experience goes hand in hand with providing better tools for both customers and internal teams. HealthEdge Professional Services is harnessing the power of digital tools to elevate project management and visibility. The organization is piloting new tools that provide real-time insights into project progress, helping to identify deviations from the course and making timely adjustments. This is not just about keeping projects on track; it’s about facilitating transparent communication and informed decision-making.

From a governance perspective, the introduction of dashboards and stoplight indicators ensures that all stakeholders have a clear understanding of project health. This level of transparency extends to executive leadership teams, ensuring that they are well-informed and equipped to provide the necessary support. The goal is not just project success; it’s a collaborative effort to achieve excellence at every step.

A Powerful Partner in Digital Transformation

HealthEdge Professional Services’ journey is an inspiring tale of transformation fueled by collaboration, customer-centricity, and innovation. By embracing cross-functional cooperation, adapting offerings to customer needs, and leveraging digital tools, the organization is not only enhancing customer experiences but also fostering a culture of continuous improvement.

As the healthcare landscape continues to evolve, HealthEdge stands as a beacon of change, demonstrating that by aligning efforts and embracing change, remarkable accomplishments are achievable. The future promises more growth, more collaboration, and more innovation, as HealthEdge Professional Services continues to shape the healthcare landscape with a customer-centric mindset and a commitment to excellence.

To learn more about how HealthEdge Professional Services can lead your organization through a digital transformative change, visit www.healthedge.com.

 

In the fast-paced world of healthcare, the management of payment integrity initiatives has emerged as a critical challenge for payers. The increasing complexities of healthcare claims have led to a pressing need for a more efficient and effective approach to ensure accurate payment processes.

The traditional methods of handling payment integrity are proving inadequate in the face of evolving requirements, resulting in recurrent inaccuracies, inefficiencies, and wasted resources. It’s time for a paradigm shift, and Source Platform Access is leading the way.

The Challenge

Traditionally, payers have resorted to layering multiple editing solutions to address payment integrity concerns. However, this approach brings its own set of complications. Each editing solution operates on its own update schedule and data sets, leading to fragmented processes and siloed information.

Plus, the inherent incentive for primary and secondary editing vendors to safeguard their own intellectual property has led to a lack of collaboration and sharing among stakeholders. This not only hampers the overall accuracy of the payment process but also perpetuates a cycle of continuous charging for the same issues month after month, without any issue-resolution in sight.

The Solution

There is a better way, and it’s called HealthEdge^® Source Platform Access. It challenges the status quo and creates a new path to payment integrity improvements by giving payers the power to identify the root causes of payment inaccuracy issues and correct the issues earlier in the process for greater efficiency gains and lower contingency fees.

Behind the innovative technology of Source Platform Access is a highly seasoned team of payment experts who work in partnership with Source clients. This collaborative approach ensures that the technology is not only implemented effectively, but it is also aligned with the long-term goals of the organization.

Today’s hectic healthcare environment requires an innovative approach to payment integrity, and Source Platform Access stands at the forefront of this evolution. With Source Platform Access, the path to transformative payment integrity is clear, and the possibilities are limitless.

Learn more about how Source Platform Access can help your organization challenge the status quo and dramatically improve the effectiveness of your payment integrity initiatives here.

 

In the dynamic world of healthcare, consumer expectations are rapidly evolving. The rise of retail experiences has empowered healthcare consumers with higher expectations, prompting health plans to rethink their strategies to ensure member satisfaction.

In response, HealthEdge conducted an independent research study of more than 2,800 insured individuals in the United States to gain valuable insights into consumer preferences, perceptions, and expectations. The 2023 study reveals crucial findings that can help health plans adapt and thrive in today’s competitive landscape.

Snapshot of Key Findings

The study uncovered several significant findings that hold vital implications for health plans:

1. Member Satisfaction: Only 45% of healthcare consumers report being fully satisfied with their health insurance provider. Interestingly, member satisfaction levels increase to 56% among those with assigned care managers. The answer to closing this satisfaction gap lies in delivering personalized member experiences – which is no easy feat.
2. Social Determinants of Health (SDOH): While members who have a care manager report higher satisfaction levels, care managers still have significant opportunity to better leverage available SDOH data to deliver personalized, relevant services and address members’ individualized needs.
3. Communication Preferences: An overwhelming 82% of consumers report higher satisfaction when payers communicate with them in their preferred ways. Adopting omni-channel communication strategies is crucial for enhancing access, convenience, and engagement.
4. Improving Member Satisfaction: The survey identified two key actions for improving member satisfaction: enhancing customer service and increasing access to self-service tools. Equipping customer service representatives and care managers with data and tools for personalized care is essential, as is empowering members to take a more active role in their healthcare journeys.
5. Trust in Health Plans: Despite increasing competition from non-traditional players, health plans remain the most trusted source among 70% of respondents for administering health insurance. However, generational differences affect trust levels, highlighting the importance of accommodating each generation’s needs.
6. Transforming Perceptions: 40% of respondents blame health insurance companies for the high cost of healthcare. To change this perception, health plans must be perceived as partners in care rather than just payers of care.

Three Reasons Why Member Satisfaction Matters More Than Ever Before

1. Choice: Historically, healthcare consumers had limited choices. Many simply accepted their employer provided benefits without question, as most employers covered 100% of medical expenses. Millions of Americans did not have health insurance. Medicare was the primary health plan for the majority of seniors. Most benefit plans left little financial burden on the consumer, and as a result, the average healthcare consumer didn’t think twice about the high cost of healthcare. Today, healthcare consumers have more choices than ever before. There are nearly 4,000 Medicare Advantage plans from which seniors can choose, with the average beneficiary having more than 39 different options in their coverage area.
2. Competition: Market choice drives competition, and the competition among health plans has never been greater. Health plans that operate on outdated technology are unable to adapt to changing market conditions or deliver the innovative solutions today’s market requires. As more non-traditional players like Amazon, CVS, and Walmart enter the market and continue to raise the bar on consumer experience, health plans must match this new wave of tech-savvy competitors with modern care management and member engagement platforms.
3. Criteria: New and expanding government regulations continue to put pressure on health plans to improve transparency and the member experience. In fact, the Centers for Medicare & Medicaid Services (CMS) doubled the weight of member satisfaction scores for the 2023 rating year. The increase means member satisfaction has a larger impact on performance metrics that affect health plan bottom lines.

Practical Guidance for Health Plans

To address growing consumer expectations and remain competitive, health plans should focus on innovation backed by modern technology. Implementing modern platforms, deploying digital member engagement tools, and empowering care management teams can significantly enhance member satisfaction and improve the overall healthcare experience.

The 2023 HealthEdge consumer satisfaction survey report highlights the urgency for health plans to prioritize member satisfaction in today’s competitive landscape. By leveraging modern technology and adopting innovative strategies, health plans can meet consumer expectations, remain competitive, and prepare for the generations of members to come. As healthcare continues to evolve, empowering the future of healthcare lies in delivering personalized, transparent, and convenient experiences to consumers. The time to act is now.

Visit the HealthEdge website to access the full research report or watch a recording of the recent AHIP webinar where HealthEdge clinical and business leaders discuss the survey findings.

Recently, I had the privilege to catch Martin Makary, MD, a surgical oncologist, chief of the Johns Hopkins Islet Transplant Center, and author of The Price We Pay: What Broke American Health Care And How to Fix It, present at the THAP Texas Healthcare conference.

During his presentation, “The High Cost of Health Care and How People can get a Better Deal During and After COVID-19,” Dr. Makary started down a list of key aspects of care that are rising around value-based, such as the appropriateness of care and referral processing by quality. Additionally, Dr. Makary touched on the European public markets, like Italy, that are finding success with globally capitated value-based arrangements versus the broken fee-for-service revenue stream we see more commonplace in our commercial markets here in the states today.

The Importance of Value-Based Care for Health Plans

Continuing the value-based care theme at the same conference, Dr. William Shrank, Chief Medical Officer at Humana, discussed topics like de-adopting low-value care, reducing waste, and re-imagining prior authorization and utilization management.

Dr. Shrank reviewed a gold card approach to value-based care that would exempt physicians based on performance for authorizations or referrals. Focus on high-value, quality care, value-based reimbursements are driving Humana’s shift to shared risk models.

Humana is not alone. In September of 2020, CareFirst BlueCross BlueShield and MedStar Health announced a value-based care initiative they project could save $400 million. The concept of Total Care includes new value-based care reimbursement models that focus on outcome-based medicine utilizing coordinated care to reduce costs and improve quality.

As my colleague, Harry Merkin, previously wrote, “The COVID-19 pandemic has also highlighted the flaws of the fee-for-service model, with providers of all types experiencing the delay of preventative and elective medicine resulting in revenue disruption… leading to higher costs for both health plans and providers.” Janet Barros also has a great blog, Value-Based Care Requires Payer-Provider Collaboration, where she reviews how sharing data and analytics can help with Social Determinants of Health (SDoH) and understanding how it impacts high utilizing members. Sharing data and analytics can help with SDoH and understanding how it affects high-utilizing members. A couple of aspects to consider around value-based reimbursement and the many moving parts.

A core solution that can both integrate with best-in-class care management applications and providers via EDI transactions with near real-time insights into the business will be integral in this enablement. Above integration, however, how easily the core system and ancillary components can be configured to implement these emerging models will directly impact the costs of change. The automation and level of business user enablement to accommodate these (and many other similar) changes directly attribute to the overhead of implementing these market-driven needs. Modeling, projecting, i.e., the analysis of any claims testing transactions, including quality, all of these activities will need to come together, like any other implementation, in order to make these concepts reality. The payers that can execute these aspects the best will likely determine their success in the landscape of value-based reimbursement.

In the ever-evolving landscape of healthcare technology, HealthEdge has emerged as an integral player in providing innovative solutions to streamline healthcare processes and enhance patient care. However, the intricate nature of the healthcare industry demands a meticulous examination of the differences, similarities, and cooperative relationship between corporate compliance and security compliance within the context of HealthEdge.

Corporate Compliance:

Corporate compliance encompasses a comprehensive framework of regulations, laws, and ethical guidelines that govern a company’s business operations, governance structure, and interactions with stakeholders. At HealthEdge, corporate compliance serves as a fundamental pillar for ensuring transparent and ethical conduct, mitigating legal risks, and upholding the company’s reputation. HealthEdge follows the seven (7) foundational elements established by the United States Federal Sentencing Commission:

• Policies, Procedures & Code of Conduct.
• Training & Education.
• Reporting.
• Monitoring & Auditing.
• Enforcement & Discipline.
• Response & Prevention.
• Compliance Officer & Compliance Committee.

By adhering to these elements, HealthEdge demonstrates its commitment to ethical conduct and builds trust with healthcare providers, patients, and investors.

Security Compliance:

Security compliance, is centered on safeguarding sensitive data, digital assets, and information systems from unauthorized access, breaches, and cyber threats. In the context of HealthEdge, security compliance is pivotal to protect sensitive data, and other confidential information from potential vulnerabilities.

Prominent security compliance frameworks, such as The Health Information Trust Alliance (HITRUST), and the National Institute of Standards and Technology (NIST) 800-53, provide guidelines for implementing cybersecurity controls. These controls encompass a spectrum of measures, including encryption, access controls, intrusion detection systems, data loss prevention, regular vulnerability assessments, and incident response plans. By adhering to security compliance standards, HealthEdge establishes a resilient defense against cyber threats and data breaches.

Security compliance goes beyond mere regulatory adherence—it fosters a culture of data protection and risk management. As healthcare companies increasingly become targets for cyberattacks, security compliance at HealthEdge ensures confidentiality, integrity, and instilling confidence in both clients and end-users.

Interaction and Collaboration:

While corporate compliance and security compliance have distinct focal points, their interaction and collaborative relationship are evident within the operations of HealthEdge. Effective security measures often align with corporate compliance objectives, particularly in safeguarding sensitive data and maintaining the company’s ethical standing.

For instance, secure data handling practices mandated by security compliance regulations contribute to maintaining privacy and fulfilling regulatory requirements including HIPAA. Establishing a strong security posture can prevent data breaches and legal penalties, thereby preserving the company’s reputation and financial stability.

Benefits of Integration:

Integrating corporate compliance and security compliance yields comprehensive benefits for HealthEdge. The alignment streamlines efforts, minimizes redundancies, and ensures that compliance requirements are addressed. This initiative-taking approach reduces the risk of overlooking critical regulatory and security obligations.

A unified compliance strategy enhances risk management capabilities. By identifying vulnerabilities from both corporate and security perspectives, the company can proactively mitigate potential risks and respond effectively to emerging threats. This approach fosters a culture of caution and accountability throughout the organization.

The integration of corporate and security compliance bolsters stakeholder trust. Our customers are more inclined to engage with a company that proves a commitment to ethical conduct and data protection. This trust translates into improved customer retention, client satisfaction, and competitive advantage.

Conclusion:

The cooperative relationship between corporate compliance and security compliance is essential for success. The fusion of ethical conduct, legal adherence, and data protection creates a foundation for sustainable growth and innovation. This integration not only safeguards sensitive data but also preserves the company’s reputation as well as reinforces stakeholder trust and competitive positioning.