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Unlike legacy systems, Next-Gen CAPS like those offered by HealthEdge integrate seamlessly with third-party applications, offering more interoperable data and workflows across payer or third-party applications. 

What are Next-Gen CAPS?

Unlike legacy systems, Next-Gen CAPS like those offered by HealthEdge:

●      Integrate seamlessly with third-party applications, offering more interoperable data and workflows across payer or third-party applications

●      Enable all users to see real-time data

●      Enable flexible delivery methods including value-based contracts

●      Are customized for each health plan and department including interfaces

●      Allow all team members to access, edit and configure data independently, without IT support

●      Effortlessly merge new and complex product lines

What Benefits do Next Gen CAPS Offer Over Previous Legacy Systems?

Comprehensively, these new features allow for:

●      Lower transaction costs, freeing capital for innovation

●      Improved data access including real-time data and transaction processing

●      Streamlined operations that support agile regulation updates

●      Greater customization in business models such as enabling value-based payments

●      Higher security and more utilization of economies of scale

●      Decreased reliance on IT or expensive professional services to update regulations

Why Will Next Gen CAPS Be Widely Adopted Within The Next Two Years?

There are a number of market influences making Next Gen CAPS like HealthEdge a must-have technology for payors in the coming months. These include:

1. Payers diversifying their business models to include complex care delivery and retail vertical integrations

2. More policy exceptions and innovations in areas like medical necessity and provider network alignment

3. Regulatory mandates requiring payers to improve timeliness and transparency of administrative processes.

Why are Next-Gen CAPS Solutions Not Standard Technology Now?

The major reasons why Next-Gen CAPS systems have not already been widely adopted are:

• Conflicting payer business priorities
• Risk aversion
• Solution costs

• End-to-end implementation requirements, including replicating legacy processes
• Difficulty with configurability

How to Start Implementing Next-Gen CAPS At Your Health Plan?

When you are selecting a vendor for your Next-Gen CAPS system there are a number of important things to consider.

You should place greater importance on strategic CAPS capabilities versus those that are commodity.

Your teams should analyze whether licensed applications, Saas or business process outsourcing solutions for each CAPS capability are the best.

As well, health plans should make sure considered vendors have:

• New versions of CAPS as greenfield
• Good previous track record with your company to date

• Modular CAPS components for phased implementation
• Configurable interfaces
• Significant proof of concept in your primary market

Read the rest of the Gartner Hype Cycle report to learn more about Next-Gen CAPS like HealthEdge’s HealthRules Payor.

What are Prospective Payment Integrity (PPI) solutions anyway?

PPI solutions enable health plans to proactively avoid paying claims improperly. They include features like:

• Claims editing
• Data mining
• Complex clinical Review
• Advanced analytics and AI

With minimal payment leakage, they also address:

• Contracts
• Services
• Eligibility
• Payment accountability

How is that different from how claims are paid today?

The most popular payment method today for health plans is the pay-and-chase method. With this strategy, payers conduct claims quality assurance after claims are paid.

As per Gartner 3%-7% of healthcare claims are paid inaccurately the first time, with only a small portion of those claim payments later corrected.

Unlike previous payment strategies, PPI technologies like Source from HealthEdge ensure proper payment the first time, directly confronting improper claims payment activities.

Why PPI practices will become industry standard by 2027…

There are a number of reasons why PPI technologies like Source will become industry standard within the next few years. These include:

Increasing claims complexity due to:  

• COVID-19 payment policy exceptions
• Specialty drugs
• Medically complex patients
• Value-based payment arrangements

In-demand and complex capabilities built into PPI solutions like:  

• Social analytics
• Predictive modeling
• Machine learning
• AI-enabled fraud reduction, case management and payment integrity
• Ongoing expansion and scaling of virtual care solutions leading to increased fraud in areas like durable medical equipment (DME) and prescription drugs.

 Why are PPI solutions not industry standard now?

Some health plans may be hesitant to implement PPI solutions today because the ROI for cost avoidance is harder to calculate than for cost recovery. Additionally, payers often implement incentives for staff to open cases for post-pay audits that create an unintended disincentive for PPI.

Finally, “Few payers have an enterprise payment integrity program that provides governance and oversight across all regions, products, provider networks, capabilities and vendors. Fragmented procurement and operations of PPI solutions diminishes the ROI of cost avoidance or, at least, accurate aggregation of savings realized across the organization and provider networks.”

Implementing change and choosing the right solution for the future

Implementing PPI solutions may include foundational change at some health plans—shifting focus from KPIs based on recoveries and other post-pay activities to prospective avoidance. It’s imperative that payers choose the right partners that offer a modular approach to implementation.

Additionally, Gartner outlines the following key offerings in PPI solutions that health plans should consider.

To learn more about the future of prospective payment integrity solutions and other technology trends for healthcare payers, access the Gartner® Hype Cycle™ for U.S. Healthcare Payers, 2022.

GARTNER and Hype Cycle are a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and are used herein with permission. All rights reserved.

Stuart Myer, Chief Information Officer, VillageCare, a community-based, not-for-profit organization in New York, recently joined HealthEdge leaders Christine Davis, Vice President, Product Marketing and Len Rosignoli, Vice President, Customer Success in a live webinar to share how his health plan is advancing care management through digital transformation. The webinar was hosted by the Association for Community Affiliated Plans (ACAP).

In the discussion, Myer shared real-world scenarios that his organization experienced along its digital transformation journey and explained how every stakeholder in his organization is benefiting today. In case you missed the webinar, here is a snapshot of what the team covered.

1. Industry dynamics and challenges are driving health plan executives to realize that now is the time for digital transformation.

Workforce shortages, regulatory changes, evolving business models, and shifting consumer expectations are pushing health plan executives to seek new ways of reducing costs, improving efficiencies, and investing in innovation. Davis shared highlights from the company’s Annual Health Plan Market Survey that showed the majority of leaders are focused on aligning business and IT teams, as well as investing in innovation and moving to modern technology.

2. Digital payers are leading the way in transforming the industry.

“HealthEdge defines digital payers as those bringing business and IT areas together to create a modern, digital organization that constantly improves health and financial outcomes,” explained Davis. A digital payer can be identified by five key attributes:

1. Leveraging digital tools to improve end-user and member centricity.
2. Achieving higher levels of quality to deliver better outcomes for members and communities.
3. Increasing business transparency, breaking down siloes and improving exchange of information.
4. Advancing customer service by empowering teams with next-generation solutions.
5. Constantly reducing transaction costs through automation and connectivity.

3. VillageCare leaders implemented a digital transformation strategy that enabled a more data-driven approach to every aspect of their business, which is driving better care for their community and more efficient operations.

“Using a digital foundation has allowed us to become a data-driven organization that operates more efficiently. We are in it for better outcomes for the community we serve. A more efficient workforce delivers better care,” explained Myer.

Using the GuidingCare® platform from HealthEdge, VillageCare was able to support their top business and clinical objectives in many ways, including:

• Improving clinical and business operations through integrated work processes
• Creating a data-driven organizational culture
• Advancing clinical partnerships through data integration
• Sharing data with members and clinical partners using industry standards
• Using best-in-class applications that integrate to create a seamless systems environment

4. Becoming a digital payer transformed experiences for five key groups across VillageCare and the healthcare ecosystem in which they operate:

• Members: VillageCare consolidated data and streamlined process to better enable a member-centric approach. They migrated disconnected touchpoints (such as finding providers and eligibility, benefits, and cost information), to easy-to-use, self-service tools within GuidingCare. With a frictionless member experience, they increased member engagement and satisfaction, while ultimately improving health outcomes.
• Providers: The organization transformed their relationship with providers by delivering instant access to real-time patient benefits, claims data, authorizations, and more in GuidingCare’s easy-to-use digital collaboration tool.

“One way we were able to improve the experience for providers was the GuidingCare Utilization Management application that is tightly integrated with the claims processing system,” Myer explained “This process was a big pain point for our staff. Many health plans have staff managing these processes in separate environments, manually entering information into both systems. We solved this problem, and as a result were able to launch an authorization portal. So rather than having providers fax or make phone calls to request authorizations, they can now request them electronically. We also use a claims portal where they can check the claims outstanding.”

• Member Services: VillageCare streamlined the disconnected workflows that were a result of multiple software systems and improved access to information to transform the experience for their member services teams. With better tools and more accurate, real-time data, member services teams have been able to improve service quality, reduce costs, and improve the member experience.
• Care Managers: VillageCare also eliminated functional siloes and put accurate, up-to-date data in the hands of care managers to streamline workflows and improve outcomes.

“We aim for integrated, care management processes. Systems should support the work processes, which was not always the case. But through our digital transformation and using GuidingCare, we have much more structed work processes. This frees up our care managers to focus on care management, while also forcing compliance and regulatory adherence through the system. In addition, we now have proper segmentation of membership so that we can develop real-time alerts, improve population health, and direct efforts where needed as opposed to being the same across the whole organization,” explained Myer.

• Information Technology: VillageCare has consistently focused on aligning business and IT teams to successfully use technology to address priority needs and challenges across the organization. By transforming the IT foundation, they delivered on their goal of becoming a data-driven organization. Now, the organization uses business intelligence to improve operations and deliver better care for members. In addition, through implementing solutions that use interoperability standards such as Fast Healthcare Interoperability Resources (FHIR), they have advanced integrations that allow for more streamlined processes and seamless workflows.

“The transformation has truly changed the way our teams operate, improving the experience for members, providers, member services, care management, and IT. All of these components are part of our digital transformation strategy. It is important to touch each of them and ensure that they talk to each other,” stated Myer.

VillageCare is addressing top challenges facing many health plan leaders today through their digital transformation journey,. They are delivering benefits for key stakeholders across the healthcare delivery systems by improving connectivity, enabling access to accurate data, and streamlining workflows.

Ultimately, the digital transformation is enabling VillageCare to deliver better health outcomes for the community they serve.

Learn more by watching the webinar here.

Leveraging his experiences as the Chief Information Officer at VillageCare, Stuart Myer discusses successfully attaining executive board buy-in for long-term technology investments.

Issues Technology Partnerships Solve for Safety Net Health Plans

Safety Net health plans face a unique set of challenges in comparison with other payers. These include an acute focus on community health and social determinants of health, an increased demand for complex care and more fragmented workflows.

Safety net health plans have been addressing these challenges while also seeking regulatory compliance, adapting their business models to align with patient demand for improved consumer experiences, and dealing with workforce shortages and the rising cost of labor.

One of the most effective ways to manage costs while comprehensively tackling these issues is through technology investment. By working with IT vendors offering interoperability and the sharing of real-time data among stakeholders, health plans can maintain ownership of their data while:

• Gathering reliable and accurate community health and social determinants of health data
• Fostering business transparency with all stakeholders including patients
• Developing and sharing complex care plans with all stakeholders and manage claims
• Creating digital experiences for patients to interact with and understand their healthcare

In the long run, such technology partnerships are some of the most impactful investments for health plans that intersects both cost and quality of care.

Barriers to Technology Implementation

Executives are highly concerned with cost savings. In fact, according to a 2022 survey of executive health plan leadership, the most pressing issue this year is managing costs.

Thus, it’s no wonder that despite the considerable benefits, upfront technology investment stands as a potential impediment to implementation.

Considering this, how can professionals approach their executive boards as well as internal teams to get buy-in on this important investment?

Tips For Successfully Obtaining Buy-In For New Technology Partnerships

Gain Leadership & Board Buy-In

Executive leaders championing new technology investment is a key driver toward organizational engagement and widespread buy-in.

The arguments for technology partnerships should be so compelling that the partnerships are not just approved for IT to carry out, but that the executive board co-leads the initiatives with IT and other departments.

The c-suite is concerned with every aspect of business and therefore has a finite bandwidth for championing initiatives. How do you make a technology partnership stand out?

Your technology investment cannot be presented as an IT project only. It must drive business strategy and align with blue chip items for the year. For instance, health plans may have long term goals related to risk mitigation and regulatory compliance. By explaining in as much detail as possible how this technology investment will deliver ROI on those goals, you’re more likely to get buy-in. If you’re having difficulty quantifying ROI, vendors often will work with health plans to develop reliable forecasts.

Myer suggests establishing a strong link between technology investment and organizational priorities. This ensures the project gets the attention and resources necessary. Health plan leaders can review their K10 or other strategic documents. Use short and long-term goals to create KPIs for deployment.

Continued support by the executive board is needed. There should be annual updates on progress to the c-suite. This investment should also be included as a component in the annual budget.

Identify Opportunities to Introduce Technology Partners

It takes time and effort to find the right technology partners. Consider how each vendor could grow with your company and the customization available in their solutions. Carefully review RFPs and connect directly to vendors through video calls and meetings. Make sure your vendor understands the unique challenges and opportunities of your health plan. What can they do to help your health plan meet these challenges?

Make sure technology vendors are:

• Cloud-based
• Have automated updates
• Allow for your firm to own your own data
• Offer raw data downloads to easily integrate into your platforms

3 Steps To Maintain Internal Momentum for New Technology Partnerships

1. Plan Strategy & Digital Transformation Initiatives

Health plans cannot fully implement new software to their tech stacks right away. Instead, technologies need to be integrated in phases. Myer suggests creating a detailed plan for when each integration will be deployed.

Start with the integrations most important and easiest to implement. Work your way down to more time-consuming and less impactful deployments.

For VillageCare, Myer prioritized data strategy first, as it was one of the largest pain points for the organization. For any given report, whether clinical or business related, there were multiple sources of information and large variations between statistics. This led to immense costs for VillageCare, in both resources and time, to validate data and discern which source was the most accurate for a given metric.  By leveraging GuidingCare®, Myer was able to consolidate reports and make decisions based on more reliable data.

Myer also recommends deploying cloud-based solutions within the first few months of launch. This allows health plans to take a foundational approach and put data warehouse capabilities at the forefront of technology investments.

2. Establish Governance

When deploying a new technology, it is important to develop a structured and formalized process for IT investments at an organizational level. Part of this process should be ensuring there is strong governance overseeing the implementation project.

One of the most important factors in VillageCare’s success creating patient-facing data portals was Myer’s creation of a governing board of members. These members provide feedback on projects and influenced VillageCare initiatives.

With member feedback, VillageCare captures and documents key needs and challenges of their population before and while developing member tools. This provides assurance that their investments will be received well by patients and minimizes troubleshooting post-deployment.

In addition to member governance, having an internal technology implementation team led by various department stakeholders, ensures the alignment of the investment with strategic initiatives and the company’s budget process.

To create an internal business governance, leadership teams and executive boards must first buy into the project.

3. Define Time Frame

It’s important to be patient with technology deployments. Estimate 2-5 years with key milestones before a strong ROI and organization-wide buy-in is seen.

For example, at VillageCare, Myer is in his 3rd year deploying GuidingCare. The past few months data strategy has taken off and is now part of the overall culture of the organization.

“It stopped being an IT thing and became an organizational mission” says Myer, “It is now embedded in our employee handbook. We offer a minimum level of training for staff and optional higher levels of training regardless of job function.”

To learn more about organizational buy-in for technology initiatives and VillageCare, view HealthEdge’s ACAP webinar If you’d like to learn more about GuidingCare and its capabilities find out more here.

In 2022, HealthEdge once again commissioned an independent survey of health insurance executives to capture and monitor perspectives regarding current challenges and priorities. There were over 300 responses received – from Directors and above in a variety of types and sizes of health plans.

We’d like to focus on one of the reported Top Challenges Facing Health Plan Executives – operational efficiencies.  The challenge of operational efficiencies came in second place and jumped 33% from 2021 to 2022, from 31% to 41% of respondents. To satisfy your curiosity, ‘managing costs’ came in first place, and ‘member satisfaction’ third in the 2022 study. In 2021, operational efficiencies ranked sixth. Member satisfaction and managing costs tied for third in 2021 behind ‘competitive pressure’ and ‘IT/business alignment’ (fourth and fifth in 2022, respectively).

When we began discussing and evaluating this internally, the comment came up about the pent-up demand for care as some consumers stopped seeking care during the COVID years of 2020 and 2021. It’s a complex dynamic, as the varying impact on payers and providers differ and could also be positive or negative.  Capitated health plan members seeking less care might be good for the provider financially, albeit temporarily. The influx of care may also have a positive or negative impact for payors and providers.  The increase in unemployment caused an increase in uncompensated care – but also an increase in Medicaid membership. It is anything but simple and there are many factors to consider – type of health plan, type of patient, type of reimbursement, conditions, diagnoses, contracts, etc.

Managing costs and operational efficiencies go hand-in-hand, so it makes sense that they both increased significantly in the responses for top challenges.  With the “great resignation”, the need to become more efficient is at play in all types of organizations – and is directly related to operational efficiency.

We’d like to focus on three potential areas to consider related to operational efficiency – auto-adjudication and first pass rate, digital transformation and return on investment (ROI), and staffing.

Auto-adjudication and first pass rate

Most health plans continue to focus on improvements to auto adjudication rate, a key indicator for improving operational efficiency. The obvious benefit here is the assumption that fewer claims will be touched by a human. However, first pass rate is often overlooked or not measured, and is equally, if not more important. For those that are unclear on the difference – the auto-adjudication rate is most often measured by simply calculating the percentage of claims successfully processed without manual intervention. Without more complex calculations, what is sometimes overlooked are claims that had previously suspended – maybe even more than once – and are now processed a subsequent time successfully – then counted as having auto-adjudicated, skewing the results.  Some of those claims were actually touched by a human, sometimes more than once.  First pass rate calculates those claims that were never suspended and successfully processed the first time. However, both measures help with evaluating operational efficiency.

Digital transformation and return on investment (ROI)

The buzz words “digital transformation” have been top of mind for the last several years, and remain a priority for improving operational efficiency.  What IS digital transformation? Each organization must carefully define what this means internally, but in general, it is increasing and improving the efficient use of technology. There is a cost to increasing the use of technology. There is certainly a ROI to come, and it’s critical to not only anticipate the ROI, but to continue to measure it.  The measurement can help to justify future improvements to and investments in technology once ROI calculation and measurement becomes routine and is demonstrated. The simple fact is that money must be spent to eventually save money – just like how converting a home to solar power includes a significant initial investment that pays off over time.

Software vendors are being asked more than ever to justify the cost of technology and demonstrate (in advance) the ROI. In some cases, ROI and/or performance guarantees are being built into software licensing agreements. The software industry should be positioned to explain and develop the ability to measure and commit to stated ROI for purchasers of their technology solutions.

Staffing

Operational efficiency related to staffing also increased in importance as most organizations are now trying to do more with fewer resources. Health plans are trying to become more efficient through higher automation of manual processes where applicable – and somehow enabling a corresponding increase in human efficiency. The so-called great resignation has health plans understaffed and has increased the urgency of this shift. Some did not anticipate the increase in staff productivity while working remotely.  While this is not true 100% of the time and not for 100% of employees, it has been true more often than not. Interestingly, in many cases, working remotely improved work/life balance – and consequently improved productivity.  This turned out to be operationally efficient.

Recruitment and retention are more critical than ever. Alternate staffing methods have become important to defend against this phenomenon. This includes some tried and true options such as 9/80 or 4/40 work schedules, part-time and shift work, full- or part-time remote work, additional paid holidays and/or time off, and other common staffing solutions. In addition, internship programs are increasing, as is the untapped value of the intern.  While many internship programs were and remain focused on the summer, many programs are now year-round. Many colleges and universities offer cooperative education (or co-op) programs – where paid full- or part-time jobs are taken for credit during what would be the typical school term (or longer). Internships are being made available to others, including recent graduates or master’s program graduates.

While the need for operational efficiency may increase or decrease in any given year, it is a continual challenge that can be achieved in many ways. We hope we’ve offered just a glimpse into a few potential contributors.

Read the full report here: Annual Market Survey Reveals What 300+ Health Plan Leaders are Thinking

The ‘pay and chase’ model of reimbursement is prevalent in the health care industry. This means many health plans know and accept the fact that payments to providers are simply incorrect and will require remediation.

At HealthEdge, we’re asking lots of questions about this traditional model and challenging the status quo.

• What if health plans modeled contracts before or during negotiations with providers?
• What if health plans understood how contract terms would affect their claims before putting them in place?
• Could health plans streamline contract terms and ensure that reimbursement methods pay correctly and automatically?
• Could health plans remove manual processes and rework?

Getting to the root cause of conflict

The friction between providers and health plans is multi-faceted. Erroneous payments are simply accepted, allowing the pay and chase model to be normalized and standard. But consistent errors wear on both health plans and providers. Allowing a claim to be underpaid or overpaid by even a few cents, will become a substantial amount over time, increasing tension between health plans and providers.

The pay and chase model also takes time away from the individuals working to remediate the discrepancies. Rework requires time to be spent on the same tasks that could have been correct the first time. Overall, this leads to waste in the form of time and dollars.

What is contract modeling?

Contract modeling can be thought of as testing terms for reimbursement. This allows a health plan to gain valuable insights into impacts of the terms within contracts prior to applying them to production claims.

Contract modeling can build a comparison of ‘what if’ scenarios to help a health plan make important decisions when it comes to negotiating provider contracts.

The benefits of contract modeling: how it can resolve the abrasion between health plans & providers

Contract modeling can also be valuable to a health plan that is negotiating contract terms with a provider. It will allow for the health plan to understand the contract terms and their application to claims, while also bringing the same clarity to the providers, creating a strong and transparent relationship.

A comprehensive approach to accuracy & efficiency

Can we change the status quo of reimbursement with contract modeling? Perhaps the process of creating provider contracts is backwards. Instead of the traditional approach, what if we first know and understand the payment that providers are expecting and how contracted terms will behave on claims prior to negotiations? With a complete and transparent approach, we can stop the pay and chase model and start paying claims accurately and efficiently the first time.