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Interoperability may be one of the most over-used words in healthcare. Everyone has their own definition of the term, and everyone says they do it. But when it comes to the role interoperability plays in care management, it’s important for health plans to understand the difference between a system that says they support interoperability and one that can prove it.

The Definition of Interoperability

The most basic definition of interoperability was recently updated by HIMSS, and it reads, “Interoperability is the ability of different information systems, devices and applications (systems) to access, exchange, integrate, and cooperatively use data in a coordinated manner, within and across organizational, regional, and national boundaries, to provide timely and seamless portability of information and optimize the health of individuals and populations globally.”

But what does it really mean to your organization and how can an interoperable care management platform help you better meet the care needs of your members and the cost effectiveness of your care plans?

Well, it all comes down to being able to access and use important clinical and care plan data across your enterprise, including third-party systems that support your core care management system.

When done right, true care management interoperability means care managers can get access to up-to-the-minute claims data, clinical guidelines, benefit information, and more to help them have more focused conversations with members and construct care plans that can address an individual member’s healthcare needs more directly. It also means claims administration and payment processing teams can access real-time clinical data, which helps them improve the accuracy of the claim, develop more effective benefit packages, and enable better relationships with providers and members.

The Benefits of an Interoperable Care Management System

For health plans using modern systems, like GuidingCare®, the benefits of being able to seamlessly exchange information can be substantial, including:

• Access to more actionable data that can give better insights for smarter business decisions about member populations, market expansion, and cost containment.
• Freedom from having to use one care management system to do everything because the data is locked inside that one system. Data is free to flow between applications, vendors, lines of business, functional areas of the business, and even care settings.
• Care managers can make more informed decisions about their member populations, which results in better patient outcomes and lower utilization management costs.

How do you Know if Your Care System is Truly Interoperable?

It’s not just what vendors say, it’s all about what they are doing today. If you have a highly interoperable care management system, the following real-world scenarios are highly possible. These are scenarios that current GuidingCare customers have reported to HealthEdge:

• Claims data from multiple core administration systems inform care managers when putting together the proper care plan for a member in GuidingCare. Indicators such as repeat provider visits, lack of medication adherence, and missed encounters can be seen directly in the care management interface, enabling care managers to easily create the most effective care plans.
• Care managers get a 360-degree view of members enabled by HealthRules® Payor and GuidingCare working together to capture and present a more complete view of the member’s most recent history. This eliminates what would otherwise be the manual process of searching through claims data to piece together the pertinent longitudinal view of the patient’s history.
• Nurses eliminate manual data entry in GuidingCare because member-specific information automatically populates the system data and insights, such as prior authorizations, from HealthRules Payor.

Interoperability is important across virtually all systems that health plans depend on, but it is particularly important in care management since there are literally hundreds of applications health plans can use to optimize member outcomes and reduce costs. That’s why GuidingCare takes a multi-faceted approach to interoperability that includes an integration and API Suite as well as productized integrations with other vendors in its broad partner ecosystem.

To learn more about GuidingCare’s interoperability strategy, download our recent white paper, Transforming Healthcare: The Role of Open and Flexible Care Management Systems.

The one with the best data typically wins, right? We’ve seen it happen time and time again in our personal lives and in other industries.

If you are a parent of a teenager, you know that the data you’ve collected over the years of being an adult typically makes you a more informed decision maker than your teenager.

And just think about the amount of personal data Facebook has on its users or the amount of professional data LinkedIn can access about its users. The more data these social media platforms have about you, the more successful their advertisers will be, which ultimately results in more ad dollars being spent on the most effective platforms. The greater the data, the greater the success.

This same concept holds true in the healthcare industry. Those who are able to embrace the massive amount of healthcare data being generated by the digitization of healthcare are the ones who are most likely to succeed. Health plans that can use their data to automate more businesses processes, build better experiences for providers and members, and make smarter business decisions are the ones with the competitive advantage.

Data is Everywhere

All different types of healthcare data are funneled into payers from everywhere and at all different intervals. This includes everything from a member’s Apple watch to remote patient monitoring devices, claims administration systems, and even unstructured provider clinical notes. But how can health plans leverage this data to create competitive advantages and thrive in the new age of digital healthcare?

The secret is in the IT systems they choose. Building a solid foundation of workflows and business processes based on accurate, timely, and complete data that is centralized and managed efficiently is at the core of successful health plans. Let’s take a look at what good data can do.

For example, with a modern claims payment processing system like Source, health plans can:

• Adjudicate more claims correctly on the first try: By leveraging claims edit data to identify and resolve issues earlier in the adjudication process, fewer claims require rework and more claims get processed correctly on the first pass. This translates into lower transaction costs and higher margins.
• Automate more of the claims payment processes with new workflows, such as prior authorizations, because they trust that the data is accurate and is going to drive smarter processes that require fewer manual touches. This translates to lower risk of human error and helps reduce the burdens brought on by workforce shortages.
• Enable a better provider and member experience. When fewer over-/under-payments are made due to more accurate data, providers begin to trust these payers and can work more collaboratively to facilitate a better member experience. This translates to stronger provider relationships and higher member loyalty.
• Make better business decisions. With accurate and complete data, health plan administrators are in a better position to make more informed decisions. Modern systems, like Source, offer analytics and modeling capabilities that make what-if scenarios possible. Whether it is contract negotiations or adapting to new value-based care payment models, good data makes the difference between well-informed decisions vs. shots in the dark. This translates into better decisions that facilitate smart growth.

Accurate, timely, and comprehensive data can not only help you lower operating costs, but it can also give you insights that can be used to create distance between you and your competitors. And in today’s highly dynamic, rapidly evolving health insurance market, that distance is a welcome sight for many health plans.

Better data

To learn more about how to use your data to create a competitive advantage, check out our latest white paper and see 314 Billion Reasons Why Better Data Wins.

Health plans are constantly looking for new ways to reduce operational costs and improve efficiencies, but many of the issues that have plagued health plans for decades come down to one thing: the inability to get accurate, dependable, and transparent data.

Why is that? When it comes to healthcare data – it is everywhere, and it comes in many different forms, such as claims data, clinical content, edits, pricers, contracts, audits, and more unstructured data. Medicare is constantly evolving its policies, but the pace of change has dramatically increased in the past few years as government programs move toward value-based care payment models. Each managed care organization running state Medicaid programs has its own set of rules, waiver programs, and special pricing, as states attempt to meet the needs of their most vulnerable populations and the demands of the growing number of lives it must cover. And every entity updates its data set, pricing, and regulations at different intervals.

To further compound the problem, many health plans remain tethered to their legacy systems with no centralized way to make sense of the multitude of different data sources and formats; the human resources required to keep track of all these moving parts drag at profitability and stifles innovation.

To remain competitive, health plans need a modernized, comprehensive solution that can easily integrate with their entire ecosystem to orchestrate accurate data into every process and decision.

Now more than ever, payers need to make data accuracy a top priority. The trickle-down effect can be huge. Let’s take a look at the true cost of bad data:

1. Extreme inefficiencies: Inaccuracies due to disjointed data processes result in time wasted on rework and over-/under-payment recovery efforts. The cost to support these efforts is substantial.

2. Inability to adapt: More than ever, the continuously evolving healthcare landscape requires agile health plans. Lack of data transparency slows down health plans and prevents rapid responses to market conditions, like rising consumer expectations, ongoing legislative fluctuations, and new competitive entrants.

3. Provider burnout: A health plan’s legacy technology environment leads to poor processes, inaccuracies, and lack of transparency for providers to see and understand contracts. These gaps lead to administrative hardships and contribute to provider burnout.

4. Uniformed business decisions: Without complete data transparency, health plans may not fully understand the fiscal impact of an industry shift, such as a new CMS policy. This can lead to ill-informed decisions or even the inability to make decisions about reimbursement rates.

What Happens When We Get It Right?

While some vendor solutions claim to address these fundamental issues, their solutions are built on a legacy foundation, often designed for on-premise installations with additional, gap-filling solutions bolted on over the years through mergers and acquisitions. This perpetuates the current state of multiple instances with multiple update cycles and multiple data calls to claims systems.

However, some leading health plans are beginning to understand the value of addressing the root cause of data issues and favoring solutions designed to enable them to use their data as a strategic asset.

These solutions are designed specifically to empower payers by delivering:

• Cloud-supported infrastructure and single API
• Single update cycle
• Single call and single source for fee schedules and payment policies
• Single instance to connect with all claims systems
• Ability to automatically connect with third-party content within the same UI

Source is one such solution that challenges the status quo, giving payers more control over their payment integrity operations and greater transparency into their own data to orchestrate business decisions in ways that make sense to their unique challenges and operations.

If you are interested in learning how Source can help your organization reduce operational costs and improve efficiencies through better data, visit us at www.healthedge.com or email [email protected].

Better Data 

Check out our latest white paper and see 314 Billion Reasons Why Better Data Wins.

Background

Many health plan customers have historical workflows that rely on batch processes – file a claim on Day 1 and the results are available on Day 2 (or 3 or 4). Because of limitations with compute, storage, and network performance years ago, the idea of processing a piece of information in milliseconds was unheard of, primarily since it was not technically feasible to do it in a cost-efficient manner. However, in 2022, real-time, scalable, and global systems are commonplace.

Innovative companies across industries have taken advantage of these disruptive trends to deliver seamless, digital experiences that we take for granted today -– when we buy with 1-Click on Amazon or watch our Uber driver inch his or her way along the map on the way to pick us up. These become the baseline expectation. If you are the consumer of health insurance, you also expect to participate in these experiences. If you are the provider of that health insurance, you are expected to deliver this experience.

Real Time APIs (for Business Outcomes)

HealthRules Payor (and all HealthEdge products) are designed with real-time APIs. It is one of the reasons why Payor continues to be a Gartner Next-Gen solution for the Core Admin Processing Systems market. This is now table stakes for participating in this market and the baseline of our customers, who are modernizing for the coming decade.

Real-time APIs are the product that close the gap between various cloud-based health systems (CAPS, EHR, Pop Health, Portals, Mobile) and enable new experiences for members, providers, and users of these systems. Today, customers leverage the rich suite of real-time APIs to power member portals, send out correspondence, or determine member costs before they go to the hospital for a procedure. For example, HealthRules Payor real-time Trial Claim API allows for health plans to meet the government mandate for member specific pricing and cost sharing through the price comparison tools, as well as the AEOBs (Advanced Explanation of Benefits)

Real Time Events (for Business Outcomes)

The next stage of evolution for HealthRules Payor’s (HRP) integration capabilities is real-time event streaming, which is sometimes called stream processing. It sounds technical – but is conceptually easy to understand – and it solves some of the challenges that current businesses require to be even more responsive to customers. Created by LinkedIn over a decade ago and managed, now, as open source by Apache, Kafka is a technology used by most Fortune 100 companies to help with business events that occur thousands, millions, or billions of times per day (e.g., data from IoT (Internet of Things) device, a new member enrollment, LinkedIn message posts).

To achieve this, Kafka uses what is called a publish-subscribe messaging architecture. At the core of Kafka (and event streaming in general) is the concept of an “event” – i.e., something happened. It could be that a member got enrolled, a claim has been paid, or a heartbeat on a heart rate monitor exceeded a threshold. These events in small quantities or millions are “published” by applications (also called “producers”) and are “subscribed” to by downstream applications that need this information (also called “consumers”). And these events can be organized into logical “topics”. So, events related to enrollment go in one stream and events related to billing, perhaps, another. If each published event were a 3×5 card with information, those events are placed on to one of many user-defined conveyor belts in time order with each conveyor belt reflecting that different topic.

As a concrete example, an event could be a new member has enrolled for health coverage. As the source application, HRP “publishes” this event to the “Membership” topic. Any downstream application such as a correspondence solution for member ID cards or a member portal can “subscribe” to this topic. A depiction of this architecture is given below. If you want the fun, non-technical, children’s storybook illustration of how this works, please check this link out. It’s very well done.

Source: https://www.slideshare.net/KaiWaehner/the-rise-of-event-streaming-why-apache-kafka-changes-everything

HealthEdge’s objective with creating a Kafka-based event streaming architecture is to help our customers achieve digital transformation by democratizing the data in the HealthRules ecosystem, allowing them to leverage the power of “real-time” healthcare data to build modern, digital, world class experiences for their members.

Unique Capabilities and Use Cases

Because health plans are an ecosystem of integrated solutions with a CAPS at the core, there are some distinct advantages of this real-time messaging system that are especially relevant for payers:

Fault Tolerance – Because event producers and consumers are effectively de-coupled through this event streaming service, HRP can continue to publish events even if consumers are not online and vice versa. The events are backed up and consumed when the consumers come back online.

Performance – Kafka is extremely low latency (fast) and scales (powerful) to support millions or billions of events without impacting the core performance of HRP. Customers can continue to add events and topics with any number of consumers downstream and not impact HRP’s performance.

Highly Configurable – Instead of each additional use case for real-time data from HRP (and other HealthEdge products) needing an integration project or custom APIs, customers can use (and re-use) the same topics and published events across various consumers and configure these streams through a web UI.

Healthcare payors can configure and consume different data streams for a wide variety of use cases … use cases that we’re familiar and newer ones afforded by the performance and reliability:

Connecting with enterprise apps or other internal systems – Payors can use these data streams to connect to customer/provider service apps (enabling real-time response to customer and provider issues) or CRM (Customer Relationship Management) systems like Salesforce or to power new-age apps like chatbots.

Power their own AI/ML algorithms – The scale and reliability of these data streams enable payors to use them to power their custom ML models for complex use cases like fraud detection.

Analytics or dashboards – Customers with their own centralized analytics and dashboard capabilities can use the data streaming through topics to power these dashboards in real-time with claims, member and other HRP data.

A Step Ahead

Real-time experiences for members and providers are both here today, but also growing in sophistication and complexity to push the art-of-the-possible. HealthEdge is committed to keeping our customers a step ahead in delivering these experiences through evolving technologies applied to business outcomes.

Learn more about HealthRules Payor here.

Over the last 3 years, I’ve helped new HealthEdge clients implement our software. During that time, I’ve learned countless tips and tricks to improve the implementation experience.

There’s the technical software implementation, but today we’ll be looking at the people side of implementation. The team members who will be sunsetting the old software, implementing the new software, and linking it into the ecosystem.

These are my top 3 tips for a smoother software implementation:

1. Create a shared vision of the future

Even with the best possible outcome – change is hard. The people on your team are grappling with all the balls they’re currently juggling plus trying to learn this new system and get it plugged into your ecosystem. It’s natural to resist change and cling to the status quo.

The key is to create a vision of the future that’s so exciting and engaging your team can’t help but get pulled into the possibility of this amazing future state. Make the vision so compelling your team can’t help but be intrigued by the new software – even with the imminent growing pains.

For example, a health plan that implemented our product Source, achieved an amazing ROI after implementation:

• Decrease of 800,000 erroneous claims per year for an estimated savings of $4M/year
• Automated claims process saving approximately $6-12 per claim
• Reduced IT overhead, saving $350-500K annually

By getting your team excited about the possibilities and demonstrating how amazing the future can be AFTER the change, you get them engaged at the onset of the implementation.

2. Begin with the end in mind: workflow & operating procedures

It’s so easy to take a new piece of software and try to adapt it to the old way of doing things. This leads to recreating old systems, riddled with workarounds, and partial functionality. It’s a surefire way to get your team feeling frustrated and disappointed with the new software.

One of the things we focus on in HealthEdge’s Education Services is analyzing business scenarios. And then, we optimize workflow and operating procedures for those scenarios.

Encourage blank space, white board thinking – how can we leverage this innovative technology to optimize and enhance our way of work?

3. Customize training and onboarding

Each of our customers has a different business need for their implementation, and their team members have different roles and responsibilities. Custom instruction that is tailored to your needs is vital to engaging your team because each person who will be interacting with the new software wants to know, What’s in it for me? What do I need to know to be able to do my job well in this new environment? We don’t want to bore experienced analysts or overwhelm team members with less experience.

Unsurprisingly, the confidence gap is a huge barrier to software acceptance. Providing customized training and onboarding helps employees feel confident using the new software. There’s a direct correlation between new software training and new software optimization and acceptance.

HealthEdge Education Services

HealthEdge has a team dedicated to education and implementation success. I’m proud to be a part of our Education Services and help our new customers successfully implement our suite of products. Learn more about our Implementation Services here.

To remain competitive in today’s rapidly changing healthcare market, health plans need a modern solution that can easily integrate across their enterprise to infuse more accurate and timely data into every corner of their organization. There is no better place to expose the implications of bad data than claims payment administration process. This article drills deep into the importance of having consistent, accurate, and transparent data.

The Current State of Data Among Health Plans

Health plan leaders must challenge the inefficient status quo that comes with legacy claims processing systems and invest in modern technology that enables data consistency, accuracy, and transparency, which will result in greater operational efficiencies and more informed business decisions.

Today, bad data is estimated to cost the healthcare industry $314B annually and negatively impact an organization’s revenue by 10-25%. The case for more accurate data has never been stronger, given the rapidly changing dynamics of the Medicaid system and the reality of the waste:

• 5.8% expected annual Medicaid enrollment growth
• 9.5% claims payment error rate
• $25B approximate annual MCO Medicaid spend on admissions functions
• $36B improper Medicaid payments in 2019

Good Data Means Good Business

The implications of having good data flowing into and out of your organization’s systems has implications across the entire business. In particular, the claims payment processing team depends on good data for its daily functions, such as claims edits, audits, pricers, analytics, and even contract terms and negotiations.

In addition to the efficiency gains, good data also drives more informed decisions, because data is the foundation on which business assumptions and decisions are made. Provider relationships improve due to the reduction in payment recovery activities. Plus, when it comes time to respond to a CMS audit, having good data means the difference between dedicating valuable resources for days on end vs. having a few resources respond quickly and confidently to address the requests.

When good data is driving the business, health plans are able to:

• Lower operating costs: Payers reduce FTE time dedicated to overpayment recovery and redirect the resources to more productive analysis.
• Decrease operating risks: Automating claims processing reduces the chance for human error that can occur when using spreadsheets or manually updating data when using disparate systems.
• Improve provider relationships: Increased transparency and fewer overpayment recoveries will help ease provider abrasion, and the partners will recognize clerical time reduction in deadline with payment issues.

A Fresh Approach to Good Data

To achieve long-term goals of consistent, accurate, and transparent payments, successful organizations have focused on:

• SaaS technologies
• Integrated ecosystems
• Centralized data

As a SaaS-based solution, Source is empowering healthcare payers who have Medicare, Medicaid, and commercial lines of business to leverage a single, unified platform that natively brings together up-to-date regulatory data, claims pricing and editing, and real-time analytics tools. These payers have a single source of truth and a single point of accountability.

More specifically, Source’s transformational approach to payment integrity allows payers to deliver accurate, defensible payments to providers in a single pass with precise audit trails and business intelligence tools that help payers model and forecast scenarios with total confidence.

But it doesn’t stop there. Source works seamlessly with a wide range of data and solution providers, including its sister solutions: HealthRules® Payer core administration system and GuidingCare® care management solution, to leverage the power of more accurate data.

The Business Case for Good Data

When evaluating the return on an investment of a recent Source-powered health plan, the results are undeniable:

Financial Impact:

• Decrease of 800,000 erroneous claims per year for an estimated savings of $4M/year
• Automated claims process saves approximately $6-12 per claim
• Reduced IT overhead, saving $350-500K annually

Customer Service Impact:

• Higher regulatory compliance and consistency
• CMS audit support
• Increased transparency on payment results
• Actionable data for improved business intelligence

Learn more about good data

Check out our latest white paper that discusses the complexities of healthcare data and how bad data can lead to inaccuracies and waste. Using technology solutions to address this issue, payers can harness data as a strategic asset and create positive change across their organization and for providers and members. Read now.

Sources:

1 https://www.cms.gov/newsroom/press-releases/cms-office-actuary-releases-2017-2026-projections-national-health-expenditures

2 National Health Expenditure projections, 2017-26: Despite Uncertainty, Fundamentals Primarily Drive Spending Growth; Centers for Medicare & Medicaid Services, Office of Actuary, National Health Statistics Group

3 https://www.forbes.com/sites/adamandrzejewski/2019/03/23/federal-agencies-admit-to-1-2-trillion-in-improper-payments-since-2004/?sh=64484646352a

4 https://www.forbes.com/sites/adamandrzejewski/2019/03/23/federal-agencies-admit-to-1-2-trillion-in-improper-payments-since-2004/?sh=64484646352a