Transforming Health Plan Operations with BpaaS

BPaaS health plans | healthedge
Business competition concept, red arrow leading the race

An Intro to Business Process as a Service (BpaaS)

BpaaS is the delivery of business process outsourcing (BPO) services as a cloud-based subscription service. Health plans can leverage BpaaS to enhance and optimize internal operations, such as claims administration, eligibility, and other people/time-heavy back office operations – while still retaining control of their business.

What’s new in the BpaaS space

One of the biggest changes we’re seeing in the BpaaS space is the number of new players cropping up in the game. Previously, this was something more of a Third Party Administrator (TPA) niche, where a TPA hosted other health plans, typically Administrative Services Only (ASO) contracts where profit margins are razor thin and enrollment/benefit configuration complexities are high. Currently, as BpaaS is scaling upwards into a more mainstream concept, business process as a service is becoming a real differentiator being used to focus on reducing operational administrative costs and reducing Health Plans PMPM costs.

Another interesting trend is how BpaaS is fueling one of the biggest growth sectors – regional plans. In today’s market, Health plans that are looking to buy and implement new core systems are becoming less common – when issuing their core modernization strategy via a Request For Proposal (RFP) it is more common to see business process administration included in the scope of the proposal needs. I wrote a blog last year entitled David vs Goliath on this strategy that smaller Regional Health Plans are using to remain competitive in the current landscape where larger entities are growing through acquisition of smaller companies.  A great success story that underscores this is Friday Health, for example, who moved to a BpaaS partner UST HealthProof and have been able to grow their business exponentially. BpaaS partners are empowering regional plans to compete in the market.

Top 5 Benefits of BpaaS for regional plans

BpaaS empowers health plans with these top benefits:

1.       Modern technology/better systems

2.       Lower costs – including reducing PMPM costs

3.       Decreased human capital/operational costs

4.       Increased ability to compete in the market

5.    Allows the Health Plan to focus on enterprise strategy

A Growth Story: Friday Health

Friday Health Plans was founded in Denver, CO in 2015 to serve gig workers, small business owners, and creatives – individuals seeking health insurance through the marketplace. By 2018, Friday Health had 13,000 members.

Growth alone through adding new members wasn’t enough – Friday Health knew they needed to also minimize their operational costs as much as possible and streamline their claims processing.

To do so, Friday Health Plans partnered with BpaaS provider UST – who rapidly implemented the modern core admin platform solutions (CAPS) that included HealthRules Payor and GuidingCare.

Partnering with UST enabled Friday Health Plans to increase efficiency and decrease operational costs – which ultimately fueled their sustainable growth. By 2020, Friday Health had increased its membership base 500% – from 13,000 members in Colorado in 2018 to 85,000 members in 2020 in Nevada, New Mexico, and Texas.

Read the full story here.

HealthEdge & BpaaS

Are you a regional Health Plan looking to take advantage of reduced administration/IT costs and want to quickly adopt modern technology augmenting ecosystem components to create a best of breed solution?  

Check out my other blogs on this topic and reach out to HealthEdge for more information about our BpaaS partners, or to become a BpaaS partner and start hosting health plans in the largest growing market in the industry today.

Business Process as a Service, Redefining the Health Plan Operations Model

David And Goliath: Smaller Health Plans can remain competitive with the right technology

Impacts of COVID-19 on Care Management in the Dual-Eligible Population

COVID-19 has highlighted weaknesses in our healthcare system and shone a spotlight on fault lines, especially for the most clinically and socially vulnerable like the dual-eligible special needs populations (D-SNPs). Those who are dually eligible for Medicare and Medicaid are amongst the sickest and most clinically complex with more than half of this population having significant medical, behavioral health, and long-term care needs. These health issues along with social risk factors like poverty, food insecurity, housing instability, and lack of transportation have been disproportionately magnified for this cohort during the pandemic.

Some of the most challenging aspects of healthcare including gaps in care, a highly fragmented system, and lack of coordination between Medicare and Medicaid have worsened as a result of COVID-19. According to the Center for Health Care Strategies, data examined across every demographic category finds that dually eligible individuals are more likely to contract or be hospitalized for COVID-19 than Medicare-only beneficiaries. In the dually eligible beneficiary cohort, hospitalizations with COVID-19 related complications were tracked at a rate more than four times higher than Medicare-only beneficiaries according to the data.

For those health plans serving D-SNP programs, a technology platform for end-to-end care management and population health is critical. Platforms like HealthEdge’s GuidingCare enable plans to deliver a customized model of care that not only meets the needs of a D-SNP population but also enables the plan to be compliant with state and federal regulations. The right D-SNP managed care platform can:

  • Create automated and customized care plans
  • Manage compliance reporting accurately and efficiently for all required activities
  • Schedule and perform interdisciplinary care team meetings
  • Leverage social determinants of health (SDOH) connections
  • Improve member engagement
  • Enable easy updates for changing state and federal regulation requirements

GuidingCare is a next-generation care management platform that meets all these needs and more.  For health plans serving D-SNP populations, GuidingCare has a proven track record for meeting the needs of this challenging population. HealthEdge is fluent in the needs of state-sponsored programs serving the most vulnerable and high-risk populations. The GuidingCare platform integrates with both findhelp and Healthify to seamlessly connect members with services they need to address SDOH challenges. Plans that rely on GuidingCare can maximize coordination and member engagement for improved STAR ratings, better health outcomes, and increased member satisfaction.

Now more than ever, the challenges and demands on health plans serving the D-SNP populations is even more emphasized and urgent – at both the state and federal level. These health plans must adopt an efficient and effective care management platform, not only to meet the needs of its population, but also to remain competitive.

Hear from Jennie Giuliany, RN, HealthEdge’s Lead Clinician, Client Management and GuidingCare client Commonwealth Care Association in the April ACAP webinar.

Why Using Modern Technology is Critical to Serving the D-SNP Population

As the dual eligible population grows, Dual Eligible Special Needs Plans (D-SNPs) are also experiencing tremendous growth across the country. CMS reports that as of February 2022, D-SNPs are operating in 45 states and have upwards of 3.8 million beneficiaries. The growth is primarily driven by these factors:

  • Choice of Medicare Advantage over traditional Medicare due to benefits and population health flexibilities
  • Provider understanding of these plan benefits, a common thread of some of the fastest growing new entrants
  • Recent increased acceptance of managed care for this population
  • State and federal attention on ways to better manage care for vulnerable Medicare beneficiaries
  • State and federal policies that embrace well-run managed care, highlighting an opportunity for health plans with existing Medicaid lines of business that are considering expanding into Medicare offerings, including D-SNPs

While growth in D-SNPs is rapid, the offerings across states and health plans vary tremendously due to different requirements at the state level. For example, the differences between a non-fully integrated D-SNP and a fully integrated D-SNP (FIDE-SNP) determine whether Medicaid benefits are going to be fully intertwined and managed by the same managed care entity as the Medicare D-SNP covered services. Depending on which state(s) a plan is operating in, there could be a different paradigm to their approach such as Medicare-Medicare Plan (MMP) in states that opt in to running a three-way contract with CMS as part of the Financial Alignment initiative.

From a plan perspective, understanding what’s essential to the care model and adapting it to resource availability in each state requires having technology in place that enables flexibility. Depending on the state where a plan operates, there will be significant fluctuations in diversity which makes personalization and customization necessary to work in lockstep with state regulators. And regardless of the state, there’s also a certain amount of coordination as specified in state Medicaid agency contracts, such as specific protocols and population health interventions that are part of the CMS model of care proof.

Within the context of modern technology, care management technology is key to improving population health especially as it relates to the D-SNP population. HealthEdge’s GuidingCare is a next-generation technology platform that supports a health plan’s patient-centric model of care and is currently used in 29 states to help manage this complex population. These plans use GuidingCare service plans and script forms to meet the varying requirements in the different markets.

HealthEdge is fluent in the needs of state-sponsored programs serving the most vulnerable and high-risk populations. The GuidingCare platform integrates with both findhelp and Healthify to seamlessly connect members with services they need to address social determinants of health (SDOH) challenges. Plans that rely on GuidingCare can maximize coordination and member engagement for improved STAR ratings, better health outcomes, and increased member satisfaction.

Learn more about GuidingCare for Dual Eligible Special Needs Plans (D-SNP) here.

State of the D-SNP Market

Within Medicare Advantage (MA), there are Special Needs Plans (SNP) with specialty cohorts that provide coverage for members who qualify for both Medicare and Medicaid. The membership for these Dually Eligible Special Needs Plans (D-SNP) include some of the most vulnerable populations in the United States who have medically complex needs and social risk factors. As a result, this beneficiary group has a higher spend profile due to their end-to-end care management requirements and population health strategies necessary to meet their complicated healthcare needs.

When D-SNPs were introduced in 2006, they were available in just seven states. In 2022, D-SNPs are offered in 43 states and Washington D.C. This year, two new states have joined those offering D-SNPs – Wyoming and South Dakota. As of 2021, the SNP Alliance reported 627 Dual-Eligible SNPs serving 3,133,448 beneficiaries. The growth trajectory for Medicare Advantage will continue more than ever before at any point in history. Combine this with increasing Medicaid enrollment and eligibility growth, and enrollment in dual eligible specialty plans will continue to surge.

While the D-SNP market grows, health plans need a way to help members navigate their complex population health needs. GuidingCare® supports care management and population health services with a 360-degree view of the member that incorporates social determinants of health data. Recent data from the Centers for Medicaid and Medicare (CMS) show that for the D-SNP eligible population:

  • 41% have at least one mental health diagnosis
  • 49% receive long-term care services and supports (LTSS)
  • 60% have multiple chronic conditions

Health plans with Dual-Eligible members must stay compliant with changing regulations while serving this population with complex health needs. GuidingCare provides 280 evidence-based clinical and health status assessments available out-of-the-box or customizable. One in five Medicaid members are managed through GuidingCare, 29 states employ GuidingCare to help manage D-SNP populations, and 14 states use GuidingCare for LTSS.

This solution automatically delivers up-to-date Medicare and Medicaid policies and fee schedules, resulting in lower administrative costs, increased operational efficiency, and improved compliance. Not only does care management lower costs and improve health outcomes, but those plans that execute it well set themselves apart from the competition with improved Star ratings.

Learn more about GuidingCare for Dual Eligible Special Needs Plans (D-SNP) here.

Public Health Emergency Clock Ticks Forward to July

As expected, the Biden administration extended the mid-April expiration of the Public Health Emergency (PHE) another 90 days, so the countdown again restarts for July 15. The stakes are high for many parties, even as many Americans are shedding their masks and moving on.

For some states, the pandemic influx of Medicaid members was the largest enrollment action they witnessed in the 50-year history of Medicaid. Industry experts and states are keeping a close eye on what happens next.

When the PHE expires, so does continuous coverage for Medicaid enrollees. Many will become ineligible or need to proactively re-enroll to stay covered. Some estimate as many as 15 million Americans could lose coverage or need a transition in coverage, such as to an Exchange plan.

The Biden administration has promised 60 days’ notice to state Medicaid programs before ending the PHE, so the administration could signal its intent in mid-May if July is the targeted end-date. Many states say they don’t have the time or resources to effectively discern eligibility, contact and re-enroll beneficiaries even at that. Some experts think Medicaid continuous coverage could be de-linked from the expiration of the PHE to accommodate these concerns.

Other impacts PHE expiration:

  • Most beneficiaries in traditional Medicare will lose significant telehealth access unless they are in rural areas or participate in Medicare Advantage.
  • Providers will lose substantial financial support. Major provider associations are pleading for more time. Providers say they face challenges in providing care postponed during the pandemic, and have supply chain disruptions and staffing problems.
  • Popular telehealth flexibilities will continue at least five months beyond the end of the PHE, thanks to 2022 Congressional legislation.

There is mounting political pressure to end the PHE. Various emergency measures, such as those affecting skilled nursing facilities, are already winding down. Many policy experts expect the April renewal to be the last extension. If the PHE is extended yet again, the new date to watch will fall in mid-October.

CMS Opens Portal for IDR Under No Surprises Act

In the ongoing struggle to achieve clarity around how Surprise Billing regulations will work, the Centers for Medicare and Medicaid (CMS) opened a Federal IDR Portal in late April to guide resolution of out-of-network rate disputes between payers and providers after direct negotiations fail. As the saying goes, “the devil is in the details.” This process represents the last resort for payers and providers if they can’t come to rate agreements on their own.

The portal reflects revised guidance independent arbiters can use in the Independent Dispute Resolution (IDR) process and what information they shall consider when choosing between two prices – one offered by the provider and one by the payer. The arbitration method is known as the “Major League Baseball” approach – both parties make offers and an independent arbiter determines which price prevails. The arbiter must choose one award without modification, so whichever number is chosen is final.

Some of the variables the independent arbiter must consider are:

  • The Qualified Payment Amount (QPR) for the relevant service. In general, this is the median of the contracted rates, factoring in geography, specialty and inflation. The methodology for this was established in the CMS July 2021 interim final rules.
  • Other credible information as submitted by either party that is not prohibited and is relevant to the offers made.
  • IDR arbiters may also consider, for non air-ambulance services, the level of training and outcomes for the provider; the provider or facility market share; patient acuity and service complexity; the facility’s teaching status, case mix and scope of services; a demonstration of good faith or lack thereof in attempts to reach a contract.

Factors that the IDR must not consider include:

  • “Usual and customary charges,” including when expressed as a percentage or share of same
  • The amount that the provider would have billed were key rules (45 CFR 149.410, 149.420, and 149.440 as applicable) not applied.
  • The reimbursement rates for most public payers, including Medicare, Medicaid, CHIP and TRICARE. The same rule applies as above for figures expressed as percentages or shares of those rates.

The rules are both similar and different for air ambulance services. In that case, additional variables an IDR arbiter may consider are the type of air ambulance vehicle and its level of clinical capability, and the population density at the point of pickup for the patient.

The IDR entity has 30 days to notify the involved parties in the dispute of their decision. The non-prevailing party must also cover the costs of the IDR services.

Note: Please reference the Independent Dispute Resolution link for complete guidance. This blog post is a partial summary and does not represent legal advice.