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HealthEdge has identified five key attributes that drive digital payers, enabling them to rise above the competition and lead the way to better outcomes across the entire healthcare delivery system.

Digital health payers focus on:

1. Improving end-user and member centricity
2. Achieving higher levels of quality
3. Increasing transparency
4. Advancing customer service
5. Reducing transaction costs

In this five-part blog post series, we are diving deeper into each attribute, delivering resources, information, and insights to enable health plans to transform into digital health payers. As we continue the conversation around what it means to be a digital payer, this discussion focuses on embracing business transparency.

Embracing Business Transparency

Transparency is increasingly becoming a hot topic for health plans. Consumers are demanding more transparency in terms of benefits, costs, and care choices. Government mandates like the Transparency in Coverage Rule and the No Surprises Act are requiring payers to make more data available to more healthcare stakeholders. Everyone across the healthcare ecosystem including members, providers, and other partners need greater access to data as they attempt to improve health outcomes and financial decision making.

Digital health payers are embracing this new emphasis on transparency that is possible with modern claims processing, care management, payment, and member engagement technologies like those from HealthEdge. They are able to use their next-generation systems and automated processes to support better integration, break down silos across departments, and optimize the flow of information.

Consumer Demand for Transparency

Today’s more tech-savvy consumers have grown accustomed to having information at their fingertips. Digital giants like Amazon and Google make price and quality transparency simple for just about any product or service – delivering ease of comparison across multiple retailers and products.

However, consumers remain in the dark when it comes to cost and quality information to support their healthcare decisions. Patients visit doctors, schedule surgeries, or visit urgent cares with limited-to-no visibility into quality or costs to inform decisions and plan ahead.

According to McKinsey & Company, more than 60% of patients report they want more information when deciding where to get care. Digital payers are leading the way to meet this consumer demand for greater transparency by making plan pricing and information more accessible. Through member portals, digital tools, and integration with other systems requiring information for consumers, digital payers can help the healthcare industry make a giant leap forward when it comes to increasing transparency.

Transparency across the Healthcare Ecosystem

Access to real-time health data and benefits information can improve care decisions for providers, members, and other partners. Better cost and pricing transparency can also enable providers and patients to make better financial decisions. Health plans have an opportunity to lead the way in this transparency effort by improving the exchange of information across the healthcare ecosystem.

Digital payers make data more accessible to internal team members, including care mangers, customer services teams, and external stakeholders such as providers and caregivers, through fully integrated systems that optimize the flow of information. With the right information available across the ecosystem, healthcare organizations can improve care and financial outcomes for all.

Regulation-Driven Transparency

Transparency does not just benefit health plans, members, and providers. New rules require more transparency from health plans and enforce penalties for those who do not comply. According to CMS.gov, as of July 1, 2022, group health plans and issuers of group or individual health insurance are to begin posting pricing information for covered items and services. More requirements will go into effect starting on January 1, 2023 and January 1, 2024 as part of the Transparency in Coverage rule.2

In addition, the No Surprises Act implemented on January 1, 2022 is also driving the need for greater transparency and information sharing as health plans are now required to cover some out-of-network claims and apply in-network cost-sharing if their provider directories are not kept up to date, according to Kaiser Family Foundation.

To maintain compliance, digital payers are using modern technology that can support the flexibility and digital connectivity necessary to seamlessly exchange data with those needing access. Whether is it care managers needing faster access to benefit utilization numbers or prior authorizations, or members needing insight into care networks, digital payers are able to provide transparency across the ecosystem.

Enabling Transparency with HealthEdge

HealthEdge delivers next-generation solutions for health plans to transform transparency requirements into business advantages. With best-in-class solutions that seamlessly integrate and share data across the ecosystem, HealthEdge technology delivers the digital foundation that enables digital payers to use and exchange critical data in a way that is meaningful for members, providers, and other partners. Solutions including, HealthRules® Payor and GuidingCare® leverage the power of true integration capabilities to streamline data flow across all lines of business and functional departments as well as third-party systems. With HealthEdge, payers transform into digital payers, leading the way in delivering transparency in healthcare.

Learn more about how to become a digital payer and turn transparency into your business advantage by by visiting www.healthedge.com or emailing [email protected].

1 McKinsey & Company. Consumer decision making in healthcare: The role of information transparency. July 13, 2020

2 Centers for Medicare & Medicaid Services. Transparency in Coverage

3 Kaiser Family Foundation. No Surprises Act Implementation: What to Expect in 2022. December 21, 2021

HealthEdge has identified five key attributes that drive digital payers, enabling them to rise above the competition and lead the way to better outcomes across the entire healthcare delivery system.

Digital Health Payers focus on:

1. Improving end-user and member centricity
2. Achieving higher levels of quality
3. Increasing transparency
4. Advancing customer service
5. Reducing transaction costs

In this five-part blog post series, we’re diving deeper into each attribute, delivering resources, information, and insights to enable health plans to transform into digital health payers. As we continue the conversation around what it means to be a digital payer, this discussion focuses on ever-increasing quality.

Achieving Higher Levels of Quality

While high quality care and service is top of mind for all health insurance payers, digital payers constantly strive to improve quality and do so by leveraging modern, digital platforms. For these organizations, quality is a mind-set in which every aspect of the business focuses on improving.

As traditional payers transform into digital payers, there are three key areas in which the organization should focus on improving quality that will deliver the greatest impact on the entire healthcare delivery system – communication, data, and care.

Improving Quality in Communications

Today, communication occurs through a variety of channels including portals, phone, email, telehealth, and face-to-face conversation. Without a single view of these communications, key stakeholders can easily be left in the dark, resulting in less accurate claims and reimbursements and jeopardizing optimal health outcomes for members.

To improve quality in communication, digital payers can:

• Provide access to accurate, real-time information to those who need it
• Consolidate or integration communication channels to reduce the number of touch points
• Make real-time data more accessible to care managers and customer service team members facilitating communication between stakeholders
• Leverage true integration between digital health solutions across the entire health delivery system.

The CMS National Quality Strategy includes a goal of the program to Embrace the digital age, explaining that quality can increase when organizations, “Ensure timely, secure, seamless communication and care coordination between providers, plans, payers, community organizations, and patients through interoperable, shared, and standardized digital data across the care continuum to achieve desired outcomes and provide patients direct access to their information. 

• The CMS National Quality Strategy: A Person-Centered Approach to Improving Quality

In addition to HealthEdge’s inherent capability to share real-time data across lines of business, functional departments, and third-party systems, Wellframe (HealthEdge’s digital member engagement platform) takes collaboration one step further by facilitating real-time communication and insights between care managers, customer service representatives, and members.

Improving Data Quality

Digital payers strive for excellence in making high-quality, accurate data more accessible. The result? More accurate, trustworthy data is available for better contract negotiations, more automated claims processing, and smarter business decisions.

Accurate data also improves claims accuracy, saving time and cutting costs due to less rework and fewer under/over payments. Digital health payers use technology and innovation to improve data quality through:

• Establishing a central source of truth and data standards to create and maintain quality data
• Integrating disparate systems to improve access to accurate data
• Leveraging automation to improve accuracy and eliminate manual steps in which data discrepancies could be introduced
• Implementing innovative tools to extract, use, and share valuable data across the care continuum.

Improving Care Quality

Health plans have an opportunity to positively impact care quality as a digital payer. Digital payers use technology and information to constantly improve quality of care for their members by streamlining processes, improving care coordination, and enabling better care decisions.

Digital Payers can improve care quality by:

• Connecting with members in meaningful ways, delivering information and guidance at the right time
• Improving care decisions by enabling greater access to valuable health and benefit information to care managers and providers when they need it
• Facilitating better care coordination between members, providers, caregivers, and members
• Leveraging technology to improve member engagement through mobile-friendly applications and portals.

As digital payers strive for ever-increasing quality across their organizations, they enjoy the added benefits of more informed provider networks, lower operating costs, higher efficiencies, and better outcomes for their members.

Learn more about how HealthEdge can help your health plan improve quality through digital transformation at www.healthedge.com or [email protected].

5 Attributes of a Digital Health Payer

Rising consumer expectations, growing regulatory requirements, changing payment models, and new market opportunities are causing significant disruption across the health insurance marketplace. As a result, health plans are rethinking the traditional ways they do business and turning to digital technologies to help them respond.

HealthEdge offers health plans a digital foundation on which they can transform their organizations into digital payers to meet the demands of these new market dynamics more effectively.

But what does it mean to be a digital health payer? HealthEdge has identified five key attributes that drive digital payers, enabling them to rise above the competition and lead the way to better outcomes across the healthcare delivery system.

Digital health payers turn to technology to help them:

1. Improve end-user and member centricity
2. Achieve higher levels of quality
3. Increase transparency
4. Advance customer service
5. Reduce transaction costs

In this five-part blog post series, we will dive deeper into each attribute, delivering resources, information, and insight to enable health plans to transform into digital health payers.

Let’s get started. First, we dive into the topic of improving end-user and member centricity.

Improving End-user and Member Centricity

Today’s economy is all about the experience. Whether the experience is in healthcare, retail, dining or entertainment, a heightened focus on the consumer experience is front and center for all business leaders. The evolution is being driven by consumers’ everyday experiences with digital giants like Amazon and Google. Consumers are experiencing new levels of simplicity, personalization, ease of communication, instant access to information, and seamless connectivity across every location, space, or device where they might seek to interact with the company.

Payers, providers, employers, pharmacies, and all healthcare stakeholders are taking notice and prioritizing the consumer experience. Some are even calling it the “digital front door.” But in healthcare, the member experience goes beyond protecting or generating revenue and satisfaction. It actually impacts member outcomes, which is at the core of what payers were originally created to do.

Payers have an opportunity to lead the way by putting the member at the center of their digital transformation. Now is the time for health plans to become attune to member needs and transform their interactions to improve the experience – and the outcomes for members and for their own organization’s success.

Member Challenges

Today, members navigate a hodgepodge of interactions to effectively understand, manage, and pay for their care. They research providers online and through multiple plan-provided sources, working to piecemeal information and understand which providers are in-network, deliver quality care, have availability, and are within their preferred geographic area.

When seeking care, members also struggle to get insight into pricing, coverage, and benefits, making it even more difficult to pick the right path. As a result, healthcare consumers often lack strong guidance to direct their care decisions, especially when multiple specialties or providers are involved.

After seeking care, understanding claims and payment processes becomes even more complex. Consumers often make payments through multiple channels and access points, creating frustration for the member as well as administrative burden on the health plan and provider.

Finding a Solution

To address the challenges members experience in today’s environment, it requires payers to have a sharp focus on the member, which is difficult to do when their many different, disparate systems cannot talk to each other. However, digital payers using modern systems can do this through three ways:

• Deliver resources and information to coordinate care and navigate members through the care delivery system in a way that promotes better health
• Implement technology systems that put the member first – easy to access, single point of information
• Collaborate with other stakeholders to effectively integrate systems based on real-time data in a way that makes it easy for their care managers and members to navigate.

Considerations to Becoming Member-Centric

As health plans contemplate their digital transformation journeys, leaders should address the following questions:

• What is the process members will follow to obtain information about their health, benefits, coverage, care plans, and payments? How can we make this process more seamless and intuitive?
• Across each member touch point, how is information being shared? How can we make this information more accurate, up-to-date, and available in real-time across each point of access?
• How are our processes, technology, and information improving health outcomes for consumers? What more can we do?

Get started with HealthEdge

HealthEdge enables payers to become digital payers by providing a digital foundation on which they can build a more consumer-centric approach to member and provider interactions. When digital payers implement a transformative digital strategy that puts the member and users first, everyone can more effectively navigate the complexities of the current health insurance landscape, while improving health outcomes and reducing the cost of care for everyone.

To learn more about how HealthEdge can help your organization become more end-user and member-centric, visit www.healthedge.com or email [email protected].

The growth in our country’s Medicaid population has reached an all-time high in this post-pandemic society. Years of Medicaid expansion under the Affordable Care Act and increasing job losses due to economic conditions are just two of the many factors driving up the number of Medicaid beneficiaries. According to the latest enrollment numbers from CMS, 76M+ Americans are now enrolled in Medicaid. That’s a nearly 20% increase since February 2020 before the pandemic began.

In addition to helping our country’s most vulnerable citizens, payers have the opportunity to generate positive financial outcomes for their organizations with the growing number of Medicaid beneficiaries.

However, managing a Medicaid program can be tremendously complex, and many leaders often underestimate the time, money, and labor required to have a successful program.

Source, the payment integrity solution from HealthEdge, recently conducted a study of more than 400 health plan leaders to better understand the challenges and trends they are facing when it comes to their managed Medicaid programs. The survey uncovered what many leaders have learned the hard way – running a managed Medicaid program is hard to make profitable.

Top Five Challenges Medicaid Payers Face

The research revealed some interesting statistics about how complex and manually intensive Medicaid claims management and reimbursements can be. Survey respondents reported their top challenges to be:

The manual labor required to keep fee schedules and reimbursement policies updated is at the core of the issues that can wreak havoc on the profitability of your program if you do not have a modern payment integrity system in place.

Each state Medicaid has its own fee schedules and payment policies, all of which are being constantly updated at different intervals. And these updates are published on websites and downloadable files that require someone to manually review and identify what has changed. Those changes must then be incorporated into a claims system so that claims can be processed correctly and payments can be made accurately. 91% of survey respondents state that this process is done manually. For 45% of survey respondents, they have more than 100 FTEs dedicated to Medicaid fee schedules and payment policies. Another 42% have greater than 50 FTEs dedicated to the cause.

All of these manual-intensive workflows require qualified people to run them. Unfortunately, the health insurance industry, like many other industries, is experiencing extreme workforce shortages. 89% of survey respondents stated that they were challenged to find and retain qualified resources at this time.

The combination of being so heavily dependent on human resources plus the scarcity of those resources plus the rapidly growing complexities across state Medicaid programs creates a significant threat to a payer’s ability to run a profitable and successful Medicaid program.

What happens if you don’t keep up with the changes?

• Wasted time and resources reworking claims: The survey reports that payers are too often having to rework Medicaid claims, with 44% saying “most of the time” and another 22% saying “often.” Lack of automation in the claims editing process has the potential to delay cash flow and eat away at profits.
• Inaccurate payments: When claims are either under or overpaid, payers not only have to consider the amount of effort associated with repaying or recouping the inaccurate payment, but they also must consider the negative impact these actions have on member and provider satisfaction. Getting it right the first time makes a lot more sense.
• Missed revenue opportunities: If the claims are inaccurate due to outdated fee schedules and policies, payers often miss out on revenue opportunities that are key to driving the profitability of their programs. When survey respondents were asked about the reasons they felt like they were missing out on revenue opportunities, 68% said higher administrative costs, 12% said lack of qualified resources to rework claims, and another 9% said outdated fee schedules. For a struggling program, leaving money on the table is like pouring salt in a wound.

Getting it Right. Making it Easy.

There is a better way to handle the process of keeping your fee schedules and reimbursement policies up to date. Source recently announced a new service that automates these complex, manually intensive processes. Just as Source has done for years with its Medicare offering, they are now rolling out the same service to payers running Medicaid programs.

Payers who wish to improve the profitability of their Medicaid programs and take advantage of the growth the industry is expecting to see should consider Source as a better way to manage their Medicaid offerings.

To learn more about Source’s state Medicaid program, visit www.healthedge.com/products-services/burgess-source or email [email protected].

The old saying goes, “If you’ve seen one state Medicaid program, you’ve seen one state Medicaid program.” The increasingly complex and dynamic state-by-state regulatory and payment environment across Medicaid has become nearly impossible for Medicaid-managed care plans to keep up with the pace of change and scale their Medicaid lines of business.

With varying fee schedules that get updated at different intervals and policy updates that can change on a dime, most health plans have accepted the fact that much of the work required to keep up with Medicaid has to be done manually.

In fact, in a July 2022 HealthEdge survey of more than 400 health plan leaders serving Medicaid populations, 91% reported that they depend on human resources to manually perform this work on a monthly or quarterly basis.

During normal times, keeping up with these complexities can be challenging and expensive, but also rewarding for those organizations who get it right.

However, we are not living in normal times.

The healthcare industry has been hit hardest by “the great resignation” as the survey results show that 89% of health plans are experiencing clinical and administrative shortages.

The combination of severe workforce shortages and intense reliance on manual resources to maintain accurate and timely Medicaid payment data has introduced new risks for many health plans. More specifically, survey respondents claimed their top five challenges to be:

• Staying compliant with changing reimbursement policies, 75%
• Installing updates to the fee schedule in a timely manner, 62%
• Having transparency within your system to response to audits, 54%
• Keeping up with changing fee schedules, 50%
• Too many manual processes, 33%

To date, there has been very little innovation and automation in this space due to the unique, state-specific schedules and policies. But that is changing with Source, the prospective payment integrity solution from HealthEdge.

Source dramatically improves efficiencies when it comes to Medicaid claims processing by automating the delivery of in-depth, state-specific fee schedules and payment policies across a wide range of facility and professional provider types.

The Source team has an aggressive plan to leverage their renown Medicare expertise and content development and apply it to state Medicaid programs. And they’re moving fast, already delivering schedules and policies every two weeks for many states. Their goal is to cover 35 states over the next few years. The Source solution for Medicaid programs also includes a comprehensive range of provider types such as hospital inpatient, hospital outpatient (HOPD), professional services, suppliers, home health agencies, hospice organizations, nursing facilities, dialysis centers, and ambulatory surgery centers.

To learn more about how our focus on automating state Medicaid updates can help your organization, talk to a Source specialist at www.healthedge.com/products-services/burgess-source.

The first tool to automate repricing of claims, variance reports for over and under payments and monitoring of retroactive changes.

Today, payers looking to reconcile inaccurate payments rely on laborious manual processes, multiple (and disparate) vendor solutions, and toggling between multiple interfaces—resulting in inefficiency and waste.

Source’s Retroactive Change Manager alleviates these issues by automating:

• Monitoring of retroactive changes
• Reconciliation of inaccurate claims
• Repricing of claims by payers
• Variance reports displaying all claims needing adjustment and by how much

With this tool, payers can manage pricing, editing, configuration and policy updates internally from a single API.

For all retroactive regulatory updates, the Retroactive Change Manager automatically reprices affected claims. For configuration updates, users can run ad hoc jobs and reprice affected claims.

Additionally, no other vendors currently offer flagging of under payments to providers. By addressing under payments health plans will decrease provider abrasion and become more compliant with CMS audits.

The Retroactive Change Manager is deployed within minutes and seamlessly integrates into current claim adjudication processes. Health plans can continue to reprocess and adjudicate claims using their current methods requiring no additional resources or attention from internal teams.

How is the Retroactive Change Manager different from current retroactive solutions?

1. Comprehensive Pricing and Editing Management in 1 Platform

All claim pricing and editing activities are conducted in 1 cloud-enabled platform. This allows for an optimized user experience without toggling between interfaces. It also automates content updates into a single environment, to eliminate time-consuming and costly manual updates to multiple software solutions.

2. Identification of Underpayments

For health plans, identification of under payments prevents provider abrasion and helps maintain compliance with CMS. Vendor solutions working off contingency models are disincentivized to offer underpayment flagging simply because it is not as profitable to them.

3. Automation: Requires 0 Lift from Internal Teams

The unique automation capabilities of Source conducts optimized contract management without any internal lift from health plan teams.

Why haven’t health plans leveraged automated claims variance reports before now?

Any claims automation activities built in-house require significant upfront capital, time, and resources, which leads health plans to often outsource these activities to vendor solutions. But vendor solutions have traditionally focused on the most profitable activities to them: retroactively chasing payments.

Today, however, payers are realizing the benefits of prospective payment integrity, and understand that to achieve long-term payment integrity goals, they must invest in cloud-enabled, single-API solutions that enable productivity and provide complex business insights.

Payers are demanding more from their vendor solutions—and rightfully so. Equipping payers with the tools they need to improve provider relationships and member experience begins with delivering authentic transparency into the inner workings of claims IT ecosystem.

Will this technology cause current IT systems to run slower?

Source ensures health plan IT systems will continue to operate as efficiently as before.

Repricing happens off internal production servers.

Activities are also strategically scheduled for when IT systems have greater bandwidth.

In addition, health plans can customize how often reports are run, permitting scheduled and ad hoc reporting.

How long will implementation take?

For current Source clients, full implementation takes under an hour and requires no effort from your internal teams.

When will this tool be available?

The Retroactive Change Manager will be available in Q4 2022.