Introducing Personalized Service Solutions with EDGEcelerate™

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
  1. 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
  1. 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.

  1. 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

Crop

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.

The Key to Improving the Member Experience Through Improved Payment Integrity

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.

 

The Synergy Between Security and Privacy

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 usData 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.

Three Things Every CIO Should Consider When Evaluating Care Management Software Solutions

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.

Next Generation Payer Care Management: Why Now, and What Next?

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

KLAS Emerging Solution Spotlight on Source

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

Source emerging

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.