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New York represents one of the country’s largest populations of Medicaid beneficiaries, according to Medicaid.gov. Keeping up with the payment and policy updates that the New York State Department of Health (NYSDOH) sets for Medicaid providers is no easy task for payers trying to successfully serve this growing population. In fact, in a 2022 survey of more than 400 payers offering Medicaid as a line of business, the three most popular challenges payers faced were all tied to staying compliant with all of the changes:

• 74% = staying compliant with changing reimbursement policies
• 62% = installing updates to the fee schedule in a timely manner
• 52% = keeping up with changing fee schedules

That same study revealed how manual-intensive it is for payers to keep their Medicaid program fee schedules and policies up-to-date, with 84% claiming that they do it “mostly manually.”

Due to the complex nature of Medicaid, payers have historically relied on a patchwork of disparate workflows and vendor solutions to provide pricing for their Medicaid lines of business. Today, Source is taking its expertise developed over decades of supporting Medicare reimbursement and applying that same depth and breadth of content to Medicaid. New York is the latest state supported by HealthEdge Source.

The uniqueness of state Medicaid programs is what makes it so challenging for many solutions to keep up. One size does not fit all, and change is constant. Each state has its own set of rules that payers must play by so there are very few common rules that can be applied. For example, in New York, the state doesn’t post nursing facility rates by NPI or Medicaid ID, but by operating certificate. Many states are still using grossly outdated Medicare guidelines and prices. And when you combine these unique complexities with those of the multiple Managed Care Organizations (MCOs), it can quickly become overwhelming to manage, resulting in non-compliance and inaccurate payments.

HealthEdge Source: How it Works

When it comes to payment integrity for Medicaid programs, the Source experts have payers covered with two dedicated teams – one for data research and new developments and a second for maintaining the Medicaid edits currently available. Armed with advanced web monitoring tools and seasoned research analysts, Source delivers updates to customers every two weeks. And because it is a cloud-based solution, those updates are automatically applied. That means IT teams are free to focus on strategic initiatives instead of trying to maintain complex pricing.

Many industry experts believe that state Medicaid programs will continue to become increasingly complex as the necessity of finding more cost-effective ways to deliver high quality care becomes more urgent due to rising costs. To learn more about how Source can help your organization stay on top of the ever-evolving New York Medicaid program requirements, visit Source Medicaid Reimbursement.

Health insurers increasingly understand that delivering a delightful customer experience to members is critical for success. In a survey of health insurance executives conducted by market research firm Survata and commissioned by HealthEdge, when asked about the most important organizational priority, the number one response was “member satisfaction.” This surpassed lowering costs, investments in innovation and the shift to new business models, and represents a heightened awareness that members are actually customers, and act as consumers of a health insurers’ services. Effective communications are a critical component of creating a satisfying customer experience. Expectations from consumers reflect their experiences with services provided by virtually every other industry, enabling real time transactions and access to relevant and up-to-date information on demand.

Top Challenges of Effective Customer Communications

Health insurers must continually provide timely and accurate communications to tens of thousands of their customers throughout the year. Challenges, particularly with legacy communications solutions include:

• Maintaining a large library of templates to tailor communications to specific requirements
• Significant IT resources along with costly services engagements to maintain and upgrade communications solutions
• The inability to scale with speed to market for competitive advantage
• Resource intensive requirements to maintain and update complex documents

3 Musts of Effective Customer Communications

As you develop and enhance your communication protocols, or partner with a service provider, there are 3 communication musts:

• Easy complex logic – templates must be easy to use, feature drag and drop functionality, and enable your team to easily incorporate videos, charts, multiple attachments, and more
• Flexible & streamlined communication management – templates must be able to support multiple brands, languages, and communication channels
• Security & compliance – all communication must be PCI, HIPAA, SSAE 16, ISAE 3402, and ISO compliant

HealthRules Payer^® & Smart Communications^TM – Enhancing Customer Communications

HealthEdge’s next generation core administrative processing system, HealthRules Payer, has partnered with Smart Communications to empower HealthRules Payer customers to improve the member experience with more customized communications across more channels. Smart Communications is the leading cloud-based platform for enterprise customer communications. As the only cloud solution ranked as a Leader in Gartner’s Magic Quadrant for Customer Communications Management, more than 350 global brands — many in the world’s most highly regulated industries — rely on Smart Communications to make multi-channel customer communications more meaningful, while also helping them simplify their processes and operate more efficiently.

Learn more here about how HealthRules Payer and Smart Communications are paving the way to more impactful communication.

Prior authorization is a challenge for both providers and patients. The new CMS proposed rule on interoperability and electronic prior authorization aims to decrease provider abrasion and enhance the member experience – and ultimately improve both member and population health.

Today’s prior authorization challenges

Prior authorization hinges on accurate data and easy access to that data.  Today, the exchange of information between providers and insurance is often challenging and convoluted, and the processes for prior authorizations are no different.  Determining which services and procedures require prior authorization and what supporting documentation is needed to reach a decision often delays the delivery of care.

Many providers still rely on fax to get the prior authorization information to and from the insurance company. Providers send the information, wait for a response from the health insurance plan, send the requested information, wait for a response, and so on.

In a world, where nearly anything can be instantaneously ordered and delivered overnight, from your mobile phone or laptop, it seems inconceivable that prior authorizations, something so critical to member and population health, is managed by such a slow, tedious, and antiquated system.

Interoperability in healthcare data is poised to close the gap.

Making provider abrasion less painful through interoperability in healthcare

Interoperability offers the possibility of streamlining the prior authorization process with the seamless interchange of data via APIs, in real time. The new CMS rule proposes requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization. With this:

• Providers can easily find out if a prior authorization is required for a patient/procedure
• If yes, providers can then see the documentation requirements for that prior authorization

For example, if a member needs an endoscopy, the API pulls the information and tells the provider what information is required for the prior authorization.

Furthermore, since the early 2010s, most provider offices have electronic health records. This API would facilitate linking the electronic records to the prior authorizations and exchanging the information that needs to be shared between the provider and insurance.

This seamless exchange of data will reduce provider abrasion, improve the member experience and potentially their health outcome, and ultimately decrease the cost of care – as the manual effort and time linked to prior authorizations markedly decreases.

Patient Access API

The CMS Interoperability final rule which has been in effect since January 1, 2021, and CMS began enforcing as of July 1, 2021 included the Patient Access API and the proposed rule looks to expand the scope.

The Patient Access API enables a Medicare Advantage (MA), Medicaid, Children’s Health Insurance Program (CHIP), and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) member to access their healthcare information using smart apps of their choice.

The proposed rule adds prior authorizations and decisions to the information available via the Patient Access API along with annual metrics of prior authorization requests and decisions on the plan or issuer’s website.

Member health information is a mountain of data – a lifetime of different doctors, procedures, and experiences. You move or change doctors – sometimes you collect your health records and sometimes they’re lost to the shuffle of life. All this data, in so many different places, makes it challenging for members and their providers to understand and analyze it all.

Extending the interoperability API to members puts all their health data at their fingertips – across doctors, geography, and time – empowering members and populations to improve their health.

Provider Access API

For providers, there’s the possibility of sharing patient data within a network of providers. Members can grant providers access to share their data – empowering the providers to better collaborate and see the full picture of a member’s health and medical experience. This could ultimately improve patient outcomes.

The Proposed Rule also looks to return focus on the Payer to Payer Data Exchange rules which CMS deferred enforcement to allow for creation of supporting structure and standards. The Payer to Payer Data Exchange required a plan or issuer to share up to 5 years of membership and claims information for a member when the member moved to a new plan or issuer, upon the members request. CMS is proposing to also allow a member with concurrent coverages to request the plans or issuers to exchange the data quarterly. The addition of prior authorization requests and decisions to the data exchanged is also proposed.

HealthEdge: On the Forefront of Interoperability

The HealthEdge suite of products are built on solid processes that produce accurate, real-time data. With this data, providers and plans can easily access data and improve population health, increase customer satisfaction, and decrease provider challenges. Learn more here.

The good news: COVID-19 numbers across the country have gotten low enough (daily reported cases are down 92%[1]) that the Federal government feels the Public Health Emergency status issued in March 2020 that enabled the government to weather the worst of the virus, is no longer needed. The bad news for the American healthcare system: Estimates show up to 18 million Americans will lose their health insurance coverage through Medicaid within 14 months[2].

The Medicaid line of business grew more than 17% from February 2020 to September 2022 from an increase in the unemployment rate as well as the Continuous Enrollment Provision as part of the Public Health Emergency. That growth may now tumble downward as states begin to comply with CMS and State guidelines for Medicaid eligibility.

[3]

While the current Federal guidelines give states up to 14 months to resume normal income eligibility for Medicaid enrollees, many states can choose to do so more rapidly. What this all means for health insurers is a renewed need for outreach to potential Medicaid members who are in danger of being disenrolled to communicate options for Marketplace coverage. This can become increasingly complex for states with federally facilitated Marketplaces that can oftentimes operate in siloes.  Others losing Medicaid may become eligible for Medicaid Premium Assistance in the Employer Sponsored Insurance (ESI), but while employment levels nationally have returned to pre-pandemic levels, it can vary widely from state to state.

But amidst this looming unrest lies an opportunity for an often-broken healthcare system to work as it should. States are encouraged to partner with health plans, MCOs, community health centers, ancillary care providers, and other health care partners to reach out to enrollees to conduct their annual Medicaid renewal application. Each entity plays a role in ensuring the fewest number of Americans become uninsured. With HealthEdge’s family of products, modern health plans can operate Medicaid lines of business with maximum efficiency while staying compliant with state-specific frequently changing regulations. To learn more visit: https://healthedge.com/lines-of-business/government/medicaid/

 

[1] https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html

[2] https://www.urban.org/sites/default/files/2022-12/The%20Impact%20of%20the%20COVID-19%20Public%20Health%20Emergency%20Expiration%20on%20All%20Types%20of%20Health%20Coverage_0.pdf

[3] https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/

Data Protection in All States

Data must be protected in all states, when in use, in motion, and at rest. Data in use is data that is actively being accessed, processed, or updated. Data in motion is data that is being transmitted from one source to another. Data at rest includes any data that is stored and not actively transmitting from one source to another.

Data Loss Prevention

HealthEdge understands how critical it is to protect data, in all states, with a layered security strategy. As part of this strategy, we deploy Data Loss Prevention, or DLP, tools that monitor sensitive data, which alerts our security operations team to any potential findings. We also implement continuous training for everyone on the HealthEdge team. DLP ensures sensitive data is not exfiltrated from managed to unmanaged sources, such as transferring data from our corporate cloud storage to a personal storage and/or device. DLP policy configurations are designed to discover and protect data in real-time on the corporate network, endpoints and the cloud.

• Protecting the Network – DLP monitors data in all states on the corporate network and prevents data from being transmitted internally if it violates any HealthEdge information security policy.
• Hardening Endpoints – DLP monitors company endpoints and prevents data misuse and loss from endpoints both on and off the corporate network, including web traffic or email usage.
• Securing the Cloud – DLP monitors data on authorized cloud applications and prevents unauthorized and unsecure data transmission and unauthorized access.

Security Information Event Management and User Behavior Analytics

Security information and event management, or SIEM, collects logs and events from the HealthEdge environment. This capability allows our security operations team to analyze threats that have been identified by correlating data from different log sources. “Normal” behavior, such as where a user authenticates from and accesses data, are used to establish baselines. If the logs indicate a change in the baseline, an alert will trigger, and our security team will investigate further. This process is known as user behavior analytics, or UBA.

Log and event correlation can detect changes in access, authentication, or account changes. If a user attempts to access sensitive data using an unauthorized account, such as an employee account versus an administrative account, an alert will trigger additional analyses. If a user attempts to override established privileges, access will be blocked, and the attempt will be recorded in the user logs. Users are assigned risk scores based on role and privilege. When users attempt unauthorized access, even if blocked, the user’s risk score will increase. The greater the risk score, the greater the monitoring.

User Education and Awareness

The security operations team utilizes a hands-on approach, ensuring users with an increase in risk are aware of responsibilities to be good stewards of data. Humans make mistakes and the tools we deploy to prevent data loss work in conjunction with good cyber hygiene. In addition to notifications letting the user know the access or transmission has been blocked, security operations will reach out to the user directly to review information security policy requirements and answer any questions they may have regarding DLP. Security education and awareness is a continuous process and the HealthEdge team is the first line of defense when protecting data.

Medical necessity is one of the hardest things for both payers and providers to get right due to the complexity these policies usually require. However, medical necessity serves an important role in patient safety and fraud prevention, so it must be verified.

Medical necessity is a determination that a particular healthcare service, procedure, or treatment is appropriate, reasonable and necessary for the diagnosis or treatment of a patient’s medical condition.

For payers, getting it wrong can mean thousands, if not millions, of dollars wrongfully paid or wasted on downstream work associated with excess claim denials and recoupments. Getting it right means providers are reimbursed accurately the first time; patients receive the appropriate level of care and correct medications; and payers minimize overhead costs associated with claims review and rework.

To help payers get it right and be compliant with CMS National Coverage Determinations (NCD) and Local Coverage Determination (LCD) policies, MediQuant, a partner in the Source ecosystem, offers the full range of medical necessity edits, including:

• Procedures and diagnosis codes
• Add-on procedures
• Primary and secondary LCDs
• Covered and non-covered diagnosis codes
• Denied codes
• Frequency limitations
• I/P restricted CPT/HCPCS
• Effective dates
• Commentary on rule changes with every update

Making Medical Necessity Easier for Source Customers

As a transformative payment integrity solution for payers, Source has developed partnerships with many different best-of-breed vendors, including MediQuant. As part of the Source ecosystem, MediQuant 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. Plus, it’s easy to configure, as Source automatically indicates if/why a policy impacts a claim.

The result of Source + MediQuant?

Results include streamlined clinical policy maintenance, prior authorizations, coverage determination, and claims processing.

Payers are also able to minimize provider abrasion related to wrongful denials while also better managing utilization across all care settings, including hospitals, physician offices, labs, and imaging centers.

To learn more about how Source + MediQuant can help your health plan dramatically reduce denials due to improper or incomplete documentation of medical necessity, visit the Source third-party integrations page here.