Category: Uncategorized

“Healthcare organizations face increasing complexity in reimbursing care with value-based payments, self-funded business and more; however, claims-pricing software remains largely stagnant. U.S. healthcare payer CIOs need to procure claims-pricing software that addresses this complexity.”

— Gartner® “How U.S. Healthcare Payer CIOs Handle Effective Claims Pricing” Austynn Eubank, 5 December 2023

Complexity can be found everywhere you look in the healthcare industry today. But never before has there been so much pressure on payers to respond to providers’ rising expectations for timely and accurate payments while also addressing members’ rising expectations for more personalized and flexible benefit plans. 

When you combine these pressure points with the industry’s shift toward value-based care models, the growth in self-funded employer contracts, and evolving Medicare Advantage Star Ratings criteria, it’s easy to see how payers can become overwhelmed by the complexities of accurate and timely payments.   

In an attempt to address these challenges, payers have stacked claims editing and pricing solutions on top of each other, but many have found that their antiquated systems are creating more problems than solutions. In fact, in a HealthEdge research report, 90% of payers depend on two or more payment vendors. However, many of these systems do not afford the flexibility that is necessary to support payers’ ability to meet rapidly evolving provider and member demands.   

It’s Time to Reevaluate Claims Pricers 

“U.S. healthcare payer CIOs advancing healthcare digital optimization and modernization should: Build flexibility and efficiencies into the claims adjudication process by leveraging modular, cloud-native and API-first platforms for claims processing, pricing and editing that support members’ and providers’ needs.” — Gartner® “How U.S. Healthcare Payer CIOs Handle Effective Claims Pricing” Austynn Eubank, 5 December 2023 

Flexibility is the name of the game, especially for payers with multiple, state-managed Medicaid contracts, unique self-funded arrangements, or wide provider networks that require more flexibility and fee scheduling capabilities.  

HealthEdge Source™ (Source) delivers the flexibility today’s payers need to address complex provider contracts and multiple fee schedules, ensuring that payers can meet the needs of their providers while also optimizing operational efficiencies.  

How it Works 

With Source, payers can combine dynamic configuration capabilities with a smart hierarchy structure to reduce the overhead of maintaining and updating contracts. Source also automatically supports the consistency of terms across provider contracts without jeopardizing the unique requirements of each contract.  

Several health plans that have implemented Source have benefited from a 90% reduction in the number of managed configurations, leading to faster times to contract, more accurate payments, and less provider abrasion.  

A Flexible Future For Claims Pricing Solutions

As payers work to implement more flexible claims pricing solutions that can accommodate today’s fee schedule complexities and rising provider demands for more timely and accurate payments, Source delivers a modular, cloud-based solution supported by a robust set of APIs that can connect to any existing CAPS via a single instance. As a result, payers can develop more collaborative and trusting relationships with their provider networks that ultimately lead to better member outcomes and lower operating costs.  

To learn more about how HealthEdge Source can help your organization meet the evolving demands for more timely and accurate claims payments, visit www.healthedge.com.  

1Source: “How U.S. Healthcare Payer CIOs Handle Effective Claims Pricing” Austynn Eubank, 5 December 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’s 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. 

  

In a recent Becker’s podcast, Steve Krupa, CEO of HealthEdge, and Ryan Mooney, EVP and General Manager of Payment Integrity at HealthEdge, discussed the transformative role of technology and transparency in payment integrity practices. The leaders reviewed how traditional payment integrity solutions often operate retrospectively, identifying and recovering erroneous payments after they have been made. This reactive approach can lead to inefficiencies, provider friction, and higher costs.

In contrast, Krupa and Mooney revealed how HealthEdge’s prospective payment integrity solution, HealthEdge Source™, aims to correct errors before payments are made, emphasizing the importance of accuracy and efficiency from the outset. This forward-looking approach reduces the need for costly post-payment recoveries, minimizes provider abrasion, and improves payer-provider relationships.

From Black Box to Open Book

A key innovation of HealthEdge Source is its departure from the industry’s “black-box” methodology, where payment integrity processes are opaque, and solutions are proprietary, to an “open book” philosophy. This transparency lets payers see precisely where and how errors occur, facilitating root cause analysis.

The first solution to bring together contract configuration, reimbursement, editing, and analytics, HealthEdge Source provides the tools payers need to in-source capabilities to make real-time corrections—completing a virtuous cycle of payments.

This shift enhances operational efficiencies by empowering payers with the information they need to correct any process errors further upstream before the claim is paid. It also fosters a more collaborative environment between payers and providers, ultimately contributing to a more transparent and effective healthcare system.

The Payment Paradigm

• Post payment: You’ve already made a mistake, and the claim gets paid, leading to excessive recoupments and provider abrasion.
• Pre-payment: Let’s catch the mistake before it leaves the door, but its root cause is unknown.
• Prospective payment integrity: You can identify the root cause of the mistake and correct the issue to avoid the mistake entirely in the future.

The Solution to Payment Integrity: Payment Accountability®

Payment integrity transformation can inform various aspects of a payer’s organization enterprise wide. While traditional payment integrity solutions provide a quick fix to problems, HealthEdge Source delivers Payment Accountability with software that creates transparency to address root cause inaccuracies so payers can pay claims accurately, quickly, and comprehensively the first time.

With HealthEdge Source advanced analytics and machine learning algorithms, payers have the tools needed to identify and prevent payment errors. The cloud-based platform can quickly analyze large amounts of data from multiple sources to identify patterns and anomalies that may indicate payment errors and proactively correct them.

Here are a few examples of how HealthEdge Source also helps payers go beyond claims accuracy to gain greater insights and make more informed decisions.

• Retroactive change management identifies claims impacted by retroactive changes and reprocesses them, which helps improve provider satisfaction and performance during audits.
• Predictive Policy Modeling monitors any new payment policy edits before they are put into production to determine the impact prospectively. This enables health plans to make appropriate business decisions and improve provider-payer relationships.
• Contract Modeling enables a transparent analysis of the performance of contract changes or conversions to new contracted payment methodologies before implementation with a plan’s providers.

HealthEdge Source was recognized in the 2023 Gartner^®  Hype Cycle™ as a Representative Vendor for Prospective Payment Integrity Solution Category. From 2019 to 2021, HealthEdge was recognized as Burgess Group in the Gartner Hype Cycle for Payment Integrity (PPI) Solutions category. HealthEdge acquired Burgess Group in August 2020.

To learn more about how HealthEdge Source can help your organization get out of the black box and embrace an open-book approach to payment integrity, visit www.healthedge.com.

Gartner, Hype Cycle for U.S. Healthcare Payers, 2023, Mandi Bishop, Connie Salgy, Austynn Eubank, 10 July 2023

GARTNER and HYPE CYCLE are registered trademarks of Gartner, Inc. and/or its affiliates in the U.S. and internationally and are 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.

 

A pivotal moment has arrived in the ever-evolving landscape of the healthcare insurance industry. Healthcare consumers are no longer content with traditional engagement methods and seek more personalized experiences from their health plan providers. It has never been more important for health plan leaders to be aware of the key issues surrounding members’ rising expectations. The challenge is two-fold:

1. Consumer buying experiences in other industries: Consumers now expect a level of engagement and convenience from their health plan providers that mirrors their experiences in other sectors, such as retail and banking. The days of primarily relying on phone calls for problem-solving are giving way to more digital and automated solutions. They want omnichannel communications that adhere to their lifestyles and interests.According to a recent HealthEdge survey of more than 2,800 healthcare consumers, the number one way health plans can improve member satisfaction is by adhering to members’ communication preferences. This shift underscores the need for insurance companies to adapt and equip their teams with modern, omnichannel engagement solutions.

 

2. Increased access to healthcare information: With more health and wellness information available on the internet, members have unprecedented access to healthcare information. They are more educated about their conditions, treatment options, and even the costs associated with healthcare services. They can more easily find doctors on the internet who meet their specific needs. When they do engage with their healthcare provider, they typically leverage digital tools, such as appointment reminders, portals, and even text messaging.

This newfound knowledge and availability of more modern tools empower consumers to play a more active role in managing their care. As a result, they also expect greater access from payers regarding benefit information, authorizations, costs, and even clinical guidance that can help them make better decisions about their health.

A New Generation of Members Requires New Engagement Strategies

Health plan leaders must be cognizant of the changing preferences of consumers in a post-COVID world.  According to the same HealthEdge consumer study, today’s members seek self-service mobile tools and prefer to engage with their healthcare plans and providers on their own terms. Furthermore, when assigned a care manager, members want care managers to:

1. Communicate with me in the ways I prefer
2. Enable me to actively participate in my care plan
3. Refer me to social services and resources
4. Help me get and manage my medications
5. Have my health information on hand when we communicate

Healthcare consumers are not the only ones pushing for greater transparency and better experiences. One significant regulatory development driving change in the industry is the Transparency in Coverage Act, which requires health plans and providers to provide members with greater visibility into the cost of services before they receive them. This transparency places additional pressure on healthcare payers to offer solutions that enable their members to access pricing information easily and make informed decisions about their care.

Additionally, CMS announced that it is doubling the weight of member experience when calculating payers’ 2023 Star Ratings.

Never before has there been a more important time for health plan leaders to address their members’  evolving demands when it comes to digital engagement strategies.

The HealthEdge Approach

HealthEdge recognizes these challenges and offers health plans a comprehensive strategy to address them. By providing both data and software solutions, the company aims to support healthcare payers in meeting the demands of the evolving healthcare market. From clinical engagement tools to benefit and health risk predictions, HealthEdge’s solutions are designed to enhance member experiences and improve overall wellness.

Here are some practical examples of how the HealthEdge portfolio of solutions helps payers create more personalized and meaningful member experiences:

HealthRules^® Payer

• • Enabling health plans to provide superior customer service with first-call resolution
  • Real-time data allows members and providers to make decisions at the point of care
  • Enable self-sufficiency for members seeking cost transparency
  • Faster and more accurate claims payments lead to higher member satisfaction

HealthEdge Source™ payment integrity platform

• • Delivering accurate and transparent claims payments reduces the clerical burden on clinicians, which leads to burnout
  • Minimizing clerical burden on providers by removing rework, review, and waste
  • Ensuring that member eligibility and benefits information is accurate and available
  • “Every minute they spend on administrative tasks reduces the time they spend practicing medicine”

GuidingCare^® care management platform

• • Drives secure member communication with their designated care team
  • Mobile clinician application enables offline access for care management staff in the field, enabling connection to members anytime, anywhere
  • Designed to meet NCQA health plan guidelines for Member Self-Management
  • View care plan goals and actions, access personal health records, track health and wellness data, complete health assessments, and more.

Wellframe member experience platform

• • Enables highest needs members to get access and support outside of traditional care delivery settings
  • Omni-channel communication seamlessly connects members
    to designated care teams, with an average of 34 digital touchpoints/member/month
  • Self-service digital resources empower members to reach their health
    and wellness goals proactively
  • Modern user experience increases both member satisfaction and engagement

Visit www.healthedge.com to learn more about how HealthEdge can help your organization engage with your members more personally and meaningfully, proactively reduce costs, and address ever-evolving regulatory requirements.

 

From rapidly changing regulatory requirements and new competitive forces to changing payment models and rising consumer expectations, 2024 is shaping up to be another challenging year for health plans. In this 5-part blog series entitled HealthEdge Horizons, we dive deeper into the trends that are shaping our industry and explore how HealthEdge solutions are helping payers address their biggest challenges head-on. Be sure to check out the entire series:

• Simplifying the Complexities of Healthcare Industry Regulations
• The Evolution of Health Insurance Technology: Embracing End-to-End Integration – Coming soon!
• New Market Expansion in 2024
• Value-Based Care in 2024
• The Changing Face of Healthcare Engagement in 2024 – Coming soon!

The Origins of Value-Based Care

Since the Institute for Healthcare Improvement (IHI) first articulated the Triple Aim in 2008, the healthcare industry has undergone a massive transformation over the past 15+ years, shifting from paying for services (fee-for-service or FFS) toward paying for quality (value-based care or VBC).

Initially, the Triple Aim provided a framework for “optimizing health for individuals and populations by simultaneously improving the patient experience of care (including quality and satisfaction), improving the health of the population, and reducing per capita cost of care for the benefit of communities,” according to the IHI. Several years later, it evolved to include a focus on the well-being of the healthcare workforce and advancing health equity, with some now referring to it as the Quintuple Aim.

With the passing of the Affordable Care Act of 2011, the concepts of healthcare providers and payers working together to embrace quality finally began to take hold. However, when the existing FFS payment structure was put to the test in the Medicare Acute Care Episode (ACE) Demonstration Project in 2018, the feasibility of value-based care became apparent. It ushered in a new era of bundled payment initiatives, including what we now know as value-based care.

The Financial and Care Incentives

Value-based care introduces financial incentives for healthcare providers to ensure patients stay healthy. Under this model, providers are financially rewarded for maintaining their patients’ well-being. The key lies in value-based contract arrangements that distribute funds to providers at a broader level, such as a “bucket” or global level.

When patients remain healthy, cost savings are shared with the provider, creating a win-win situation. Patients benefit from improved health, lower expenses, and better care coordination. Providers are incentivized to focus on preventive care and wellness, as it directly impacts their financial compensation. In this way, value-based care aligns the interests of patients, providers, and payers.

Value-Based Care Today

So, where do VBC payment models stand after all of these years? According to a May 2023 Healthcare Payer Intelligence report, CMS recently reported successfully linking 90% of payments to value, and 40% of all payments flow through alternative payment models (APMs). While the rest of the healthcare industry is transitioning toward value-based care contracts, fee-for-service arrangements still represent a significant portion of the market. However, administering these contracts and transitioning from traditional models to value-based care has proven challenging. This is where modern technology, like HealthEdge solutions, comes into play.

The Role of Modern Technology

Transitioning from fee-for-service to value-based care requires a fundamental shift in managing and reimbursing healthcare. Traditional systems designed for fee-for-service models must adapt, but unfortunately, many legacy and outdated systems cannot support this transformation.

It’s one thing to say you are going to move from fee-for-service to value-based care, but it is another to administer the many different forms of value-based care, such as shared-risks, capitated arrangements, and many different forms of bundled payments.

How do payers take a traditional system that was designed for the model of “patient gets sick, patient goes to the doctor or hospital, a hospital gets paid, repeat the cycle” and convert it to supporting new models that tie reimbursements to patient outcomes and experiences with the doctor/hospital?

The answer: They can’t. Modern, flexible systems are a must-have in value-based care.

A Brighter Future with Value for All Stakeholders

HealthEdge recognizes the need for an integrated approach that combines contracting, claims administration, and care coordination in a single entity. This holistic approach ensures that the financial and care components of value-based care align seamlessly. With HealthEdge’s ecosystem of these three essential components, payers can efficiently manage value-based care programs and control costs effectively.

With HealthEdge, digital health plans have a unique opportunity to make this transition highly successful for all stakeholders: payers, providers, and patients. They can do so by leveraging the advanced automation capabilities and real-time data insights readily available in modern core administrative processing systems (CAPS) like HealthRules^® Payer. With the right CAPS in place, the value of value-based contracts becomes crystal clear:

• Cost Control: Value-based care models can help health plans control costs over the long term by focusing on preventive care and early intervention
• Improved Member Health: By promoting healthier lifestyles and proactive healthcare management, value-based care can lead to improved health outcomes among members. This enhances members satisfaction and reduces the financial burden on payers.
• Competitive Advantage: Payers that embrace value-based care early gain a competitive edge. They can attract providers and members who appreciate the benefits of this approach.

Here are a few practical examples of how all HealthEdge solutions are helping health plans navigate this transformation successfully, improving patient outcomes and reducing healthcare costs in the process:

• HealthRules^® Payer
  • Agile & flexible HealthRules Language
  • Quickly configure new benefit plans and contract arrangements
  • Share actionable data
    with stakeholders
  • Make value-based reimbursement & improved customer satisfaction a reality
  • Up to 96% billing accuracy, including with complex value-based agreements
  • Learn more about our core administrative processing system.
• HealthEdge Source™ payment integrity platform
  • Accurately price claims based on complex contractual arrangements
  • Run in parallel with fee-for-service contract terms
  • Handle both prospective and retrospective bundles
  • Enable predictive modeling and impact reconciliation reports
  • Learn more about our payment integrity platform.
• GuidingCare^® care management platform
  • Facilitates complex workflows to manage care plans in value-based arrangements
  • Intuitive gaps-in-care analytics identify high-risk patients and potential health improvement opportunities
  • Evaluate performance across configurable measure sets such as HEDIS and Star ratings, plus state and custom measure sets
  • Learn more about our care management platform.
• Wellframe member experience platform
  • Assigned programs focus on whole-person health and improved care outcomes
  • Proven ROI in utilization management outcomes, with a 17% reduction in inpatient admissions** and a 23% increase in preventive medicine utilization**
  • Builds framework for assessing target population and managing clinical needs
  • Learn more about our member experience platform.

Health plans that want to remain competitive and win new business need to support value-based arrangements at every touchpoint in their ecosystem and have access to relevant data outputs for internal and external tracking and analysis.

To learn more about how HealthEdge solutions can help your organization successfully implement value-based care, visit www.healthedge.com.

The landscape of health insurance has experienced a significant transformation in the past decade, with new market expansion becoming a key driver of competition and growth. Health insurance providers, both large and small, have had to adapt to changing consumer preferences and the evolving competitive landscape.

Payers need to recognize the critical role modern technology solutions can play in supporting their growth plans, whether it be through membership growth, mergers, and acquisitions, or even the rollout of new products or geographies.

As the market becomes more complex and the competition heats up, industry leaders reported technology to be both their biggest challenge and their greatest ally in the coming year in the recent 2024 HealthEdge Annual Payer Market Survey [link to report when ready]. Among the 350+ health plan leaders surveyed, 62% said “investing in modern technology for digital transformation” was the number one way they intend to achieve their organization’s goals. However, their most significant challenge was reported to be “alignment between IT and the business.”

The Shift in Health Insurance Markets

Historically, health insurance primarily operated within group-oriented markets, catering to large employers and their employees. Players in this space often stayed within their established markets, with national plans dominating the scene. Smaller regional players, on the other hand, often focused on specialized networks to differentiate themselves. Medicaid and Medicare programs operated at the regional level, with large group-oriented plans utilizing Administrative Services Only (ASO) arrangements to manage their offerings.

However, a significant shift occurred roughly a decade ago, moving the focus from employers to consumers. The rise of public and private exchanges marked the beginning of a new era, where consumers started to take a more active role in choosing and purchasing their health insurance plans. This shift introduced a fundamental change in how health insurance providers needed to operate and compete.

Competing in a Changing Landscape

In this new landscape, health insurance plans, whether large national entities, smaller regional players, or government programs, found themselves competing differently. They needed to appeal to various populations with unique needs and preferences while facing a broader range of competitors. In this changing environment, flexibility and speed became critical factors for success.

• Flexibility: Health insurance providers had to adapt to the diverse needs of their target populations. What works for one group may not work for another, necessitating flexibility in plan offerings and services.
• Speed to Market: In a world where consumers are now shoppers and buyers, quickly bringing new offerings to market is a competitive advantage. Health insurance plans needed systems to respond rapidly to changing demands and opportunities.

The Role of Modern Technology

To meet the demands of this new, expanding market paradigm, payers must leverage modern technology that can support their efforts in several key areas:

• Rapid Benefit Package Creation: In the past, it might have been acceptable to take 3-4 months to create a new benefit package. However, insurers need systems that can swiftly design and build benefit packages to meet evolving consumer needs in today’s fast-paced market.
• Digital Care Management: Offering new care management programs and digital care management platforms is crucial for addressing members’ health needs. The speed at which insurers can deploy these programs can be a decisive factor in their success.
• ASO Arrangements: Health insurers often need to sign new ASO agreements with various entities that value health insurance offerings. The ability to do this quickly and efficiently is essential for expanding into new markets.

HealthEdge’s Approach to Supporting Payer Growth

At HealthEdge, we understand the importance of modern technology in supporting health insurance payers’ expansion efforts. We recognize that success hinges on what a system can do and how fast and flexibly it can do it.

• Empowering Customers: We enable our customers to build and administer their functionality. Once customers are trained on the value of our solutions, they can control their destiny.
• APIs and Testing: Everything we do focuses on the speed and efficiency of our technology’s tasks. Our emphasis on Application Programming Interfaces (APIs) and rigorous testing ensures that our systems can handle tasks quickly and reliably.
• User Experience: We prioritize the user experience, ensuring that our technology is powerful and user-friendly. A seamless and intuitive interface allows insurers to operate efficiently and respond swiftly to market demands.

Here are a few practical examples of how HealthEdge solutions support payers’ ability to expand their businesses and grow into new markets successfully:

HealthRules^® Payer

• • Create virtually any benefit plan or provider contract in hours and days versus weeks and months. Average set-up time for a new contract can be as little as 10-12 minutes
  • Mirror a plan’s actual world and setup
  • Ability to scale and keep up with the pace of membership growth. Up to 97% enrollment accuracy

HealthEdge Source™ payment integrity platform

• • Single API to support all claims systems and provider types
  • Easily create and customize contract configurations with synchronization of rules management across all LOBs
  • Designed to scale for your organization’s future growth, agility, and transformation

GuidingCare^® care management platform

• • End-to-end solution with flexibility and scalability
  • Highly configurable for specific health plan needs and wants
  • Consolidated member information in a single, comprehensive care record
  • Built to scale to millions of member records, millions of transactions per week and 10K+ concurrent users​

Wellframe member experience platform

• • On-demand member content and benefits resources, plus digital customer service advocacy solutions
  • Enables health plans ownership of the member relationship, mitigating competition
  • Proven 6x increase in member interactions and double the staff capacity for active caseload size

HealthEdge: Your Competitive Edge for Growth in 2024

The evolution of health insurance markets from group-oriented to consumer-focused has brought about a need for health plans to adapt quickly and efficiently. In this dynamic landscape, speed to market and flexibility are the keys to success. Modern technology plays a pivotal role in supporting health insurance providers as they expand into new markets.

HealthEdge’s commitment to delivering systems that empower customers, emphasize APIs and testing, and prioritize user experience positions for health insurance payers for success in a highly competitive environment. With the right technology partner, health insurance providers can navigate the changing landscape with agility, meet consumer demands promptly, and achieve their expansion goals in a fast-paced and consumer-driven industry.

To learn more about how HealthEdge solutions can support your organization’s growth strategies, visit www.healthedge.com.

 

From rapidly changing regulatory requirements and new competitive forces to changing payment models and rising consumer expectations, 2024 is shaping up to be another challenging year for health plans. In this 5-part blog series entitled HealthEdge Horizons, we dive deeper into the trends that are shaping our industry and explore how HealthEdge solutions are helping payers address their biggest challenges head-on. Be sure to check out the entire series:

• Simplifying the Complexities of Healthcare Industry Regulations
• The Evolution of Health Insurance Technology: Embracing End-to-End Integration
• New Market Expansion in 2024 – Coming soon!
• Value-Based Care in 2024 – Coming soon!
• The Changing Face of Healthcare Engagement in 2024 – Coming soon!

The Early Days: Integrated Systems

The landscape of health insurance has transformed dramatically over the last three decades, driven by advances in healthcare IT and back-office administration. From claims processing to digital care management, technology has reshaped the way health insurance payers operate. Now is the time for payers to explore emerging concepts and opportunities associated with end-to-end system integration to better support their 2024 clinical and operational goals.

In the early days of healthcare IT, the prevailing wisdom was to consolidate as much functionality as possible within a single system. The goal was to have everything in one place, minimizing the need for complex integrations. This approach had its merits:

• GOOD: Centralization was seen as a way to simplify operations, reduce administrative overhead, and gain better control over various processes.
• BAD: A single system could only do so much, limiting its ability to adapt to the rapidly changing healthcare landscape. As the industry evolved, it became clear that a single system could only address some of the specialized needs of health insurance payers.

The Shift Toward Best-of-Breed

Over the last several decades, the health insurance industry gradually shifted away from the all-in-one integrated systems to embrace a best-of-breed approach. Instead of trying to fit all functionalities into a single system, payers began adopting specialized software and systems tailored to their specific needs. This shift had several advantages:

• Expertise: Specialized systems allowed payers to leverage the expertise of vendors who focused exclusively on claims processing, care management, or other critical aspects of their operations.
• Efficiency: Specialized systems were often more efficient and effective in their respective domains, leading to improved performance in key areas.
• Flexibility: Health insurance companies could choose the best tools for each aspect of their operations, allowing for greater flexibility and adaptability.

The Challenge of Separation: Care Management and Claims

While the best-of-breed approach offered clear benefits, it also introduced new challenges, particularly in integrating care management and claims processing. Unlike integrated systems, where these functions naturally worked together, the best-of-breed approach separated them into silos and created several new challenges:

• Expertise: Claims processing and care management requires different skill sets and expertise. This separation led to administrative and technical challenges in bridging the gap.
• Complex Integration: Integrating separate systems, with their own data structures and communication protocols, proved to be a complex and costly endeavor. Companies faced difficulties in ensuring that these systems worked seamlessly together.
• Vendor Fragmentation: Another complication arose as health insurance companies started purchasing various products from different vendors to meet their needs. Each vendor had its own requirements for integration, further fragmenting the technology landscape. While technology improved over time, integration challenges persisted due to the diversity of systems and vendors.

The Path Forward: Integrated End-to-End Solutions

Today, health insurers are revisiting the concept of integration, but in a different way. Integrated end-to-end solutions are gaining traction, offering the best of both worlds – the efficiency of specialized, best-of-breed applications and the seamless integration of a single vendor’s ecosystem. This new approach delivers several key advantages:

• Controlled Integration: When a single vendor provides claims processing, digital care management, and other functionalities, they can control the level of integration between these applications. For example, automating claims and payment editing becomes more straightforward when one vendor owns both components.
• Real-Time Automation: Integrated end-to-end solutions enable real-time automation, improving the accuracy and efficiency of processes. This is particularly important to ensure claims are paid correctly the first time.
• Future-Proofing: The market seems to be returning full circle to the best-of-breed concept, but this time with the added benefit of integrated end-to-end automation. Health insurance operations can be more adaptable and better equipped to meet evolving needs and technology trends.
• Improved Member Engagement: Integrated end-to-end automation breaks down silos and fosters a smoother flow of data and processes. This results in better member engagement, creating a more satisfying experience for insurers and consumers.

The HealthEdge Advantage: Breaking Down Silos

Currently, many health insurance organizations operate in silos, relying on custom-built bridges between different components of their operations. The move towards integrated end-to-end solutions aims to break down these barriers, allowing health plans to take full advantage of a best-of-breed approach while benefiting from a cohesive ecosystem.

HealthEdge solutions were designed with integration in mind. As the HealthEdge solution portfolio moves toward integrated end-to-end solutions, they are breaking down barriers and allowing health plans to take full advantage of a best-of-breed approach while benefiting from a cohesive ecosystem.

In addition to productized integrations between HealthEdge solutions, including Care-Payer, Payer-Source, and the newly available Care-Wellframe, HealthEdge products themselves support an integrated end-to-end approach:

• HealthRules^® Payer

  • Auto-adjudication rates over 90%, with at least 99% claims accuracy
  • Highly automated features greatly increase productivity and transparency
  • Auto reprocessing capabilities
  • Hyper-automation supports remote operations

• HealthEdge Source™ payment integrity platform

  • Cloud-hosted solution with continuous content updates that are delivered automatically
  • Parallel processing of payment policies and pricing to enable real-time claims transactions
  • Source SMEs research, develop, and maintain content and IT infrastructure
  • Built to enable seamless technology, open APIs, and true interoperability

• GuidingCare^® care management platform

  • API integration suite with 75+ unique vendors for all use cases
  • Automation tools proactively build and sustain robust member care plans
  • Best-in-class rules engine automates business processes and workflows
  • Streamline and consolidate the full appeals management process across all levels and reviewers

• Wellframe member experience platform

  • Mobile delivery of 70+ pre-developed, automated care programs
  • Web-based staff dashboard with member prioritization, templated messaging, and 1-to-many workflows
  • Auto-generated SDOH and clinical risk survey questions and assessments routinely surfaced to members
  • Direct member access to self-service risk assessments

Moving Forward

The evolution of healthcare IT and back-office administration in health insurance has been a journey of trial and error. From integrated systems to best-of-breed approaches and now integrated end-to-end solutions, the industry has finally found the right balance between specialization and integration.

By combining the efficiency of best-of-breed applications with seamless integration, HealthEdge is enabling health plan operations to be efficient and adaptable to the ever-changing needs of the industry.

To learn more about how HealthEdge solutions can support an integrated end-to-end approach to your enterprise, visit www.healthedge.com.