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As a trusted partner in the ever-evolving healthcare landscape, HealthEdge understands the importance of transparency in healthcare pricing for health plans and their members. The recent implementation of the No Surprises Act (NSA) and the Transparency in Coverage (TIC) Final Rule Online Shopping has introduced new challenges and opportunities for health plans to enhance their services and provide vital information to their members about healthcare costs.

Empowering Informed Decision-Making

At HealthEdge, we believe that informed decision-making is crucial in empowering health plans and their members. Price transparency serves as a powerful tool in this endeavor, enabling health plans to provide members with information about the cost of medical services, treatments, and medications. Our Price Comparison Tool, integrated into HealthRules Payer, equips health plans with easy-to-use resources to compare prices and deliver personalized estimates, allowing members to make well-informed decisions tailored to their unique healthcare needs and financial priorities and enabling payers to be compliant with key provisions of the No Surprises Act and the Transparency in Coverage Final Rule.

What is the No Surprises Act?

The No Surprises Act is a federal law enacted to protect patients from unexpected and excessive medical bills. The Act ensures that patients are only responsible for their in-network cost-sharing amounts, shielding them from surprise medical bills and providing greater financial security in healthcare transactions. The legislation passed in December 2020 as part of the Consolidated Appropriations Act, 2021.

What is the Transparency in Coverage final rule?

The Transparency in Coverage final rule, issued by the Centers for Medicare & Medicaid Services (CMS) with a phased implementation period that started in January 2021, promotes price transparency and empowers consumers to make informed healthcare decisions. The rule requires most health plans to disclose cost-sharing information and negotiated rates for specific healthcare services and items to their beneficiaries.

Enabling price transparency and compliance with the No Surprises Act with HealthRules Payer

The No Surprises Act and the TIC Final Rule place significant requirements on health plans to ensure price transparency and accessibility to pricing information. HealthEdge’s HealthRules® Payer is designed to support compliance with these regulations by providing health plans with the advanced Trial Claims functionality. Through Trial Claims, health plans can deliver required pricing information through various channels, including online, over the phone, and in paper form, as mandated by the legislation.

The tool leverages a capability called Trial Claims that has been used by health plans for many years, making it simple for health plans to meet these regulatory requirements. Here is how it works:

1. Members access the Member Portal and provide details that determine claim elements for their price comparison
2. Claim elements are passed to HealthRules Payer for Trial Claim Adjudication via API
3. Trial Claim adjudicates the claim in HealthRules Payer
4. Pricing and cost sharing information is returned to the Member Portal via API
5. The Member Portal presents the cost sharing information to the member

A similar process is followed when the member prefers to receive the information by phone or mail. The member just contacts a customer service representative who conducts the Trial Claim Adjudication and informs the member of the cost sharing information.

A Bonus: Increasing Member Trust

Delivering exceptional member experiences is at the core of every successful health plan. With the HealthEdge Price Comparison Tool functionality, health plans can improve member satisfaction by providing easy access to transparent pricing and cost-sharing information. The user-friendly tools enable members to access accurate and up-to-date cost-sharing details specific to their benefit plan and usage, promoting transparency and fostering trust between health plans and their members.

A Bright Future

At HealthEdge, we are committed to supporting health plans in their journey towards price transparency and regulatory compliance. By embracing the spirit of the No Surprises Act and the TIC Final Rule, health plans can build stronger partnerships with their members, foster trust, and deliver exceptional care that puts members’ needs first.

To learn more about how your organization can achieve compliance with the Transparency in Coverage and No Surprises Act while also empowering your members, visit www.healthedge.com.

Over the past several years, health plans have been hit by a tsunami of regulatory changes, and two primary themes have emerged: transparency and interoperability. From the Transparency in Coverage Act to the No Surprises Act, CMS has made it clear that the collection, retention, and use of electronic data that can improve the member experience, improve health outcomes, and reduce inefficiencies are top priorities for years to come. This blog highlights some of the most recent regulations, proposed rules, and payer interoperability.

Price Transparency

• Machine Readable Files: It has been one year (July 1, 2022) since the Transparency in Coverage Final Rule went into effect. This rule requires health plans to make pricing data available, free of charge, to the public in Machine Readable Files. According to an April 2023 American Hospital Association article, more than 200 payers have posted machine readable files, up from only 68 in July 2022. This data now represents all sites of service, and more than 95% of commercially insured lives in the United States.The HealthRules Payer product team made these capabilities available to its customers via APIs and continues to make enhancements to improve processing time for the creation of these mega files. Our professional services team ensures a smooth transition for HealthEdge clients.
• Price Comparison Tool: The first phase of this rule, which went into effect January 1, 2023, required health plans to make 500 shoppable items accessible to members. The final phase is scheduled to take effect on January 1, 2024, and will require health plans to make pricing available for all shoppable items covered.Again, the HealthRules Payer teams are making compliance easy with advanced API and specialized services. In addition, for customers who choose to use other solutions, the team is prepared to support customers’ compliance efforts.

Payer Interoperability

While interoperability is not a new topic within the healthcare industry, a wave of proposed rules focused on facilitating the exchange of health data between patients, providers, and payers are proving to be formidable challenges for payers dependent on legacy or outdated technology.

While the industry anxiously awaits the final rule on interoperability, health plans must prepare now to support more advanced interoperability goals.

• Electronic Prior Authorizations: According to the CMS announcement in December 2002, the proposed rule aims to improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services. It requires payers to implement an electronic prior authorization process, which will shorten the time payers can take to respond to prior authorization requests and establish policies to make the prior authorization process more efficient and transparent. The rule also supports the development of standards that payers will follow when exchanging data, making it easier to ensure complete patient records are available when transitioning between payers.The mechanism the rule uses to enforce the mandate will be APIs. More specifically, the proposed rule will require health plans to use a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorizations. By providing standards that all health plans must use, it is likely that in the long run, the rule will be more effective.
• Interoperability Standards: According to CMS, the proposed policies in this rule would also enable improved access to health data, supporting higher-quality care for patients with fewer disruptions. These policies include: expanding the current Patient Access API to include information about prior authorization decisions; allowing providers to access their patients’ data by requiring payers to build and maintain a Provider Access FHIR API, to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship; and creating longitudinal patient records by requiring payers to exchange patient data using a Payer-to-Payer FHIR API when a patient moves between payers or has concurrent payers.HealthRules Payer customers will be able to use the advanced set of APIs from HealthEdge to comply with the final rule.

Additional regulatory changes are coming to the Medicare Advantage Designated Special Needs Programs (D-SNP) that follow the same transparency and interoperability themes. These changes, including the collection of social determinants of health and health equity, are outlined more specifically in a recent blog post by HealthEdge’s Compliance team.

The Bottom Line

Transparency and higher levels of payer interoperability are front and center on the regulatory stage today. With the provider side having been through much of this transformation in the past 10-15 years with the adoption and use of electronic health record (EHR) systems, CMS and the regulators are turning their attention to the administrative side of healthcare claims, zeroing in on opportunities to improve transparency and interoperability.

To learn more about how HealthEdge is supporting its customers’ ability to meet current and future regulatory requirements, please visit www.healthedge.com.

In today’s rapidly evolving healthcare landscape, health plans face increasing challenges to provide quality care while identifying new efficiencies. As a result, more health plans are turning to technology and modern payer solutions software to help automate manual tasks, improve payment accuracy, and empower team members with more real-time data.

Six things health plan leaders should expect from their modern payer solutions software:

Streamline administrative operations:

Payer solutions software should automate labor-intensive processes such as claims processing, enrollment management, and provider network management. Health plans should be able to consolidate and manage data from various sources, which enables payers to reallocate resources to more critical areas, ultimately leading to increased operational efficiency.

Improve payment accuracy:

Payer solutions software must be able to help health plans increase efficiencies within their claims payment operations to not only streamline processes, but also increase payment accuracy. This, in turn, helps reduce the downstream work staff members have to perform to reconcile inaccurate payments.

Enhance member engagement:

By using modern payer solutions software, health plans can more efficiently identify at-risk member populations and deploy more targeted member outreach, health plans are able to not only streamline care management workflows, but also increase the productivity and scale of care management teams. Plus, with more personalized engagement, members are more likely to adhere to their care plans and improve outcomes.

Optimize claims and configuration management:

Payer solutions software should support automated claims processing and contract configuration. As the industry evolves at a rapid pace, the system should enable business agility and speed to market. Additionally, the solution should provide advanced analytics help health plans identify cost-saving opportunities, such as identifying and preventing fraudulent claims, negotiating more favorable contracts with providers, and optimizing risk adjustment models.

Facilitate value-based care:

As the healthcare industry shifts towards value-based care models (paying for value and outcomes vs. paying for volume), modern payer solutions software must be able to accommodate for multiple, complex payment models. Strong data analytics and reporting capabilities are also important capabilities that help health plans assess provider performance, identify high-risk members, and implement targeted interventions, which in turn enables health plans to drive better health outcomes and cost savings.

Promote interoperability and integration:

Modern payer solutions software must be able to support interoperability and integration with third-party systems to not only comply with emerging regulatory requirements, but also to meet rapidly evolving market dynamics. A robust set of APIs should be available to support the exchange and use of third-party data, and in some cases, pre-packaged integrations should be available to help minimize the IT burden and accelerate time to market.

Health plans achieve extreme efficiencies with HealthEdge payer solutions software

In the face of an ever-changing healthcare landscape, health plans need modern payer solutions software like HealthEdge’s comprehensive suite of software solutions that can enable business agility and create extreme efficiencies.

• HealthEdge’s core administrative processing system (CAPS), HealthRules^® Payer, revolutionizes the way health plans handle administrative tasks, leading to significant time and cost savings.
• HealthEdge’s prospective payment integrity platform, Source, enables health plans to transform their operations at the reimbursement, payment integrity, and enterprise levels.
• HealthEdge’s complete Care Management workflow platform, GuidingCare®, offers both health plans and providers easy-to-use, next-generation data integration and workflow management tools that streamline workflows, facilitate coordination and collaboration, accelerate quality improvement, and promote provider and patient engagement.
• HealthEdge’s digital health management and engagement platform, Wellframe, helps organizations extend their reach across more critical touchpoints and deliver modern member services more efficiently. Members can access their health information, review claims, and even schedule appointments.

HealthEdge’s comprehensive suite of payer solutions software applications meet the above-mentioned requirements for modern payer solutions software, and more. To learn more about how HealthEdge can help your health plan drive extreme efficiencies, visit www.healthedge.com.

Earlier this year, a select group of clinical leaders from across the country gathered with HealthEdge and Wellframe at the Clinical Leadership Forum, an event that provided a unique opportunity for thought leadership, in-person connection, and learning. Through the lens of leveraging care management as a catalyst for digital transformation, sessions focused on strategy, regulatory compliance, innovative technology, value-based care, member engagement, and more.

Of particular interest to attendees was the growing connection between regulatory compliance and the member experience – a topic that spurred thought-provoking conversation and discussion. Today, this topic continues to hold relevance for health plans as an increasing number of regulations emphasize the member experience.

Here, we summarize key learnings and takeaways from the session, “Quality Insights & Regulatory Update,” which covered evolving regulatory changes and the increasing influence of health equity and member experience as factors for achieving compliance. The session presenters, clinical experts from HealthEdge, also discussed how health plans can prepare and support compliance in the rapidly changing landscape.

Let’s dive into the key learnings and takeaways from this informative session.

The Importance of Member Engagement Reaches New Heights

While member engagement has long been recognized as crucial, it has now reached unprecedented importance. The COVID-19 pandemic highlighted existing health disparities and underscored the need for enhanced member engagement to address the challenge. Health disparities are preventable and new regulations aim to put better measures in place to improve engagement of priority populations and advance health outcomes where disparities exist today.

Changes in Regulatory Measures

The presenters discussed the Centers for Medicare & Medicaid Services’ (CMS) proposed changes set for December 2024 that target improvements in member engagement and health equity, which ties member satisfaction closely with outcomes. Proposed changes include:

• Reducing the weight of patient experience to better align with outcomes.
• Identifying and offering health education to improve digital health literacy.
• Improving language accessibility by delivering materials in all languages spoken by members.
• Delivering culturally competent care to better support diverse populations.
• Changing and enhancing calculations to better align with other programs.

The presenters also covered updates to HEDIS measures to better support diverse and underserved populations and improve their engagement.

A New Trend in Regulatory Changes: Member Engagement

The presenters pointed to an underlying theme across many new regulatory changes: increased focus on member engagement. As a result, optimizing the member experience and engagement is becoming even more of a top priority for health plans. To deliver on this priority, health plans should evaluate how they are supporting members needs in five key areas:

1. Multiple channels of communication: Health plans should work to understand how their members want to communicate and strive to offer those methods. Offering the right methods of communication is the first step to ensuring members receive the information they need to better manage their care.
2. Strategic outreach & follow-up: Intentional follow-up to build relationships or outreach after appointments and procedures can improve engagement.
3. Streamlined member service experience: Health plan leaders should know customer service call stats and hold times, listen to calls to understand if issues are truly being resolved, and find out how customer service teams are engaging with members. Deeper knowledge of the real customer experience allows health plan leaders to assess and make improvements as needed.
4. Identify unengaged members and activate campaigns to re-engage: Gather data to holistically understand the member experience and identify unengaged members. Using claims data, encounter data, failed outreach attempts, and more gives health plans the opportunity to assess whether members are taking steps needed to effectively manage their health.
5. Understand the impact of member experience on outcomes: Health plans should consider conducting surveys to understand the member experience and make improvements. Also, consider the value of annual wellness visits and regular appointments, as members who are getting next level care through mammograms, lab testing, colonoscopies, and more can take steps to manage their health concerns as needed – and have a significant impact on outcomes.

Partner Expectations: Using Technology to Advance Member Engagement

The right technology partner can support health plans in their journey toward improving member engagement and outcomes tied to regulatory compliance. Seek care management partners that deliver the following capabilities:

Robust reporting: Ensure reporting capabilities can facilitate quality improvement projects and demonstrate that the plan is improving member health. Effective reporting should allow health plans to identify unengaged members, get them engaged, and keep them engaged.

Member demographics: Ensure the system can capture key data points, report out, and stratify that data. Key demographics include geographic location, gender identify, race, ethnicity, and more.

Detailed HRAs that drive Plan of Care & Service Plan: Use technology with capabilities to enter surveys, get members responses, and capture data. The technology should allow care managers to use the data to ensure the care plan is specifically targeted based on information collected.

Real time referrals to Social Determinants of Health (SDoH) providers: Implement full integration with social care providers to enable care managers to better manage all individualized member needs.

Care gap monitoring and closure: Use technology that identifies care gaps and supports methods to intervene and drive closure.

Programs identification and management: Seek partners with capabilities that automatically identify members for complex and disease management programs through self-reported or automated data collection. Ensure the technology uses the data to assign members to the right care coordinator to ease the process of improving engagement for high-risk populations.

Integrated educational content: Implement technology with the ability to deliver clinically sound, evidence-based data through effective communication channels. This capability is critical to combat misinformation and improve care outcomes.

Interdisciplinary team management: Deliver tools, such a provider portal, to allow the full team to understand member needs, see their goals, talk to members about those goals and help work towards achieving them.

Take the Next Steps Toward Supporting Regulatory Compliance and Member Engagement

By promoting health literacy, addressing disparities, and prioritizing member engagement, health plans can navigate the shifting regulatory landscape. Collaborating with the right partners and leveraging modern technological capabilities allows health plans to deliver high-quality, equitable care and achieve positive health outcomes.

Learn how GuidingCare and Wellframe from HealthEdge can help health plans achieve these goals by visiting www.healthedge.com.

 

In an era where healthcare costs continue to rise, the concept of value-based care has emerged as a game-changer in the health insurance industry. Value-based care focuses on achieving better patient outcomes while reducing costs and improving the member experience.

To effectively implement and manage value-based care contracts, modern software solutions have become essential. In this blog post, we will explore how value-based care software is transforming the health insurance landscape and optimizing outcomes for patients, providers, and payers.

Understanding Value-Based Care

Value-based care is a departure from the traditional fee-for-service model, where providers are reimbursed based on the volume of services rendered. Instead, value-based care focuses on aligning incentives between payers and providers to promote quality care, patient satisfaction, and cost-effectiveness. Contracts are structured around outcomes, quality metrics, and patient satisfaction.

The Challenges of Implementing Value-Based Care Contracts

While the concept of value-based care is promising, its implementation poses significant challenges for health plans. Tracking and analyzing vast amounts of data from multiple sources, calculating reimbursements based on outcomes, and ensuring accurate reporting require sophisticated software solutions that can handle complex computations and streamline processes.

Value-based care software solutions, like those from HealthEdge, play a pivotal role in successfully implementing and managing value-based care contracts. These modern solutions offer a range of features and functionalities that optimize the healthcare ecosystem:

Data Aggregation and Analysis

Value-based care software solutions facilitate the aggregation of data from various sources, such as electronic health records, claims data, and social service providers. Advanced analytics capabilities allow for the extraction of valuable insights, identifying patterns, and predicting member outcomes. These insights drive informed decision-making, enabling health plans to determine which members may be at risk for developing costly complications and need more personal, proactive care.

Care Coordination and Communication

Value-based care software can enable more seamless collaboration and communication among care teams, members, and payers. Real-time updates, shared care plans, and secure messaging platforms ensure effective coordination and enhanced member engagement. By fostering continuity of care and reducing duplication of services, value-based care software optimizes patient outcomes while minimizing costs.

Performance Monitoring and Reporting

To ensure accountability and adherence to quality standards, modern value-based care software solutions enable continuous performance monitoring and reporting. Payers can monitor network performance, measure the effectiveness of interventions, and drive network optimization strategies. Providers can track their performance against established quality metrics, identify areas for improvement, and proactively address gaps in care.

Benefits of Value-Based Care Software

Implementing value-based care software offers numerous benefits to all stakeholders involved:

1. Improved Member Outcomes: By leveraging real-time data and analytics, value-based care software empowers health plans to deliver personalized care plans, preventive interventions, and evidence-based treatments. Members receive more comprehensive, proactive, and coordinated care, resulting in improved health outcomes and enhanced member satisfaction.
2. Cost Savings and Efficiency: Value-based care software streamlines administrative processes, reduces paperwork, and automates tasks, enabling care managers to allocate more time and resources to at-risk and rising-risk members. By promoting preventive care and early intervention, costly complications can be minimized, leading to significant cost savings for payers and patients alike.
3. Enhanced Provider-Payer Collaboration: Value-based care software promotes collaboration between providers and payers, fostering a shared commitment to delivering quality care. Through transparent data sharing, real-time performance feedback, and aligned incentives, providers and payers can work together to optimize care delivery, drive population health management, and negotiate mutually beneficial contracts.

Driving Value Through Value-Based Care Software

As the health insurance industry continues to evolve, so will the ways in which health plans create and manage their value-based care contracts. Value-based care software empowers stakeholders to harness the power of data, streamline processes, and foster collaboration, ultimately revolutionizing the healthcare ecosystem. By embracing value-based care software, the health insurance industry can unlock the full potential of value-based care, leading to better patient outcomes, increased cost savings, and better member experiences in the future.

At HealthEdge, our full suite of software solutions supports our customers’ efforts to embrace value-based care contracts in many ways, including:

• GuidingCare^® care management solutions that help health plans coordinate and manage care for members more effectively. These solutions include care coordination tools, population health management tools, and analytics to identify high-risk members and deliver more personalized care plans for better health outcomes.
• HealthRules^® Payer, an advanced Core Administrative Processing System (CAPS), supports health plans’ ability to manage multiple, complex payment models with the efficiency, flexibility, insights, and agility necessary to control costs, embrace change, and move quickly to take advantage of new opportunities value-based care models afford.
• Source, HealthEdge’s prospective payment integrity platform, includes rich editing libraries with history-based capabilities and enables easy development of customized edits, improved transparency, and reduced downstream work from inaccurate payments, which leads to better provider and member relations.
• Member Engagement: HealthEdge’s Wellframe solution enhances member engagement and empowerment. This may involve mobile apps or member portals that enable patients to access their health information, schedule appointments, receive reminders, and communicate with their care team.
• Data Analytics: All HealthEdge solutions incorporate advanced data analytics’ capabilities that help health plans gain actionable insights from virtually any data source, identify cost-effective treatment options, assess provider performance, and optimize care delivery.
• Integration and Interoperability: Seamless data exchange and interoperability are critical in value-based care. HealthEdge solutions aim to integrate with various electronic health record (EHR) systems, health information exchanges (HIEs), and other healthcare applications to ensure smooth data flow and better care coordination.

To learn more about how HealthEdge value-based care software solutions can help your organization thrive in a value-based care world, visit www.healthedge.com.

Star ratings have long been a cornerstone of assessing the quality and performance of health insurance plans from the Centers for Medicare & Medicaid Services (CMS). These ratings play a crucial role in helping beneficiaries make informed decisions about their healthcare options. For payers, Star ratings bring incentives to improve their services and member outcomes to achieve higher ratings.

However, recent developments in the Star ratings program are set to bring about significant challenges for many payers.

One of the most notable changes is the introduction of a health equity index in 2027. Social risk factors, such as income, education, housing, and access to transportation, can significantly impact individuals’ health outcomes. The health equity index aims to evaluate how well health plans are addressing these factors and working towards reducing health disparities among their beneficiaries. However, this presents signification challenges for payers:

• Data Collection and Standardization: Assessing social risk factors requires reliable and comprehensive data. Payers will need to collect and analyze data from various sources to accurately evaluate their performance. Standardizing the data collection process across different plans and regions may also prove to be a complex task.
• Resource Allocation: Addressing social risk factors often involves implementing community-based programs, outreach initiatives, and partnerships with social service organizations. Payers will need to allocate resources effectively to support these efforts while balancing their financial viability and sustainability.
• Collaborative Approach: Tackling social determinants of health (SDoH) requires collaboration among multiple stakeholders, including healthcare providers, community organizations, and government agencies. Payers must foster partnerships and cooperation to drive meaningful change in social risk factors, which may require navigating complex networks and overcoming potential resistance.
• Long-Term Impact Measurement: Evaluating the impact of interventions targeting social risk factors requires a long-term perspective. Changes in health outcomes may not be immediately evident, requiring payers to invest in ongoing monitoring and assessment to accurately gauge the effectiveness of their efforts.
• Addressing Inequities: The health equity index aims to reduce disparities in health outcomes among beneficiaries. However, payers may encounter challenges in identifying and addressing specific inequities within their member populations, as these disparities are influenced by a range of complex and interconnected factors.

Other proposed changes to Star ratings:

• Limited Application of the “Better of” Methodology: In response to the COVID-19 pandemic, CMS allowed all contracts to use the existing disaster provision in 2022. This provision enabled contracts to choose the “better of” current or historical performance for most measures. However, in 2023, this methodology will no longer apply universally.
• Implementation of Upper and Lower Limits (Guardrails): Starting in 2023, CMS will implement annual guardrails on changes in cut points for non-CAHPS measures. Cut points define the ranges within which a contract’s score on a specific measure needs to fall to achieve each Star value. These guardrails will introduce more challenging cut points, potentially impacting the ratings of MA plans.
• Removal of Performance Outliers: In 2024, CMS will use the Tukey outlier deletion method to remove performance outliers from the calculation of non-CAHPS measure rating cut points. This change aims to enhance the accuracy of the ratings but may pose additional challenges for MA plans.

To mitigate negative impacts, Medicare Advantage plans must turn to modern care management systems that support the growing complexities of performance measurement programs. Payers should embrace these challenges and use them as opportunities for growth and improvement. The journey towards achieving higher Star ratings and ensuring equitable healthcare requires dedication, innovation, and a deep understanding of the diverse needs of the communities they serve.

To learn more about how HealthEdge’s GuidingCare care management solution suite can help your organization address the growing challenges associated with Star ratings, visit www.healthedge.com.