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Too many obstacles stand in the way of implementing a person-centered model of care. Complex workflows. A lack of coordination among medical, behavioral and community health organizations. Inadequate partner and patient engagement. No access to real-time, actionable data. An inability to identify gaps in care. And more.

If your organization strives to improve member health outcomes and better manage costs, these are the 9 care management platform must-haves:

1. Deep Clinical Expertise

Robust understanding of clinical operations, regulatory compliance and technical aspects of the business, bridging the clinical and technical is critical.

2. Leading Innovations

Market-leading capabilities enable the most complex clinical models today, with significant investment and growth toward composable digital health solutions.

3. Ease of Integration

An out-of-the-box integration suite facilitates easy connectivity across your vendor ecosystem for lower costs and better member outcomes.

4. Operational Efficiency

An advanced rules engine and user-friendly workflow capabilities automate business processes to streamline operations.

5. Reimagined Implementation & Upgrades

Using the latest technology innovations makes it easy for payers to incorporate standard new functionality and innovations frequently and easily for a lower cost.

6. Resiliency to Change

Highly configurable features and workflows enable payers to embrace change, stay competitive, and take advantage of opportunities created by a variety of market dynamics.

7. Actionable Insights

Near real-time business intelligence arms your leaders to make informed key operational and clinical decisions.

8. Regulatory Support

Managing the ever-evolving state and federal requirements so you can stay compliant while improving member engagement and satisfaction, STAR ratings, health outcomes, and more.

9. Security & Compliance

HITRUST certification is a must to reinforce robust enterprise compliance and security safeguards.

HealthEdge’s GuidingCare

The GuidingCare suite of solutions enables health plans to support care management, utilization management, appeals and grievances, authorizations, and population health in a next-generation, fully integrated platform. The unique solution enables digital payers to transform care management by improving mission-critical workflows and delivering access to real-time data that drives superior financial and health outcomes. Learn more here.

 

At SummaCare in Akron, Ohio, the customers’ voice can be heard loud and clear. In fact, listening to the needs and wants of the communities it serves is a fundamental principle that has guided this local health plan since it started more than 25 years ago. But the company’s secret sauce to success has been its ability to turn that customer input into action while also meeting ever-evolving regulatory requirements. Today, SummaCare covers more than 62,000 lives and offers a wide range of services, including Medicare Advantage, self-funded, fully insured, and the government Marketplace.

According to Melissa Rusk, VP of operations at SummaCare, “Listening to our customers, whether it is our members, brokers, or even our employees in our own self-funded plan, is the first and most important step to success. But what really sets us apart is our ability to use modern technology to help us put our ideas into action fast. Products like HealthEdge Source really give us that edge.”

The System Behind the Success

For more than 20 years, SummaCare has trusted Source, the industry’s leading payment integrity platform that is now a key component of the HealthEdge suite of solutions, for its claims editing and pricing. Originally implemented to support its employer group customers who had members traveling to and living in multiple states, Source helped SummaCare navigate the complexities of pricing in many different states. However, as the business grew, so did the need for other pricing tools that addressed the complexities of commercial payers.

“For years, we were dependent on multiple editing solutions for our different lines of business. But when we upgraded to the latest version of Source, we were able to move everything to the new platform. Now, we are running all of our claims, including Medicare and commercial, through Source. It’s now a one-stop shop. This not only reduces the IT burden of having to maintain and update multiple systems, but it also makes it easier for our team members to investigate claims issues. They only have one place to go.”

In addition to finding new efficiencies in the editing process, the team was able to move all pricing data out of its legacy claims system, freeing them to evaluate more modern core systems that can help them adapt even faster to customer input and competitive threats. They also brought the edits into their provider portal so members and providers can see the edits themselves and submit questions or appeals directly through the application. This has reduced the phone calls and emails coming into the provider engagement teams.

Rusk added, “No one holds a candle to the information you have at your fingertips with Source. For example, you can look at fee schedules that existed 10 years go if you need to. You can model future things, like new contracts and the reimbursement implications, so you can make better decisions. We’ve seen Source evolve over the years, and we’re pleased with how they actively engage their own customers’ voices, just like we do with our customers. It’s been a great partnership.”

The Future Looks Bright

As SummaCare looks to the future, the team plans to move to more modern systems that allow them to collaborate with their customers and respond to changing regulatory and competitive market dynamics on a whole new level. Functions such as contract modeling and exploring new payment models are definitely on the horizon, according to Rusk. “We look forward to being more innovative and forward-thinking when it comes to what our contracts should look like. And as new payment models, such as bundled payments, emerge, modern technology like what HealthEdge provides will give us even greater flexibility.

Learn more about Source here.

Health plans today can face challenges managing their day-to-day operations because of staffing challenges, the regulatory environment, and the need to reduce administrative costs. With the Core Administrative Processing System (CAPS) system at the heart of this dynamic and challenging world, it needs to run smoothly to facilitate business operations.

Top 4 Health Plan Challenges 

1. Staffing  

80% of health plans are having self-described staffing problems, including:

• Overworked staff & high turnover
• Extended replacement time
• Over-reliance on senior staff
• Employee burnout

2. Regulatory Environment

Managing and adhering to regulatory requirements & changes is a constant challenge. Health plans are consistently faced with:

• Reaction time to mandated changes
• Knowing what comes next

3. Administrative Costs 

In a 2022 survey of 300+ health plan leaders, when survey respondents were asked to report the top three challenges that their organizations face today, managing costs and driving operational efficiencies were top of the list – jumping dramatically from the prior year’s fourth and fifth positions.

4. Consistent CAPS Quality of Service

Many factors can impact CAPS quality of service, including:

• Manual processes
• Issues/defects impacting operations
• Maintaining high auto-adjudication rates
• Reducing operational PMPM costs

Introducing EDGEcelerate: A Path to Minimize the Challenges 

Health plans need flexibility and personalized solutions as they grow and respond to market pressures. HealthEdge’s new tiered services solution, EDGEcelerate, can offer the targeted, personalized solutions health plans need to tackle these multi-dimensional challenges.

HealthEdge EDGEcelerate  provides customized, full life cycle support of the CAPS system HealthRules® Payer. With this, health plans can:

• Create efficiencies through automation
• Experience a reliable CAPS system tuned to your needs
• Reduce manual work arounds
• Improve KPIs
• React & respond faster to regulatory mandates

Every health plan has challenges. Let’s solve them together. Learn more about HealthEdge’s personalized service solutions with EDGEcelerate.

Minimizing member abrasion is a constant challenge for all payers. In fact, according to the 2023 Gartner Group CIO and Technology Executive Survey, improving the member experience is one of the top three enterprise priorities[1]. To address this challenge, organizations typically look to care management practices, member engagement technologies, and even retrospective payment integrity.

However, one of the most effective ways to improve the member experience is to improve prospective payment integrity. That’s because a retrospective approach continues to add strain and create complexities that drives a wedge further between payers and their members. Prospective payment integrity improvements can eliminate many of the issues before they become challenges.

“By investing in a prospective payment integrity solution that highlights inaccuracies before the payment is made, you can stop the costly retroactive repayment process that negatively impacts your providers and members through administrative costs”[2] – Gartner®,  U.S. Healthcare Payer CIOs Must Invest in Prospective Payment Integrity to Improve Member Experience, 24 March 2023, Austynn Eubank, Mandi Bishop

When taking an enterprise-wide approach to payment integrity, payers should consider focusing on these four areas:

1. Improve accuracy: To build trust with their members, payers must strive to be proficient and transparent in their payment integrity processes. Payment integrity platforms, such as Source, that offer a single API, automated and regular cloud-based updates, and a single source for fee schedules and payment policies, create a more seamless and centralized data source that informs more accurate payments.
2. Address root cause payment issues upstream: The traditional approach to payment integrity is stacking third party payment recovery services on top of one another. Most of these services are based on contingency fees, so there is no incentive for these vendors to provide insight into the root cause of issues. As a result, payers continue to make the same mistakes month after month, never really having the opportunity to make meaningful changes that can deliver meaningful results.
3. Take a member-centric approach to payment integrity: When payment integrity takes a singular, departmental approach that is focused on payment recovery, members are typically last in line for consideration. The responsibility of recovering inaccurate payments are then passed off to other departments who are left to deal with member communications. An enterprise approach to improving payment integrity and more accurate payments are made more often, there are fewer opportunities for member abrasion and less manual work for staff. Everyone wins.
4. Shift to prospective payment integrity: Looking forward and improving payment accuracy in advance of payments makes logical sense, but until Source started delivering a transformative approach to payment integrity, the cost vs. value was simply not there. Forward-leaning payers who are implementing the Source Platform Access and suite of solutions are able to experience continuous process improvements across their enterprises, and ultimately reduce member abrasion while gaining significant efficiencies.

To learn more about how Source’s transformative approach to payment integrity can help your organization reduce member abrasion, visit the Source page on the HealthEdge website.

 

[1] Infographic: Top Priorities, Technologies, and Challenges for Healthcare Payers in 2023

[2] U.S. Healthcare Payer CIOs Must Invest in Prospective Payment Integrity to Improve Member Experience, Gartner 24 March 2023, Austynn Eubank, Mandi Bishop. GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved.

 

Data privacy, although often confused with data security, is a discrete sector in the data protection field drawing upon expertise in law, technology, and ethics. Where data security focuses on how we protect information, data privacy focuses on why we protect information as well as what we are doing with the information entrusted to us.  Data privacy professionals ensure compliance with legal and regulatory requirements, such as the Health Insurance Portability and Accountability Act (HIPAA), the California Consumer Privacy Act (CCPA), and the European Union’s General Data Protection Regulation (GDPR), and are critical stakeholders in protecting the confidential information of both the organization and our customers and members. Privacy professionals can help navigate decisions around what level of data access is appropriate, are we using data in a responsible way, and often inform the direction of information security policies, including:

• Data retention
• Geographic data storage
• Identity and access management
• User onboarding and offboarding
• Data classification
• Acceptable use
• Risk management

Technology professionals are likely familiar with the term DevSecOps, which is the integration between the development and security team, incorporating security and scalability at the beginning of and consistently throughout the software development process.  However, a less common term is PrivSec, or the collaboration between the privacy and security teams integrating data protection and data use into all major business decisions. Here at HealthEdge, there is a strong partnership between the information security and the privacy teams and our programs are designed to ensure that both teams are engaged where their analysis is required. Some common programs that involve both teams are:

• Vendor risk management
• Incident response
• Product change management
• Data handling and governance
• Employee data access from abroad

In addition to HealthEdge selling healthcare services, it also is in the business of selling trust to its customers and end-users. As custodians of highly sensitive data that could cause real life harm to patients and members if misused or abused, the integration of PrivSec into business and technology operations is paramount for maintaining trust. By identifying risks to information and systems containing information, implementing security measures, and building processes for responsible handling of healthcare data, we can ensure that patient data is kept confidential and secure and that HealthEdge remains a trusted partner for our customers.

The pace of change in healthcare has accelerated at record speeds in recent years. Many health plan CIOs are struggling to help their businesses adapt quickly due to their dependencies on legacy care management systems that were built on outdated technology platforms.

As a result, there is a growing level of frustration among business, clinical and technical leaders alike, and therefore a growing number of payers looking to upgrade their care management capabilities. To help CIOs better understand and prioritize evaluation criteria, Gartner recently issued a report entitled, “Market Guide for U.S. Healthcare Payer Care Management Workflow Applications.”

The report stresses the urgency by which health plan CIOs should consider new, more modern care management software solutions. In fact, the Market Guide states, “The care management function is one of the few remaining levers available to a payer organization to impact its most important KPIs (namely top-line revenue, medical costs, quality measure improvement and operational efficiency).”

But with so many options and considerations to make, how should CIOs go about evaluating care management software solutions? Below are three of the most important criteria every CIO should consider.

Interoperability with Other Systems 

As the role of the traditional care management function continues to expand, care managers are being asked to support a wide variety of business and care delivery models that depend on coordination with a non-traditional service providers, such as home-based care, community services, and behavioral health specialists.

To support this evolving role, technical leaders are being asked to implement a wide variety of systems, which has led to complex infrastructures, massive data silos, and frustrated care managers.

The importance of having a highly interoperable care management platform that works seamlessly with virtually any third-party system cannot be understated. Interoperable systems with advanced APIs that require minimal IT overhead is no longer a nice-to-have – it is a must have. No single care management system can address all of the unique needs and care management goals of each payer so CIOs must place interoperability and the seamless exchange of data, whether it be structured or unstructured, as a top criterion.

Regulatory Compliance

For health plans, keeping up with the rapidly changing regulatory environment is one challenge, but making sure an organization’s care management platform and workflows can also be adapted to keep up is a whole different ballgame. Traditional systems often require significant IT involvement and complex rewiring of workflows to prepare for and implement regulatory changes. Some changes can take months and mountains of manual resources to implement in a traditional care management system. And with the pace of change ever-increasing, it’s often too late for system changes and payers end up building manual-intensive workarounds that cost time and money.

This is especially true for health plans serving government populations, where each state can have its own set of rules. And with the rapid growth in Medicare Advantage plans, Managed Medicaid programs, and self-funded employer plans, health plan CIOs must have a modern, agile care management software solutions that facilitates rapid change to meet regulatory requirements such as Medicare Advantage plan proposed changes or Medicaid state plan amendments.

In addition to a highly flexible platform, CIOs should look for care management vendors who have proven expertise in the government space. With seasoned experts on hand to translate business and technical decisions into clinical workflows that enable upholding compliance, payers can be confident in their ability to meet regulatory guidelines and even turn regulatory efforts into competitive advantages.

Health Equity & Social Determinants of Health (SDOH)

As the popularity of value-based pricing and risk-sharing arrangements reaches new heights this year, care managers are being forced to take a more holistic view of their members’ health, which includes social factors and community services that can have a profound impact on a member’s ability to access care and adhere to treatment plans.

Things like lack of transportation, limited access to healthy foods, and financial insecurities must be considered when building successful care plans. Community services and local groups must be incorporated into the care team, and as a result, care management solutions must accommodate for these non-traditional service providers and the SDOH data they can provide.

Connecting members with resources available in their community plays a critical role in improving member outcomes and satisfaction levels while also reducing care delivery costs – especially if the care management system can accommodate the data and resources.

Making the Move to Modern Care Management Software Solutions

In the 2023 Gartner Market Guide, HealthEdge was recognized as a Representative Vendor for GuidingCare in the care management solutions market.

Known for its robust API network, expansive ecosystem of pre-built integrations, custom configurations, and advanced analytic capabilities, GuidingCare and its team of regulatory and clinical experts check all of the main boxes industry analysts recommend to payers looking to meet the demand for more comprehensive, whole-person member care management of the future.

Learn more about GuidingCare on the HealthEdge website or email us at [email protected].

 

Gartner, Market Guide for U.S. Healthcare Payer Care Management Workflow Applications, Jeff Cribbs, Amanda Dall’Occhio, 3 January 2023.

GARTNER is a registered trademark and service mark of Gartner, Inc. and/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 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.