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Health plans face complex and multifactored pricing and payment demands. With a robust and flexible platform like HealthEdge’s Source, plans can increase automation while working to optimize resource-intensive and manual processes like claims audits. This case study highlights one plan’s experience integrating Source with existing legacy technology and improving first-pass adjudication rates and efficiently managing claims audit and inquiry processes.

Challenges

HealthEdge® representatives recently talked to two members of the provider reimbursement team from a large non-profit health plan in the northeast. At the time of interview, the Plan was primarily using Source for pricing and reimbursement, leveraging the extensive library of pricing edits and bi-weekly updates that come standard with the Source platform. The conversation focused on two common and critical health plan challenges related to provider reimbursement. First, was the need for the Plan to replace an older tech platform while assuring the new platform would integrate with other legacy components of their tech stack. Second, was the need for the provider reimbursement team and other health plan system users to be able to audit claims and address ongoing retroactive claims inquiries from internal and external stakeholders.

Solution = HealthEdge Source

In 2021, the Plan began a phased implementation process, sunsetting an older payment and pricing platform and upgrading to Source. While Source is a modern payment integrity platform, the Plan was still working with a legacy core administration processing system (CAPS) and had concerns about platform integration especially given the significant complexity inherent in their hierarchical provider payment arrangements. Fortunately, Source has built-in integration with 10+ claims systems, ensuring that implementation wasn’t waylaid by key technology integration challenges. Source also offers hierarchical edit capabilities, enabling for example, the six different enterprise-level configurations overlaying mapping rules for 75 different rate configurations used just for one (Centers for Medicare and Medicaid; CMS) fee schedule at this particular health plan.

Not only was Source able to integrate with the Plan’s legacy CAPS system and accommodate complex hierarchical pricing configurations, but the integration and upgrade also led to a significant improvement in their first-pass claims adjudication rate. As noted by the Plan’s Reimbursement Initiatives Manager, prior to integrating their CAPS system with Source, their first-pass rate averaged about 80% and is now near 98% according to their CAPS measurement criteria. She noted that improvements are tied to both the Source product and the improved integration with their CAPS system, which has streamlined a variety of reimbursement processes.

“The overall end-to-end process was improved from the way it worked before, when we had to use robots, compared to how we’re using Source now… There are a lot of things we can do in Source now that we couldn’t do before.” – Health Plan Reimbursement Initiatives Manager

Retroactive claims inquiries and adjustments are another ongoing challenge for the Plan, particularly for providers who bill using a percentage of CMS fee schedules. CMS fee schedules are subject to ongoing policy updates and payment changes, but because only a small percentage of the Plan’s contracted providers use the CMS fee schedules, the Plan does not automatically make claims adjustments based on retroactive CMS change policies. Instead, issues usually come to their attention following a claims complaint or audit.

While the reimbursement team noted how helpful Source’s automated and bi-weekly updates are, they also noted that CMS release data gives limited information about when retroactive changes should impact reimbursement for specific types of providers. An example was when they received a complaint about 50 different claims payments across different hospital facilities that they contract with using the CMS fee schedules. In this situation, with multiple and dispersed claims issues, it was difficult to trace a payment change back to a specific CMS release.

The Reimbursement Initiatives Manager noted how critical Source’s audit feature is to address these types of provider complaints. It enables her to download relevant claims from the production to the pre-production environment and reprocess them, compare the two side-by-side, and identify changes like a capital payment amount or wage index change, that could drive such dispersed claims complaints.

“One of the best features of Source that I love is the ability to download a claim from one environment to another environment. That’s very handy.” – Health Plan Reimbursement Initiatives Manager

It is easy to see how this regional plan serves to benefit from this type of automation, and this addition may be a next step on their payment integrity journey. But Source is designed to support plans at all stages, and the audit feature (one of the Plan’s most widely used Source features) enables the Plan to meet their retroactive claims inquiries and audit needs manually. Source’s audit feature is critical for the Plan’s customer service team members who access claims detail to answer questions from providers and members, and for the audit team who hold claims audit responsibility. Further, the provider reimbursement team regularly uses the audit feature to respond to inquiries from Plan leaders.

For example, the Reimbursement Initiatives Manager was recently asked to explain to the Plan’s leadership team how ambulance services (a particularly expensive line-item for plans), are priced by CMS. It was easy for her to use Source’s audit feature to search for hospital outpatient provider type, filter by an ambulance code to narrow down the results, then find examples of claims that contained the ambulance code. With this information, she was able to provide a detailed response to Plan leadership about how CMS reimburses those ambulance services

Takeaways

• Pre-existing integration capabilities minimize challenges inherent in integrating new platforms with legacy tech stack components
• Optimizing automation will drive accuracy while minimizing resource-intensive and manual work and re-work for prospective and retroactive pricing changes
• Retroactive pricing updates aren’t going away; the right tool will enable plans to leverage robust audit features for inquiries and manual adjustments while considering more automated solutions
• Choosing an industry-specific tech partner like HealthEdge gives plans the support they need to optimize automation and accuracy despite the complexity of diverse pricing and provider arrangements

I have found the HealthEdge Source system to be very robust and flexible with regards to all of the different types of CMS and non-CMS based pricing methodologies that it offers.” – Health Plan Reimbursement Initiatives Manager

The complex relationship between payers and providers plays an important role in shaping the accessibility and quality of healthcare services. In 2023, this relationship underwent significant shifts, leading to both wins and losses. Looking ahead to 2024, several trends seem poised to further reshape how individuals access and experience healthcare.

Wins and Losses in 2023:

 

Wins:

1. Enhanced Digital Experience:

The integration of digital platforms and telehealth into benefit plans improved access to healthcare services. Insurers made strides in offering user-friendly apps, enabling policyholders to view their coverage, schedule appointments, and access medical records effortlessly. Some of these advancements were the direct results of regulations taking effect.

2. Value-Based Partnerships:

Payers embraced value-based care models even more, forging deeper partnerships with providers. The continued shift incentivizes better outcomes and promotes cost-effective, quality care.

3. Preventive Care:

Payers continued their focus on preventive care, offering incentives and reduced premiums for policyholders who proactively engaged in wellness programs and screenings. This approach aims to mitigate future healthcare costs by preventing diseases, benefiting the entire system.

4. Streamlined Claims Processing:

Technological advancements, like those of HealthEdge’s core administrative solution, HealthRules® Payer, led to faster and more accurate claims processing, reducing administrative burdens for both providers and payers. This improved efficiency in healthcare delivery and reduced claim disputes.

Losses:

1. Rising Premiums:

Despite efforts to improve efficiency, health insurance premiums continued to rise in 2023. This posed a challenge for individuals and businesses trying to balance the cost of insurance with adequate coverage.

2. Narrower Provider Networks

Some plans opted for narrower provider networks to control costs. While this helped in cost containment, it limited the choices available to members, leading to dissatisfaction and potential delays in care.

3. Data Privacy Concerns

The increasing use of digital platforms raised concerns about the security and privacy of healthcare data. Instances of data breaches and unauthorized access underscored the importance of robust data protection measures. Data breaches were felt by both payers and providers at varying levels of severity.

Looking Ahead to 2024

 

Anticipated Trends:

1. Personalized Healthcare

Consumers are still hungry for a retail experience from their healthcare partners that is personalized to their specific needs. Artificial Intelligence (AI) is set to revolutionize healthcare by enabling personalized treatment plans based on an individual’s unique health data. But in an industry known to trail others, we may still be years away from being able to utilize AI to tailor coverage and support.

2. Virtual Reality in Telemedicine

Virtual Reality is poised to enhance telemedicine experiences, providing immersive consultations and medical training. Payers may integrate Virtual Reality into their offerings to improve patient engagement and understanding. However, like AI, this may be decades in the making.

3. Global Telehealth Access

Improved infrastructure and cross-border agreements may lead to global telehealth access, allowing individuals to consult with healthcare providers from different parts of the world, expanding their healthcare choices. Global telehealth access is more important now than ever as unrest rumbles in parts of the world.

Next-generation, digital core administrative processing systems, like HealthRules Payer, can help health plans better prepare for the future and respond to regulations and market trends. Across the industry, HealthRules Payer is known for its simplified but comprehensive configuration, allowing payers to move quickly and take advantage of new growth opportunities.

The relationship between payers and providers continues to evolve, presenting both challenges and opportunities. The shifts in 2023 indicate a growing focus on enhancing the digital experience, promoting preventive care, and streamlining processes. Looking forward to 2024, exciting advancements are on the horizon, promising a more personalized and accessible healthcare landscape. Learn more about our core administrative processing solution.

New data shows that states are struggling with the administrative components of redetermination. How did we get here, and how do we solve this problem?

Following the end of the COVID-19 public health emergency this spring, states began the process of redetermining which residents are eligible for Medicaid coverage. As of early this August, KFF reports that nearly 4 million Medicaid enrollees have been disenrolled based on data reported from 41 states and the District of Columbia. Further, the U.S. Department of Health and Human Services (HHS) projects that 15 million people will lose Medicaid coverage once redeterminations are complete.

As health plans adjust to this new reality, proactive measures must be taken to offset the reduction in Medicaid enrollment. The below list describes effective medicaid redetermination strategies that health plans can adopt to ensure continued coverage for vulnerable populations while maintaining their commitment to providing accessible healthcare services.

1. Enhanced Communication and Outreach

Engage in targeted communication campaigns to educate existing and potential enrollees about the importance of maintaining Medicaid coverage. Leveraging modern technology, such as HealthEdge^®’s Wellframe^® digital engagement platform, to take an omni-channel approach to beneficiary communications, can improve connectivity and effectiveness. In these communications, payers should highlight the array of benefits Medicaid offers and emphasize how it positively impacts their health and financial well-being.

2. Streamlined Enrollment Processes

Simplify the enrollment and renewal processes to minimize administrative burdens on beneficiaries. Provide user-friendly online platforms that guide enrollees through the application process. Utilize technology, such as HealthEdge’s HealthRules^® Payer core administrative processing system, to streamline enrollment and even pre-populate application forms and ease the documentation requirements, ensuring that the process remains as hassle-free as possible.

3. Collaboration with Community Organizations

Forge partnerships with community organizations, local clinics, and non-profits to increase awareness about Medicaid and support beneficiaries in navigating enrollment challenges. Community-based assistance can play a pivotal role in helping eligible individuals complete applications and renewals accurately. Payers who depend on HealthEdge’s GuidingCare modern care management platform are able to easily create and manage these partnerships with its extensive API services and more than 75+ pre-built integrations, including some with services for social determinants of health (SDOH).

4. Personalized Assistance

Offer personalized assistance through customer service representatives or enrollment specialists. Provide dedicated helplines to address enrollees’ questions and concerns, helping them navigate the complexities of the enrollment process.

5. Outreach to Lapsed Enrollees

Implement outreach strategies aimed at lapsed enrollees. Send reminder notifications about re-enrollment deadlines, emphasizing the potential risks of going without coverage and the ease of reinstating benefits. Once again, an omni-channel approach to beneficiary communications has the potential to drive higher levels of engagement.

6. Education on Benefits

Conduct education campaigns to inform beneficiaries about the range of benefits available through Medicaid. Highlight services such as preventive care, prescription medications, mental health support, and pediatric care. Demonstrating the value of these benefits can incentivize individuals to maintain their enrollment.

7. Data Analytics for Targeted Outreach

Utilize data analytics to identify trends and patterns in disenrollment. This data can guide the creation of targeted outreach efforts, focusing on areas or demographic groups that are experiencing higher disenrollment rates. For example, care management systems like GuidingCare – which have dynamic business intelligence capabilities – grant greater access to real-time data and analytics to make this process easy for care teams and business leaders.

The Medicaid disenrollment trend following the expiration of the Emergency Act presents a challenge that health plans must address with urgency and compassion. By implementing a combination of enhanced communication, simplified processes, community partnerships, personalized assistance, and targeted outreach efforts, health plans can offset the reduction in Medicaid enrollment. These strategies not only help maintain coverage for vulnerable populations but also underscore health plans’ commitment to ensuring access to quality healthcare services for all.

To learn more about how HealthEdge is helping health plans architect and execute their Medicaid redetermination strategies, visit www.healthedge.com.

HealthRules Payer® gives plans the tools to succeed as the No Surprises Act and industry regulation evolves.

When it comes to home repair, there isn’t a lot of tool flexibility. A 1/8” Allen wrench cannot be substituted for a 3/16” Allen wrench and a Phillips head screwdriver won’t help with a flathead screw.  Every home renovation project seems to add another tool to your toolbox.

Digital tools, however, are a different story. Consider even a common tool like Microsoft Excel. While many of us use this software to perform basic calculations, we are barely scratching the surface of its capabilities. Excel is a powerhouse, and users who have taken the time to unlock more of the tool’s abilities are running advanced analytics and macros to feed critical business decisions.

From the health plan perspective, the constant evolution of health care practices, policies and communication standards can be much like the never-ending stream of repairs and renovations faced by homeowners. Health plans that invest wisely in their technology, however, can avoid an overflowing ‘toolbox’ and leverage the power and flexibility inherent in existing solutions – even as their operational and process renovation projects evolve.

The Challenge of Regulatory Evolution: The No Surprises Act

A particularly timely example is the No Surprises Act (NSA). This recent legislation requires significant revisions to the current administrative processes of most health plans, requiring plans to:

• limit member cost-sharing responsibilities
• manage out-of-network provider bills with federally regulated qualifying payment amounts
• establish web-based provider directories and price comparison tools for healthcare services
• prepare for anticipated guidelines around providing members with advanced explanations of benefits (AEOBs) detailing both pricing and individualized accumulator information

For some plans, this may feel like an overwhelming list of processes to develop and/or overhaul. But the tools for the job may already be at hand. For example, HealthRules Payer is a Core Administrative Processing Solution (CAPS) with existing technology to:

• manage conditional payment structures
• combine provider-level pricing information with individual level plan and accumulator data
• generate accurate claims data after, or in advance of a scheduled service, without triggering a claims payment

These are the foundational functions underlying many of the NSA requirements, and many plans may not be aware of the functionality that already exists in their HealthRules Payer solution. For example, HealthRules Payer has Trial Claim feature, used to prospectively review various claims payment arrangements in a test environment. This same function can be used to populate price comparison data and accurately generate claims information in advance of scheduled services. In addition, HealthEdge is continuously adding new platform features.

HealthEdge is an industry-specific technology partner and is staffed by leaders passionate about technology and healthcare – including policy. The HealthEdge team is continually innovating, serving clients with new features and platform upgrades that occur automatically with no disruption to day-to-day operations. With the NSA top of mind across the industry, soon-to-be-released HealthRules Payer features will make it even easier for plans to succeed in the existing and evolving regulatory environment.

Building on Success

With a robust and flexible CAPS, payers can meet new regulatory requirements using existing and flexible features. And, much like complex home repair projects, it will pay off to have the right partner on board. HealthEdge clients have the benefit of our deep industry expertise and technical know-how at their fingertips, making it easy to nail regulatory compliance now and into the future.

What can HealthEdge do for you? See how in our No Surprises Act Data Sheet.

About HealthEdge

HealthEdge® is the health insurance industry’s first digital nervous system to provide automation and seamless connectivity between all parts of a payer’s administrative and clinical systems. HealthEdge provides modern, disruptive healthcare IT solutions that health insurers use to leverage new business models, improve outcomes, drastically reduce administrative costs, and connect everyone in the healthcare delivery cycle. Its next-generation enterprise solution suite is built on modern, patented technology and is delivered to customers via the HealthEdge Cloud or onsite deployment. In 2020, funds managed by Blackstone became the majority owner. HealthEdge and its portfolio of mission-critical technology assets for payers, including HealthRules Payer®, Source, GuidingCare® and Wellframe are collectively driving a digital transformation in healthcare. Follow HealthEdge on Twitter or LinkedIn.

In the ever-evolving landscape of healthcare, one of the most challenging aspects for healthcare payers is keeping up with the constant changes in fee and policy schedules set by the Centers for Medicare & Medicaid Services (CMS). Each year, CMS makes numerous adjustments, amendments, and updates to these schedules that can create financial challenges and increase administrative burdens for payers.

The Frequency of CMS Updates 

CMS plays an important role in administering healthcare programs for more than 150M Americans according to CMS Fast Facts for CY 2022. As part of this responsibility, CMS continually reviews and revises its fee and policy schedules. The frequency of these updates can be daunting:

• Annually: CMS routinely publishes updates to various fee schedules and policies on an annual basis. These annual updates are eagerly anticipated by healthcare providers and payers, as they often involve significant changes to reimbursement rates and regulatory requirements.
• Quarterly: Beyond the annual updates, CMS also releases quarterly updates to fee schedules, which can include changes to payment rates, coding guidelines, and coverage policies. These quarterly updates are aimed at addressing emerging healthcare trends and issues.
• Ad Hoc Updates: In addition to the regularly scheduled updates, CMS may issue ad hoc updates in response to urgent healthcare needs or changes in legislation. These updates can have immediate and profound effects on the healthcare industry.

The Impact of CMS Updates on Payers

These updates encompass changes to reimbursement rates, policies, and regulations that directly influence how payers operate.

Reimbursement Rates:

One of the most significant aspects of CMS updates for healthcare payers is the adjustment of reimbursement rates. CMS sets rates for services covered under Medicare and Medicaid, which serve as benchmarks for many private payers. When CMS updates reimbursement rates, it affects the revenue that healthcare payers receive from government-sponsored plans and, subsequently, the rates they negotiate with providers.

Financial Sustainability:

CMS updates can pose financial challenges for healthcare payers. Reductions in reimbursement rates or changes in payment methodologies can impact the profitability of managing government-sponsored plans. Payers may need to adapt their cost structures, premium pricing, or network strategies to maintain financial sustainability.

Compliance Burden:

CMS updates often come with changes in documentation, coding, and billing requirements. Healthcare payers must invest in compliance efforts to ensure they meet the evolving regulatory standards. This can increase administrative costs and necessitate ongoing training and education for staff.

Network Management:

Changes in CMS policies can also impact payer-provider relationships. Negotiating contracts with providers may become more complex due to changes in reimbursement rates and performance-based incentives.

Member Services:

CMS updates can directly affect the services and benefits offered to members of government-sponsored plans. Changes in coverage policies, eligibility criteria, or access to certain treatments can influence member satisfaction and retention. Healthcare payers must communicate these changes effectively to members and provide support to navigate evolving plan options.

Care Coordination:

CMS emphasizes care coordination and value-based care models in its updates. Healthcare payers need to align their strategies with these priorities to improve patient outcomes and control costs.

Regulatory Compliance:

Staying compliant with CMS updates is paramount for healthcare payers. Non-compliance can lead to penalties, reputational damage, and potential legal issues. Payers must continually monitor CMS changes, update their policies and procedures, and ensure that staff members are well-versed in the evolving regulations.

Navigating CMS Changes 

One of the ways many payers are choosing to navigate all of these changes is through the use of modern technology. Payers who use HealthEdge’s core administrative processing system (CAPS), HealthRules® Payer, have the unique opportunity to leverage the company’s award-winning prospective payment integrity solution, HealthEdge Source™, as a secondary editing solution.

This productized integration, called Payer-Source, is now available as a secondary editor, which means claims can go through another layer of validation so inaccurate and inappropriate claims are more likely to be caught before they are paid. This not only reduces the risks of overpayments and underpayments, but it also helps minimize provider abrasion.

And the good news is, there is no need for payers to replace or change their primary editing solution, which can be HealthRules Payer or other primary editing vendors, to take advantage of this new capability. It simply slips in the payment workflow after the primary editor but before the claim has been fully adjudicated. Users have complete flexibility and control over whether they want to accept the Source recommendations or not.

Powerful Savings Identified 

The Source Data Study team recently completed several data studies with payers, using the Payer-Source integrated solution as a secondary editor, and the savings opportunities the solution identified were significant:

• A national health plan was able to generate $8.7M, or 1.1% in incremental savings, on 5.1M claims, representing $790M in spend from its Medicaid and Dual-Eligible populations
• A regional health plan was able to generate $9.1M, or 1.6% in incremental savings, on 2.1M claims, representing $571M in spend
• A mid-sized regional health plan was able to generate $11.1M, or 1.6% in incremental savings, on 1.7M claims, representing $684M spend

Learn more about how payers can future-proof their claims editing for real savings here.

 

The volume of changes CMS makes to its policies and pricing schedules every year is staggering, with over 600 retroactive changes anticipated for 2023 alone, making it challenging for payers who depend on outdated technology to keep up. To capture the changes, Payers must comb through manuals, fee schedules, bulletins, and news flashes. Once the changes are identified, IT resources typically have to upload them into the payer’s ecosystem in multiple places.

For example, if a new modifier is posted for Medicare, teams must figure out which claims are impacted and what impact those changes may have. Then, they must determine what actions should be taken: overpayments that may require recoupments or underpayments that may surface during a CMS audit or spark a series of calls from providers, all contributing to provider abrasion. And the same process must be followed for changes at the state Medicaid level, which can be even more taxing and time-consuming since each state is unique.

Managing CMS policy and fee schedule changes is an enormous burden on everyone. Most payers have entire teams of business and technical resources dedicated to reacting to these changes.

However, at HealthEdge Source™, we are actively working with our customers to solve this problem using modern, prospective payment integrity solutions. We’re enabling payers to take a proactive approach to retroactive changes with Source Retroactive Change Manager.

Because the pricing and editing data is in a single instance, Source can automatically identify and assess which claims are impacted by the changes and capture the price/policy used when the claim was processed. Knowing the new price/policy, the system can then analyze the impact of the retroactive changes and help business leaders easily understand potential risks for over/under payments.

The Results Speak for Themselves

The Source Data Study team recently completed a study with a regional plan with home and host capabilities. The Source Retroactive Change Manager evaluated 67,916 claims from Q1 2023 and identified $2.67M in overpayments. The health plan was also able to use the solution to reduce several administrative burdens and costs, including:

• Automate timely identification, repricing, and reporting of retroactive changes
• Remove contingency vendors
• Ease provider abrasion
• Improve compliance
• Reduce waste

A separate regional health plan with 200K+ members was looking to strengthen confidence in its pricing accuracy, compliance, and readiness for external audits. In a 90-day study, Source Retroactive Change Manager identified 95,830 claims with pricing changes, resulting in over/underpayments totaling $20,921,901.

For more information on how Source can help your organization take a proactive approach to retroactive changes to CMS policies and prices, listen to this webinar, “Preparing for CMS Updates and Retroactive Changes,” presented by Jared Lorinsky, chief strategy officer, and Carl Anderson, senior product manager for HealthEdge Source.