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Payer care management isn’t new. For decades, care managers have been providing information, support, and guidance to members facing chronic and acute healthcare challenges and complex transitions of care. Care management not only improves healthcare outcomes, but can also help health plans avoid unnecessary healthcare costs.

So why the recent attention on payer care management?

The answer is based on two ubiquitous drivers of change in the post-pandemic era. First is the increasing prevalence of physical, behavioral, and comorbid chronic health challenges caused or exacerbated by COVID-19. ^[1],[2] These challenges include the ongoing physical and mental symptoms associated with the virus in its acute and long form, as well as the secondary impacts including loneliness, depression, and anxiety. Second is digital transformation. This long-existing trend was significantly accelerated by the pandemic and our need for social distancing and remote solutions. In tandem, these two factors have increased the magnitude of opportunity for innovative and effective care management. They have also magnified the risk for missed-opportunity costs for payers who are not making the most of available solutions and existing digital investments, particularly in the world of care management.

McKinsey & Company has put forth an expended definition of care management which includes “…any payer-driven efforts to engage with targeted members and their care ecosystems to encourage and enable high-value decisions around their care and improve self-management…including traditional telephonic or in-person interaction as well as digital and asynchronous “coaching” and tech-enabled “nudges” ^[3]. Further, McKinsey estimated a 2:1 ROI for payers who can implement a care management model with the right processes, data, technology, and timing.

Key model components include:

• Identifying and targeting high potential sources of value by member archetype
• Engaging members using consumerist tactics
• Calibrating service intensity to key moments in a care journey
• Running care management as a data-based operation

While the ROI potential is clear, and the model imminently useful, this may not be something many payers are able to run with quickly. These key components require operational, procedural, technological, and possibly even marketing resources, oversight, and collaboration. This sets the stage for competing priorities that can leave many leaders unsure of where to even start.

This is where the company one keeps may really come into play. Today, most payers are using a care management platform or technology. But are they using it well? Is the technology optimized – and/or   are processes optimized for the technology? Could relatively small staff skills enhancements create big opportunities?

Payers with the right digital partners won’t have to answer these questions on their own. Instead, care management leaders have expertise to lean on, not just for technical support, but for clinical and transformational consultation as well. An external partner like HealthEdge with a solution such as GuidingCare will have insight gained working with a variety of health plans at varied stages of care management transformation, will be aware of common missteps and know the payer industry. With the advantage of distance and prior experience, trusted consultants can share invaluable advice on where to start based on current state and immediate priorities.

Don’t want to go on the journey of seeking next generation care management alone? Learn more here about how HealthEdge can help.

 

[1] The Healthcare System Is Facing Higher Acuity And More Sick Patients (forbes.com)

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7297074/

[3] The untapped potential of payer care management | McKinsey

The KLAS Emerging Solutions Spotlight on Source separates fact from fiction by conducting in-depth interviews with Source customers to understand their use of the platform, expectations and outcomes.

“Respondents are satisfied with the Source product, with all customers highlighting the biweekly updates around pricing guidelines and the first-time and real-time claims processing. HealthEdge is seen as responsive, and respondents say the vendor listens to customer needs and is willing to adapt.” – KLAS Emerging Spotlight Report, 2023

Key Performance Indicators

Source achieved top marks in all Key Performance Indicators including:

√ Supports integration goals

√ Product has need functionality

√ Executive involvement

√ Likely to recommend

Expected Outcomes

The report shows Source delivers on customers’ expected outcomes, including:

√ Automated workflows

√ More savings because of increased edits

√ Real-time processing

√ Reduction in agreement volume

√ Single source of truth for editing

Customer Comments

“I think that HealthEdge’s system is a viable longterm solution due to the cooperation that we have with the vendor in regard to new things that we may need. I see the system as a definite solution for us.” – Director

“What sets HealthEdge apart from other vendors is the capability to look up the Medicare rates in the system. I love that capability. If we have, for example, a provider that says that we didn’t price a claim correctly, we love the way that the audit tool can go in and look at the claim.” – Director

“The vendor is very good at listening to what we need, and their view of things has always been that if we need something, their other clients probably need it also. . . . HealthEdge is usually pretty good about trying to get our needs on the road map.” – Director

“The vendor does biweekly system updates. Before we had the HealthEdge tool, we only made updates to pricing once a year. HealthEdge does updates on major changes. But our claims are going through real-time processing.” – Manager

Source’s biggest differentiator?

As an interoperable, cloud-based platform built from the ground up, Source is designed to deliver rich pricing and editing content libraries while enabling our clients to address root-cause issues. With true transparency and control over their payment integrity operations, healthcare payers can finally unlock the ability to pay claims accurately, quickly, and comprehensively the first time. Unique capabilities like Retroactive Change Manager and Monitor Mode equip network management, claims operation, and cost containment teams with real-time data, thus helping to remove internal silos and enable enterprise payment integrity transformation. Learn more here.

The business of the modern Health Plan is highly complex and to be successful, plans often require the assistance and contribution of outside providers for a range of goods and services.  Those outside vendors become an integral part of the organization’s path to success – and they are truly partnered for mutual success.

When businesses come to agreement on a Business to Business (B2B) product relationship, it is commonly asserted with great optimism that the entities will be entering into a “Partnership” that will maximize the value of the new offering. The idea of a working Partnership has such positive overtones that there is very little disagreement or energy around the launch of the engagement. The realization of this objective is typically the responsibility of an Account Executive, a Customer Success Executive or similarly situated role in the entity providing the service.

However, partnerships don’t just happen when a contract gets signed. It takes work, patience, commitment and a well-defined process to integrate the organizations. To accomplish the goal, there are several key factors that must be in place:

• A shared, commonly agreed upon plan to level set expectations
• Clear and consistent communications of the key aspects of the plan
• Accurate assessment of required resources – and deployment of same to execute the plan
• Well-defined metrics to track both the successful completion and risk of missing key milestones

PACER: The Key to Strong Partnerships

Large and complex organizations require a disciplined, formal approach to cultivating a healthy, functional partnership. One method that can help focus an organization’s energy is a program with a handy acronym: “P.A.C.E.R.”

PACER creates a roadmap to drive positive interaction with clients to ensure consistency and a disciplined approach to client interactions:

1.  PLAN – Articulate the recommendations of the supplying entity for improved efficiency and efficacy

2.  ALIGN – The supplier goals and objectives with those of the customers

3. COMMUNICATE – Shared commitments and deadlines clearly and concisely throughout both organizations

4. EXECUTE – Work the plan in accordance with agreed upon timelines and accountabilities

5. REPORT – Both positive progress and challenges

1. PLAN:

The first step in planning is an introspective look by the supplier at where you are compared to where you would like to be. Not just in terms of new product opportunities, but also as it relates to client success – i.e. is your product operating at an optimal level for your customer?

One way to think about this plan is as an internal “Wish List” – i.e. “I wish the client would_______”

1. 1. • Start doing X
      • Stop doing Y
      • Continue doing Z
      • Add ______ ancillary product(s)

This plan should be created in cooperation with as large a group of your colleagues as possible.  Solicit input actively and aggressively to encourage an honest appraisal of what is needed.  You may find that your colleagues are resistant to communicate a deficiency at the client under the adage that “the customer is always right.”  While client deference is always important, it is equally important to have an accurate assessment of what is needed to ensure client success – even if the needed changes involve challenging the client point of view.

2. ALIGN:

Using the Plan created in Step 1 as a guidepost, the next step is to Align those ideas with a Strategic Plan that you develop with the customer.  The unique aspect of this process is that by going into the session equipped with a clear understanding of what your team feels will help maximize the, you will emerge with a collaborative document that maximizes the potential for Customer Success…which is the goal of this entire enterprise.

The aligned plan needs to be captured in a detailed, jointly prepared written document that includes an unambiguous list of shared objectives and an Action Plan with deliverable dates and accountabilities.  The plan is co-authored by the highest-ranking individuals who are engaged in the partnership – and who share authority and responsibility for its success.

3. COMMUNICATE:

The Plan needs to be distributed and promoted with great fan fair and appropriate resource commitments from the leaders.  To maximize the impact of the Plan, there can be no ambiguity regarding the goals and objectives, responsible players and the leadership support.  There is built in accountability in the Action Plan – but the impact of that accountability will be limited if there is not a sense of commitment and shared understanding of the Plan.

 

We live in a digital world, but one technique that can help create a breakout communication strategy is the creation of a hard copy notebook of the plan – with the authors identified on the cover – and delivered to key team members via an overnight package.  Email distributions are often ignored or minimized – nothing gets attention these days like an overnight package that arrives at the desk (or front door if virtual) of a team member.  Furthermore, if you create a professional binder with a recognizable title and visuals, it will live on a desk and serve as a regular reminder.

And as George Bernard Shaw famously said, “The difficult thing about communication is the illusion that it has been completed.”  Continual reinforcement of the importance and timeliness of the Plan will help maximize the potential for success.

4. EXECUTE:

All the work that is completed in the first three steps is simply a prelude to the ACTUAL work of PACER – which is to Execute the Plan.

If the Action Plan has been adequately prepared, every team member should have a clear view of what they need to do and when to do it. And if the team is clear on what the other members are doing, it is a self-monitoring process.  If I know that what I am doing impacts what you are doing – and vice-versa – there is a shared accountability.  And what is unique in this particular construct is that a jointly developed plan between supplier and receiver of the service means the successful execution is a team sport – played to the benefit of both organizations!

5. REPORT:

Keeping everyone clear on the progress throughout the course of the engagement helps to ensure that expectations are met – minimizing surprises.  Reporting can take many forms – from casual informal discussions in daily “Stand Up” meetings to deep dive reviews of the Action Plan deliverables as milestones come up.

Most importantly, regular accurate and meaningful reporting will ensure that future PACER reviews will build on the successes of the current undertaking and learn from any shortfalls experienced.

For Customers to Succeed with your product, both parties need to commit to an ongoing, active and iterative partnership model in which there is a feedback mechanism for continuous improvement, and honest internal appraisal of progress.  The PACER provides a framework within which organizations can collaborate and keep the Partnership fresh and successful.

Customer Success at HealthEdge

HealthEdge is very proud of the 100+ organizations that we service with our suite of state-of-the-art technologies that enable the digital future of our health plan customers.  We have a team of professionals in our Customer Success group that are committed to the Planning and Execution of a well-organized Plan – and to forming truly workable partnerships. Learn more here.

Genetic testing was once only available to individuals with a family history of certain genetic conditions or those who were experiencing symptoms. In recent years however, advances in technology have made it easier and more affordable to analyze DNA, making genetic testing more accessible to the general public. And as health plans are constantly looking for novel ways to identify individuals that may benefit from early intervention programs, genetic testing is becoming a powerful tool in this effort to provide more personalized medicine.

As a result of these trends, the volume and complexity of the medical policy, coding, and utilization review surrounding genetic testing has skyrocketed:

• 150,000+ genetic tests are on the market, compared to 10,000 only 10 years ago
• 9 codes are billed to represent a single genetic test
• 1,000+ pages of medical policy for providers and payers to try to interpret

For many payers, processing genetic testing claims is a tedious, manual, and time-consuming process. There are several reasons for this:

• Complexity of genetic testing: Genetic testing can be complex, and the interpretation of test results may require specialized knowledge and expertise. In some cases, payers may need to consult with genetic counselors or other experts to ensure that claims are processed accurately.
• Lack of standardization: There is currently no standardized process for genetic testing, which can make it difficult for insurance companies to determine which tests are appropriate and what constitutes a medically necessary test. This can result in delays or denials of claims.
• Billing codes: The process of billing for genetic testing can also be complicated. Each test may have its own unique billing code, and the correct code must be used to ensure that the claim is processed accurately.

Health plans that rely on outdated approaches are experiencing a growing volume of prior authorizations, denials, reviews, and appeals – all made more complex by multi-gene panel tests with multiple billing codes. The result is waste, variable quality, and frustrated members, providers, and medical directors.

Understanding Genetic Testing in Healthcare: A Better Way Forward

To navigate these challenges and help payers reduce the manual labor and time associated with processing genetic testing claims more accurately, Source has partnered with Concert Genetics, an industry leader in genetic test payment accuracy.

Concert Genetics has developed proprietary content and technology that streamlines clinical policy maintenance, prior authorization, coverage determination and claims processing for genetic testing. Here’s how it works:

• Payment policies that clarify and enforce test identification and standard, predictable coding.
• Clinical Edits flag tests that typically aren’t covered by health plans, such as experimental tests; tests not supported by patient age or gender; and tests not supported by specific diagnosis codes.
• Coding Edits, such as invalid procedure codes, are based on the current procedure codes and the AMA’s coding guidelines.

The scope of claims addressed by the base package of edits includes:

• Molecular Pathology
• Genomic Sequencing Procedures and Other Molecular Multianalyte Assays
• Multianalyte Assays with Algorithmic Analyses
• Proprietary Laboratory Analyses (PLA) Codes

As a transformative payment integrity solution for payers, Source has developed partnerships with many different best-of-breed vendors, including Concert Genetics. As part of the Source ecosystem, Concert Genetics is able to leverage advanced APIs from Source to deliver pre-built integrations between the two systems.

This not only eliminates the IT burden for payers who want to use both solutions, but it also creates a more seamless user experience by giving users the ability to access the Concert Genetics rules and edits directly from within the Source interface.

To learn more about how Source + Concert Genetics and the entire Source ecosystem of third-party partners can help your organization increase accuracy and reduce waste when it comes to genetic testing claims, visit the Source third-party integrations page here.

It’s no secret that change is the only constant in today’s business world. As organizations pivot to navigate the ever-evolving needs of their employees, customers, and markets, leaders must be able to keep up with the pace and thrive amidst it. The most successful people managers understand that exhibiting versatility isn’t just a nice trait; it’s essential for sustained organizational success and maximum impact among their teams. In this blog post, we’ll explore why being versatile as a leader is so important and provide great leadership examples.

Flexibility

Versatile leaders are adaptable and can adjust their leadership styles to fit different situations. They are open-minded and can embrace change, new ideas, and challenges without compromising their vision and values. A great example of this is Indra Nooyi, former CEO of PepsiCo. Nooyi was known for her adaptive leadership style, which allowed her to navigate various challenges and lead PepsiCo through a period of significant growth and transformation. She encouraged her team to think creatively and take risks, and she fostered a culture of openness and transparency. She recognized the importance of teamwork and collaboration and worked closely with her senior leadership team to develop and implement the company’s strategy.

Cultural Awareness

Versatile leaders are culturally competent and can work effectively with diverse teams. They understand the nuances of different cultures, respect different beliefs and values, and create an inclusive environment that values diversity. One example of a culturally aware leader is Satya Nadella, CEO of Microsoft. Nadella was born and raised in India, and he brings a global perspective to his leadership role. He has made a concerted effort to promote diversity and inclusion at Microsoft, recognizing the importance of cultural awareness and sensitivity in a global company. Under Nadella’s leadership, Microsoft has implemented several initiatives to promote diversity and inclusion. For example, the company has established employee resource groups to support underrepresented groups, such as women, people of color, and the LGBTQ+ community.

Communication Skills

Versatile leaders have excellent communication skills and can effectively connect with different audiences. They can tailor their messages to different stakeholders and use different communication channels, such as face-to-face, virtual, or written communication, to convey their ideas. One example of a leader who can communicate effectively with different audiences is Barack Obama, former President of the United States. In his speech at the 50th anniversary of the Selma-to-Montgomery civil rights march, he was able to connect with both black and white Americans, while also addressing the historical significance of the march and the ongoing struggle for civil rights. He spoke about the need for continued activism and engagement in the political process, while also recognizing the progress that had been made.

Emotional Intelligence

Versatile leaders have high emotional intelligence and can understand and manage their own emotions and those of others. They can empathize with their team members, build strong relationships, and resolve conflicts effectively. Mary Barra, CEO of General Motors is a great example of a leader with a high EQ. She is known for her approachability and her willingness to listen to employees at all levels of the organization. She has implemented several initiatives to promote employee engagement and development, recognizing that a motivated and engaged workforce is essential to the success of the company. She has done this while also driving innovation and change.

Strategic Thinking

Versatile leaders are strategic thinkers who can see the big picture while paying attention to details. They can analyze complex problems, identify opportunities, and develop creative solutions that align with their vision and goals. Jeff Bezos, former CEO at Amazon is an example of a leader who demonstrates strategic thinking. He recognizes the potential of new technologies and business models and was willing to take risks and invest in long-term growth. At the same time, he was able to manage complexity and scale, recognizing the importance of building strong organizational systems and processes to support a rapidly growing and evolving company.

As a leader, you can embrace versatility to create a positive and productive work environment where everyone is valued and respected. With an increased emphasis on flexibility, communication, and collaboration, versatile leaders can foster an open-minded atmosphere and collaborate effectively with teams of diverse backgrounds. Through these strategies, versatile leaders have the potential to maximize team effectiveness while creating a long-term culture of mutual trust and respect in the workplace. Ultimately, success as a leader depends on the ability to recognize problems and adjust strategies accordingly; developing versatility is essential for any leader looking to remain successful in the ever-changing business world.

Which leadership trait are you going to work on today?

Addressing Strategic Initiatives with Payment Integrity Solutions in 2023

For many Health Plans, 2023 presents unique challenges and opportunities when it comes to addressing strategic initiatives. The healthcare payer ecosystem is becoming increasingly digital, and for good reason. Data and processes that were once siloed and handled at departmental levels, are increasingly becoming more interoperable and overseen at an enterprise level with strategic investments into digital platforms, including payment integrity solutions.

In fact, Gartner cites “Payers that implement enterprise payment integrity programs and solutions are on the path to reducing medical expenses by 10% or more, with even more potential for significant reductions in administrative expense.”[1]

When it comes to Payment Integrity processes, over the past several years I’ve witnessed a significant shift away from individual point solutions that address singular pain points to digital investments that provide transparent and interoperable data and services that empower health plans to leverage up-to-date industry content, in-source capabilities, and customize the tools as needed.

For payers looking to address digital initiatives in 2023 with their editing solutions, a well-rounded approach and evaluation includes the following three items: depth of content, agility to accommodate a health plan’s unique requirements, and an “open book” approach so health plans can address the root cause of recurring payment errors.

1. Unique Data Set

Q: How does Source provide a broad, unique data set?

A: Our depth of content

Source provides a unique depth of content that includes a wide range of Medicare payment policy edits, state-specific Medicaid payment policy edits, as well as Clinical, Cost-Containment, and Validation edits maintained by subject matter experts. Source is also designed to incorporate 3^rd party specialty content into our ecosystem seamlessly including specialty content from MediQuant, 3M, Concert Genetics and TruthMD, to augment policy standards and ensure claims are paid accurately. Without this depth of content, Payers must rely on multiple vendors, perform excessive manual claims reviews, and risk over- or under-paying claims.

Our unique data set includes:

• Hands-off, automatic delivery of government, clinical, billing, and validation edits to handle complex policies automatically across all lines of business
• User-driven interface for easy development of customized edits to mimic medical policies
• History-based capability to look across claims for comprehensive editing
• Optional third-party edit libraries natively integrated into the solution

2. Agility to accommodate a health plan’s unique requirements

Q: As more and more health plans look to better understand and control their data, how does Source enable plans to deploy their own algorithms?

A: Source was designed to be agile to address a health plan’s unique business rules

Source allows Plans to deploy their own algorithms through creation of custom edits in a flexible configuration layer, existing real-time integrations to commercial claims systems, and workflow management to map to your system’s disposition codes for appropriate adjudication decision-making.

Source deployment capabilities include:

• Use of our native content with health plan-specific customizations to standard policy
• Adapting a payer’s proprietary edits through a contemporary user interface or leverage our professional services team to assist in the process
• The ability to monitor the financial and utilization impacts of an edit before deploying it for production use
• Hierarchical structure to efficiently deploy edits enterprise-wide or to specific regions, products, providers, etc.
• The ability to allow deployment of an edit to act as informational, soft denial, or automatic denial
• Single instance of the software in the Azure cloud that connects to all health plan claims systems for streamlined maintenance and consistent editing
• No technical maintenance as Source is updated and maintained by experts on a continuous basis

3. An “open book” approach

Q: How does Source enable plan to in-source a portion of their payment integrity capabilities?

A: Our “open book” approach

With Source, we’ve taken a “Black box to Open book” approach to payment integrity—ensuring that health plans have insight into root-cause analysis and the tools to address payment integrity issues upstream in the adjudication process.

This approach empowers health plans in multiple ways, including:

• Participation in Payment Integrity health checks performed by our experts to identify new cost of care or administrative savings opportunities.
• Enabling Source edit libraries in addition to your own proprietary edits through the user interface.
• Understanding the impact of edits with the use of Monitor Mode to see “what if” utilization and financial impacts that show aggregated results before turning the edit on in production.
• Enabling the edit in production with flexible adjudication decisions based on your business needs.
• Discovering new opportunities through real-time dashboards and reports while assessing the savings impacts of edits already in production.

Source uniquely provides editing content and capabilities alongside reimbursement for a comprehensive and cohesive approach to payment integrity that enables health plans to finally achieve long-term, enterprise-wide goals. This comprehensive, holistic & fresh approach to payment integrity considers reimbursement, application of medical and payment policies, analytics, and contract configuration—not as separate aspects of adjudication—but as part of an ecosystem that needs to remain agile, interoperable, and coordinated. Learn more about Source here.

 

[1]  – Gartner, Fight Healthcare Fraud With Enterprise Payment Integrity for U.S. Payer CIOs, Mandi Bishop, Refreshed 9 October 2022, Published 4 May 2021