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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 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.

States are about to get help for mental healthcare and substance use treatment because of the Bipartisan Safer Communities Act signed by the President in June. Some of this will flow through Medicaid programs, specifically the Medicaid Certified Community Behavioral Health Clinics (CCBHCs) nationwide created in 2014.

The Act also supports:

• Increased telehealth flexibility
• Pediatric mental healthcare and training for pediatricians
• One-time funding ($150 million) for the existing Suicide and Crisis Lifeline or 988 crisis number, similar to the 911 system. (States have a preexisting July 16 deadline to have these up and running.)
• School-based mental health services, crisis intervention and violence prevention, and mental health worker training

While mental health advocates are pleased by the new support, there are caveats.

• Experts agree the mental health and substance use disorder impact of the pandemic has been significant and is still being felt. Future needs are expected to be long-lasting. Some predict the impact to last a generation.
• A lack of psychiatric beds continues to be an issue. While crisis stabilization can reduce harm and identify resources, inpatient care is hard to come by in most states, resulting in emergency-room boarding and a revolving door through the justice system for the seriously mentally ill, who are often overlooked in mental health programs.
• Provider shortages continue to be a concern, although telehealth flexibilities may help mitigate them in the short term.
• Equity continues to be an issue throughout the system and mental health is no exception.

Sensing the opportunity in addressing mental health, private investors had poured $3.1 billion into mental health ventures by the third quarter of 2021 – a third of all digital health funding for that year. Technology isn’t likely to replace the human touch, but innovation and technology can certainly have a role in improving access.

Anticipating inflationary pressures around healthcare costs, the IRS has spiked limits for 2023 on Health Savings Accounts (HSA) by 5.5 percent, much higher than the previous year’s rise of just 1.4 percent. These figures were released in April so payers can get the jump on rate-setting and employers can begin to plan their open enrollment periods.

The new calculations are:

• Self-only HSA contribution limits – $3,850, up from $3,650 in 2022
• Family HSA contribution limits – $7,750 up from $7,300 in 2022

The 2023 limits are intended to encourage employers during open enrollment to ease employees into HSAs and to boost employee dollar contributions. Employers are reportedly more interested in financing HSAs than before, especially for lower-paid employees.

More broadly, some of the cost drivers and variables for 2023 include the “table stakes” that employers add or expand mental health coverage to their offerings. Pandemic-related costs for treatment and testing are flattening, but there’s no predicting whether other COVID variants will emerge or whether a fall spike will occur as in previous years. Intuitively, it might seem that provider costs would rise across the board, but many are locked into multi-year arrangements and thus provider inflation trends usually lag the rest of the economy. For the segment of the provider/payer market up for contract renewal, negotiations are expected to be fierce – a major healthcare publication used the word “bloody” to describe the battles ahead.

Other uncertainties hang over the payer ecosystem, especially for possible Medicaid disenrollment and the potential end of pandemic-related subsidies for Affordable Care Act premiums. These effects of these shifts in the risk pool are hard to pinpoint but can draw employer-sponsored plans into inflationary patterns. Some states are requesting that payers submit rate approvals in two sets – one for the scenario in which Congress extends ACA subsidies set to expire at year-end and one in which it does not.

Other variables being mentioned by experts for 2023 are utilization patterns and cost-impacts or savings from telehealth, tweaks to the ACA “family glitch” and movement among small employers to self-funded or level-funded plans.

Employers should be looking now at their health plan options in anticipation of open enrollment this fall Their calculus is a difficult one, just as it is for payers.

Interoperability Challenges and Recommendations 

Introduction

The U.S. Department of Health and Human Services (HHS) aims to have an interoperable health IT ecosystem by 2024.

This ecosystem would make the right data available to the right people at the right time across products and organizations.

Centers for Medicare & Medicaid Services (CMS) has been regulating data exchange schematic and syntax standards using 1500, 1450 Forms, HIPAA 5010 X12 EDI Messages, and NCPDP D.0 Messages.

Clearing houses, infomediaries and plan portals require connectivity across disparate systems and organizations to exchange data.

Leveraging an interoperable health IT system, patient data would be shared seamlessly among authorized practitioners and individuals. This would help all parties make more informed decisions, improving the healthcare quality and lowering costs.

Not all types of healthcare data exchanges are as in dire need of improvement. Today, revenue cycle management (RCM) data can be shared seamlessly. It has well defined standards and connections for information exchange and interpretation across ecosystems. Overall, RCM data exchange between providers, health plans, consumers and other organizations is robust and mature.

This is especially true when compared with problematic clinical data exchanges between all authorized practitioners, consumers, and health plans. With clinical data, providers face unique challenges exchanging information outside their health system.

Obtaining this data from settings outside a network requires complex data-sharing agreements and new interfaces between systems.

According to The Office of the National Coordinator for Health Information Technology (ONC)’s 2014 data brief, less than half of providers can access clinical information from outside of their systems. The brief also states that approximately 4 in 10 hospitals can access necessary clinical information from outside providers or healthcare sources.

Providers are well-aware of these challenges in sharing clinical data. According to a recent survey by a group purchasing organization (GPO), Accountable Care Organizations (ACOs) report that lack of interoperability between their HIT systems and outside providers is their biggest challenge.

Read on to explore universal challenges with clinical data exchanges and steps healthcare leaders can take today to address these challenges.

Interoperability Challenges:

·      Lack of Universal Adoption of Standards-Based EHR Systems:

With Meaningful Use Incentives, the exchange of data between lab, pharmacy and radiology center is digitized. However, Electronic Health Record HER-to-EHR communication has yet to digitize in the same way.

The only integration between EHRs today is the

exchange of summary of care documents. This exchange is not widely adopted by EHR systems.

In addition to limited adoption, summary of care documents are hard to read and include irrelevant information. This makes necessary data difficult to find for physicians.

For EHRs, data definitions and coding standards are inconsistent across providers as well. For example, for disease definition some providers use SNOWMED codes and some use the ICD Codes. As well, each EHR system has unique software types and APIs. Therefore, when data is exchanged between providers, interpreting such data and saving it in the other provider system’s patient medical record is near impossible.

These inconsistencies require custom integration and additional development for every single exchange type.  For example, custom integrations must be made for each EHR system’s supported Health Level Seven (HL7) version.

·      Prohibitively High Data Exchange Fees: 

Implementing interoperability is costly. Each integration requires upfront capital. Some EHR vendors may claim to have the capability to send and receive patient information from other systems, but this always comes at an additional cost of $5,000 to $50,000.

·      Outdated Legacy Standalone Systems:  

Legacy systems have poor interoperability. Establishing connectivity of legacy systems to middleware creates structural misalignment within existing data layers. Remediating these structural misalignments while also establishing connectively is extremely costly.

·      Impact on Providers’ Day-to-Day Workflow:  

New technologies impact existing workflows. This is especially true for industries like healthcare with highly complex workflows. Many providers are currently operating at maximum capacity. There is no reasonable bandwidth to add additional requirements of learning new workflows or record keeping.

·      Complex & Misunderstood Privacy & Security Policies:

Privacy and security policies present a major barrier to implementing interoperable systems. In order to exchange information, EHRs must integrate varying state specific privacy and security laws.

In addition to state laws differing vastly, federal laws are also poorly understood by providers. For example, HIPAA policies and certain privacy laws addressing paper-based documents are not universally agreed upon. The differing understanding of these laws impedes streamlined data exchanges between stakeholders.

·      Lack of Incentives to Develop Interoperability: 

A key inhibitor for streamlined health information exchange is economic incentives like traditional fee-for-service payment models. These fail to encourage hospitals or health information technology (HIT) vendors to prioritize interoperability. As a result, her developers have largely ignored interoperability. They have instead opted to focused on other capabilities like improving documentation for billing purposes.

·      Standards Not Adequate to Deliver Relevant Data: 

Lack of interoperability hinders comprehensive data on your patients’ health. Currently practitioner notes do not have to be written in a shareable format to share with other providers. Without a clear understanding from all specialists and health systems serving your patient, you cannot offer the most accurate diagnoses and ideal treatment options.  

Recommendations

·      Payment Incentives for Adapting Interoperability: 

High-value interoperability measures targeting both providers and vendors will help streamline data exchanges. New payer payment models and CMS’s introduction of Valued Based Reimbursements can realign incentives to prioritize interoperability for all stakeholders. In addition to rewarding high quality of care, information blocking activities should be penalized. Overall, to create an interoperable healthcare ecosystem there must be clear and specific incentives, defined measures and an actionable timeline with deadlines.

·      Interoperability Standards Definition:

The US federal government is the largest healthcare insurance payer (CMS’s Medicare & Medicaid) and provider (DoD, VA, IHS, etc.). These organizations will have a large impact on shaping the future of nationwide health information exchanges. Federal agencies have strongly supported HL7, Consolidated Clinical Document Architecture (C-CDA) and Fast Healthcare Interoperability Resources (FHIR) through Meaningful Use (MU) incentives. However, these agencies have not achieved interoperability due to lack of a defined structure and process. Without this clear structure, there is no way to drive development, adoption, and self-regulation of industry-wide standards.

In private sector dominated industries like banking, firms come together to provide necessary standards for interoperability. The US federal government should study these standards from the private sector and implement them within the healthcare ecosystem. Health systems and HIT vendors should ally with the government to support these adoption efforts to achieve interoperability.

·      Enterprise Master Patient Index: 

To enable data exchange across the continuum of care, patient identity must be reconciled accurately across organizations. Currently these patient-confirming capabilities are inferior to those delivered by an embedded Enterprise Master Patient Index (EMPI).

The core function of this technology-agnostic index is to aggregate data, including identity data, between applications regardless of data type or format. They usually employ a probabilistic matching engine. This engine leverages statistics and data analytics to pinpoint variation and establish more accurate forecasting. system can be problematic depending on the environment’s size and complexity. It is well suited for complex organizations with numerous disparate systems and databases.

·      Connecting Private Electronic Health Information Exchanges (HIEs): 

Black Book Research in April 2016 reported growing HIE user frustration over lack of standardization and preparation of providers and payers.

Today HIE’s pose additional challenges for data exchange. These challenges include added costs and resources to achieve interoperability goals, as well as needed governance and trust among entities to facilitate sharing health information.

To address this, healthcare vendors are turning to middleware solutions employed by other industries like retail, banking, and transportation. Middleware platforms facilitate transparent, yet secure access of patient health data. They do so by translating information directly from disparate systems including EHRs and HIEs. They create a business intelligence layer providing data to all stakeholders in real-time.

·      HIT Alliances Collaboration:  

The Sequoia Project and the CommonWell Health Alliance are advocating for a nationwide health data exchange and interoperability.

Sequoia supports Carequality, a public-private collaboration developing common interoperability frameworks for data exchange.

CommonWell launched in 2013 and has grown to 40 HIT organizations. CommonWell supports secure access to and exchange of health data nationwide. Its members are committed to implementation of initiatives person enrollment, record location, patient identification, linking, data query and retrieval.

Alliances like CommonWell and Sequoia should further collaborate amongst themselves to implement a common interoperability standard across various healthcare sectors.

·      Regulations to Drive Necessary Clinical Data Exchange:

Regulatory mandates don’t enforce exchange of non-standard data like notes between health systems.

As well, the adaption of FHIR, that supports non-standard clinical data, is largely limited to influence CMS’s interoperability rule.

CMS’s interoperability rule should be expanded to mandate the exchange of needed non-standard clinical data between the health systems.  The regulation should also focus on building trust across health systems to improve data exchanges.

Benefits of Interoperability:

·      A unified standard implementation enables all disparate systems to interpret data accurately.

·      Middleware enables secure exchange of data across various source systems

·      An interoperable EMPI helps identify and locate the right patient record

To achieve healthcare interoperability, synchronous collective action is needed among multiple stakeholders. It also requires consensus among all healthcare participants on an actionable roadmap, timeline, and standards for interoperability.

Interoperability Implementation at Your Health Plan

Although it takes an entire healthcare ecosystem to establish nation-wide interoperability, there are some action items your health plan can implement today to create a more interoperable environment within your company and patient and provider networks.

The most effective way to streamline interoperability is to partner with a healthcare SaaS professional, like Source, to incorporate information exchanges within a single API. To get started book a demo for your team today.