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

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

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

1. Enhanced Communication and Outreach

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

2. Streamlined Enrollment Processes

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

3. Collaboration with Community Organizations

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

4. Personalized Assistance

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

5. Outreach to Lapsed Enrollees

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

6. Education on Benefits

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

7. Data Analytics for Targeted Outreach

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

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

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

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

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

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

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

The Challenge of Regulatory Evolution: The No Surprises Act

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

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

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

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

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

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

Building on Success

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

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

About HealthEdge

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

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

The Frequency of CMS Updates 

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

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

The Impact of CMS Updates on Payers

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

Reimbursement Rates:

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

Financial Sustainability:

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

Compliance Burden:

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

Network Management:

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

Member Services:

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

Care Coordination:

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

Regulatory Compliance:

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

Navigating CMS Changes 

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

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

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

Powerful Savings Identified 

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

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

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

 

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

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

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

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

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

The Results Speak for Themselves

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

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

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

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

For all the talk about value-based care models, few payers have actually discovered the secret to successfully deploying these types of arrangements with a significant portion of their provider network partners.

However, several payers, including Independent Health, a New York-based not-for-profit health plan with 387,000 members that leverages HealthRules^® Payer as its core administrative processing system (CAPS), appear to have discovered the secrets to success. In fact, Independent Health now has 98% of its primary care practice members in full capitation contracts, with solid alignment of goals with its provider network.

So, what’s the secret?

According to Dave Mika, Vice President, Enterprise Core System Operations at Independent Health, it comes down to the flexibility and power of technology.

“When we give providers data that shows how they are performing relative to required or recommended services for members within various demographics and disease states, we’re doing so with the ability to drill down to the individual patient level.

When we understand where a single patient stands relative to utilization of inpatient and outpatient services, we can offer clarity into everything from who needs to be more active in managing their own care to how cost calculators and digital health tools can be better utilized – by providers and their patients.”

The Role of HealthRules Payer

With HealthRules Payer, health plans can quickly address market opportunities and stay in front of competition. All this while achieving high levels of customer satisfaction and transparency by providing accurate, real-time information to everyone involved in the care continuum. HealthRules Payer has also significantly lowered administrative costs for our customers by simultaneously automating critical manual business processes, resulting in an enhanced bottom line.

“HealthEdge allows us to achieve speed to market with our products in the rapidly changing healthcare environment, with the capability to configure and implement products quickly and on the fly,” says Mika. “The solution also gives us the capability to drive alternative reimbursement models for our customers, now and in the future, as evolving needs – and regulations – dictate.”

With results like this, it’s no wonder that HealthRules Payer has been named “Best in KLAS” by KLAS Research for Claims & Administration Platforms for the past two years.

Finding the Value in Value-Based Care Contracts

As the healthcare industry continues to undergo transformation away from fee-for-service models to value-based payment models, digital health plans have a unique opportunity make this transition highly successfully for all stakeholders: payers, providers, and patients. They can do so by leveraging the advanced automation capabilities and real-time data insights that are readily available in modern 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 not only enhances members satisfaction but also 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.

By harnessing the power of automation and aligning incentives with value-based care, health insurance companies can play a pivotal role in transforming the way healthcare is delivered and financed, ultimately benefiting both patients and the industry as a whole.

To learn more about how HealthRules Payer helped Independent Health, read the full case study today, and reach out to see how HealthEdge can help your organization embrace value-based care contracting by visiting www.healthedge.com.

With hundreds of health plans depending on HealthEdge’s HealthRules^® Payer core administrative processing system (CAPS) every day, members of the Customer Operations team have their work cut out for them.

How HealthEdge Customer Operations Team Supports Health Plans

This team is comprised of four different groups that work cohesively together to ensure customers have the best possible experience:

1. The infrastructure operations team ensures the company’s private cloud, networks, and operational spaces are secure and available.
2. The technical support services team manages the response to all inbound customer product inquiries and support tickets by coordinating with customers and product team members to facilitate fast responses and resolutions to any issues that may arise.
3. The customer success management team is ultimately responsible for understanding the current and future needs of HealthRules Payer customers and prioritizing the work for the rest of the organization. They are the customer “captains” who understand each customer end-to-end from an operations perspective.
4. The business intelligence team works with the data to enable the rest of the team and customers to gain actionable insights so they can proactively address opportunities for improvement.

Although much of this work sounds technical, the “north star” for this group of hard-working, seasoned professionals is all about helping HealthEdge customers give their members access to the healthcare benefits and services they need when they need them.

The internal tagline of being “Customer Obsessed” is ever-present among all team members who constantly strive to learn more about their customers’ business to provide a more personalized experience.

Equally important is the team leaders’ focus on humanizing the healthcare technology experience for employees. The work is more than just solving a technical problem. It’s about making sure that the eligibility file goes through correctly so that the mother gets access to the medications her sick child needs or the grandmother can get the medical procedure she needs to experience the joys of playing with her grandchild.

These scenarios remind the HealthRules Payer customer operations team members of their purpose: to always do what is best and suitable for their customers so their customers, in turn, can do what is best and ideal for their members.

The Future is Bright

As the HealthEdge customer community continues to expand, the customer operations leadership team is also looking to improve the lives and experiences of their employees. By establishing more standardized processes and proactively addressing the demand for unplanned work items, they are giving employees more time to focus on discovering innovative ways to support the growing customer base – all for the betterment of HealthEdge customers.

In addition, the team is working toward more standardized processes and a more integrated experience for customers of multiple HealthEdge solutions, including GuidingCare^® for care management, Source for payment integrity, and Wellframe^® for digital member engagement. As more integration points across these solutions become available, customers will have a more seamless experience working with HealthEdge.

Finally, as the organization encourages and enables health plans to become digital payers, HealthEdge is adopting more digital-centric capabilities that automate repetitive, manual tasks and improve productivity. Modern technologies that proactively monitor and adjust server capacity are also being implemented to benefit team members and customers alike.

The HealthEdge Customer Operations team is more than just a group of engineers and technical resources who support clients. They are members of a dedicated group focused on making a difference in people’s lives by enabling high-quality healthcare at the right time and the right place.

To learn more about the HealthEdge customer experience, visit www.healthedge.com.