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New federal rules set early in the year mandate that private payers cover eight free FDA-approved COVID tests per member per month as of Jan. 15. The intent is to remove barriers for consumers who need to know whether they are infected so they can keep from spreading the virus. In an ideal world, that means people not facing a fee at the point of purchase and counting on their health plan membership information to pave the way. The work of processing and paying for tests really should happen behind the scenes.

A few payers expressed to the New York Times that they didn’t have enough time to meet the deadline and that they didn’t have the proper coding and payment mechanisms in place. AHIP reports that nearly half of plans are positioned to make the tests free at the retail level. There are a number of ways payers can respond to the challenge, and they should note that HealthRules® Payer and Source® are configurable to easily processing claims in this and similar situations.

Many plans will piggyback the COVID test distribution onto existing processes, such as those they use to offer free vaccinations to members in clinics, drugstores and other settings. Even so, plans will need to reimburse members who still end up paying out of pocket and submitting paper receipts for reimbursement. HealthRules Payer is also poised to handle this process.

Health plans should communicate with members about how to proceed, and make a point of distinguishing between preferred and non-preferred locations or pharmacies where possible. Payers will be liable for the full cost of non-preferred tests, so they are wise to educate members on where to acquire tests.

Business agility continues to be a factor in whether plans thrive or just survive in today’s healthcare ecosystem. This is a vivid example of how the right partners and solutions can support health plan operations in delivering for members as well as promoting public health.

This topic and others were recently discussed at our monthly customer focus group, in which we discuss industry compliance issues and the HealthEdge response. Upcoming topics include Machine Readable Files, the advanced explanation of benefits and price comparison tools. Customers wishing to attend should contact their account representatives.

Learn more in Maggie Brown’s Regulatory and Compliance Headlines & Highlights update.

HealthEdge Software, provider of the industry’s leading next-gen integrated solution suite for health insurers, said today its HealthRules® Payer solution has been named “Best in KLAS” by KLAS Research for claims administrative processing system (CAPS). The designation is awarded by KLAS based on in-depth interviews with payers using the platform. A KLAS Performance Report released last fall showed HealthRules Payer leading the market in new purchase decisions by payers in a 24-month period.

“We are delighted to earn this respected recognition from our customers,” said Steve Krupa, HealthEdge Chief Executive Officer. “This correlates with what we have heard across the market from customers, who tell us they need the capability to scale and grow membership, expand into new markets, model new benefit plans and connect real-time data access. As digital innovators, we constantly strive to deliver these mission-critical advantages to payers.”

The KLAS Performance Report also ranked HealthRules Payer as “best technology option” based on interviews, with a highly satisfied customer base. The “Best in KLAS” designation interviews produced customer comments, noting robust configurability and flexibility:

“I have been through multiple claims systems, and HealthRules Payer is by far one of the best claims systems that I have seen in the marketplace. The ease of use and ease of configuration have been amazing. I speak all the time with our vice president of claims, and they can’t swear enough by the product and what it has done for us.” Vice President, August 2021

“I like the way HealthEdge has built their technology with APIs. I like the ease of APIs to do integrations that we don’t have with a lot of the other systems.” Director, August 2021

HealthEdge’s Chief Operating & Product Officer, Sagnik Bhattacharya, noted that market factors such as the growth of value-based care contracts, new regulations over the past two years have exposed inefficiencies in legacy architecture for many payers: “Legacy technology is getting in the way of the business agility health plans need. HealthRules Payer enables plans to innovate rapidly as they transform to become digital-first businesses.”

Customers expressed appreciation for the HealthEdge culture and collaborative style:

“HealthEdge appears to be at the forefront of the industry. There is new legislation coming out, and the vendor is proactively updating their solution to support some of the mandated functionality. HealthEdge proactively reaches out to their clients through different forums to get input, form solutions and raise awareness.” Vice President, August 2021

“The executive team is high energy. They lean in. They are collaborative … they live their mission of wanting to support our industry, and that shows in every interaction. HealthEdge has done a nice job of building relationships across the organization.” Vice President, August 2021

An October 2021 KLAS Performance Report noted, “HealthEdge has recently seen increased attention from both small and large health plans, who view the vendor’s technology as innovative and who have been asking KLAS for vendor insights.”

The “Best in KLAS” award will be presented to HealthEdge live at HIMSS in Orlando this March. Read the 2022 Best in KLAS: Software & Services report here and the October 2021 KLAS Performance Report about HealthEdge here.

Smokers, on average, die 10 years younger than nonsmokers. But that’s just one data point. What happens when you consider all the data that composes the fabric of a member’s health? When you factor in doctor visits, lab results, medication, social determinants, income levels, and more?

Then it becomes a fascinating tapestry of rich data. A very large tapestry of data – that’s impossible to manually process and synthesize.

With so much data, across so many variables, how do you pull the pieces of data together? How do you take the clues left by these health risks and translate them into concrete steps patients can take to improve their health?

Enter, predictive risk modeling.

Predictive risk modeling takes the web of scattered clues, and all that data, and distills it into actionable insights. Intervening with the right members at the right time can help improve members health. Risk scoring helps identify those individuals or populations that pose greatest likelihood for complications and costs.

What is CDPS?

The Chronic Illness and Disability Payment System (CDPS) is a predictive risk model that interprets diagnostic and pharmacy data to assign segments of a population into more than 60 risk categories.

Deploy the Right Care, to the Right Members, at the Right Time

The CDPS predictive risk model incorporates additional risk determinants such as income, social determinants of health and specific assessment scores for more holistic and accurate risk identification. These factors can be individually weighted against population data so care managers can identify individuals at the greatest risk for costs and complications. Those individuals can be targeted for care programs, allowing you to intervene with the right members at the right time.

GuidingCare: CDPS Risk Model (CDPS+Rx)

The CDPS+Rx risk model is fully integrated into GuidingCare and is available exclusively for commercial use within the solution. CDPS+Rx can be used alone or in combination with other risk measures to calculate a risk score representing the risk for future healthcare costs. Learn more here.

As our healthcare system struggles toward a model in which consumers are at the center of the equation, technology is playing a rapidly increasing role in smoothing their way through the ecosystem. Consumers are demanding a better healthcare experience, but there’s a massive collision coming between the exabytes of global health data and consumer health and insurance illiteracy.

“Interoperability” describes a set of American regulatory initiatives that are in play right now and will drive change in the industry for years to come. As president of a healthcare technology company, I believe them to be as significant as any changes to the system made in this century, including the introduction of HIPAA privacy regulations and the Affordable Care Act.

Among them are requirements that health plans must share information about a member’s past claims experience, such that a member’s history now travels from plan to plan with them. Other information-sharing regulations make enormous amounts of health and insurance data directly available to patients, most likely downloadable to their smartphones. Some health plan portals and apps are already providing volumes more data than they did just a year ago.

Poor Literacy Equals Worse Care

This creates a new set of hazards. Research results show that low health insurance literacy among consumers has negative impacts on health. For example, when consumers don’t understand that certain health screenings are free, they are more likely to skip them. High deductibles can discourage people from seeking care due to uncertainty about potential costs. A limited understanding of health concepts and terminology will hamper receiving appropriate care. The results of research from the Centers for Disease Control indicate that complex health information confuses nine out of 10 Americans. Although no consumer should be expected to have a scientist-level understanding of medical terminology, the level of basic health knowledge is dangerously lacking.

What’s likely to happen when people receive their first smartphone-full of medical terms in Latin abbreviations, industry insurance codes and administrative jargon? I expect that most will turn to their keyboards, as Google already receives more than 1 billion health queries every day. There’s an abundance of symptom-checkers online, many of which are worse than no information at all.

As it is, some providers already find themselves spending an inordinate amount of precious patient encounter time clarifying, explaining and overcoming information consumers have mustered through internet searches. Whether patients have self-diagnosed or are filled with anxiety-driven questions about their genetic profiles, they’re taxing the system in new ways. I’m all for consumers advocating for their health, but unfiltered data in the hands of the anxious or unschooled can burn up resources or lead to poor decisions.

Current Tools Are Still Primitive

In addition to encouraging consumers to become more educated, I believe we should put artificial intelligence (AI) to work in translating insurance and medical jargon into actionable data for patients. Machine-learning (ML) and natural language processing (NLP) models can decipher complex medical terminology into simple, consumer-friendly language. AI and NLP can serve as translators and clarifiers, sifting a vast universe of diagnostic and treatment data, as well as insurance coding and terminology. AI and NLP models can push structured and unstructured data, as well as noisy data, to apps in ways that make the information consumable. This will allow patients to manage their health, their worries and their finances.

Creative minds are already at work on this conundrum for patient portals, but the tools are still primitive. Smartphones are likely to require even more sophistication but hold the promise of greater interactivity and real-time responses.

The freedom of patients to have their own health data has been an objective for many years, but the wheels of legislation and regulatory implementation have turned slowly because the complexity and the stakes are high. Technology will be the essential tool making the “back end” of healthcare more streamlined and intelligent. New treatments, pharmaceuticals and surgical robots capture the headlines, but the work done behind the scenes is just as revolutionary.

The journey of transforming healthcare starts with innovation. We recently sat down with Sanjeev Sawai, Chief Innovation Officer at HealthEdge, to understand how innovation can be traced to the roots of HealthEdge and what innovation looks like going forward.

What is HealthEdge’s role in the digital transformation of the healthcare landscape?

To keep up with digital disruption in the healthcare industry, payers need intelligent, next-generation solutions. Payers who do not invest in next-generation technology will likely be left behind. HealthEdge offers modern, flexible, and inter-operable solutions that pave the way for payer strategies to meet tomorrow’s shifting market demands. HealthEdge accelerates digital transformation in healthcare through facilitating real-time transactions, integrating applications with IT systems, and making real-time data available.

How will HealthEdge provide health plans with data and technology to support the entire healthcare ecosystem?

At HealthEdge, we understand that the payer ecosystem is large and complex. That is why all HealthEdge products are built to seamlessly integrate with all vendors and technology needed for our customers to do business. Our focus is on supporting a composable architecture that includes partner relationships. HealthEdge will offer APIs for application integration, based on standards, that will allow plans to easily integrate with applications in their IT ecosystem. This will also enable HealthEdge to create an application partner program and offer a digital marketplace of valuable applications. Additionally, HealthEdge plans to offer a data and analytics platform for health plans to perform operational reporting, ad-hoc analytics, and AI/ML modeling to enhance specific business outcomes.

The HealthEdge data science team is developing analytics to identify process improvements within our products, as well as collaborating with select customers to develop ML models for specific use cases. HealthEdge is committed to supporting digital-first experiences for plans through seamless integration of applications and unified views of data.

What does innovation at HealthEdge look like going forward?

Currently, HealthEdge is focused on the following three areas of innovation:

1. Efficiency in business processes, workflows, and automation through closer integrations among the HealthEdge product portfolio. While each solution is viable and extraordinary on its own, the unique value is how these applications work together in a meaningful way. The integrated solution suite makes possible a vision where claims processing is enhanced with software-driven payment integrity at the point of service, feeding data to an end-to-end care management solution. The result: Lower administrative and healthcare costs, improved patient outcomes, and regulatory compliance.
2. Increased automation through analytics and machine learning. HealthEdge is investing in core teams and technologies to create new value and outcomes based on payer and related data. Advanced analytics on administrative and clinical data will yield operational insights into improvement areas such as auto[1]adjudication rates, member dis-enrollment, compliance reporting, member risk-scoring, care interventions and more. Embedding machine learning algorithms seamlessly into operational workflows will support efficient improvement of targeted business KPIs.
3. Creating an application partner ecosystem through API access and data exchange with the HealthEdge application platforms will provide a variety of additional solutions that deliver value health plans. Applications will be available through a marketplace and will be certified to work with the HealthEdge product portfolio. Health plans can select and deploy the partner applications that enable them to achieve their business goals.

Learn more about HealthEdge and innovation here.

Dual Eligible Special Needs Plans (D-SNP) are a special kind of Medicare Advantage Plan for people who qualify for both Medicare and Medicaid. This program takes members’ Medicare, Medicaid, and Part D needs and puts them all together into one package to provide an overall healthcare experience.  D-SNP plans are unique in that they provide extra benefits. In addition to Medicare, Medicaid, and Part D coverage, they also help with additional healthcare coverage, including transportation (to doctor visits), dental or vision coverage, and credits to purchase OTC products.

Support for Highest-Need Populations

D-SNP members represent some of the most vulnerable populations in the United States. Health plans serving D-SNP programs need a holistic platform for end-to-end care management and population health that enables their unique Model of Care and keeps them compliant with state and federal regulations.

Best-in-class D-SNP care management platforms hinge on two critical factors: compliance and member satisfaction.

Compliance

• Federal & state compliance
• Compliance reporting
• ODAG and CDAG Reporting
• User-friendly documentation management
• Complex Assessments
• STARS ratings
• HEDIS scores

Member Satisfaction

• Coordination of care and collaboration
• Coordination of activities of daily living (ADL) needs identified via responses to assessment questionnaire which will generate service plan needs that can automatically feed authorization of such required services.
• Ongoing communication and engagement
• Member care plans with intelligent automation and evidence-based goals and opportunities
• Leverage social determinants of health (SDOH) connections to address nontraditional challenges for improved member outcomes

The right D-SNP managed care platform means better health outcomes and compliance with federal and state regulations.

HealthEdge’s GuidingCare: Next-gen care management platform for health plans with D-SNP

With strong expertise and experience in providing care management and population health services for government-funded payers and plans, HealthEdge is fluent in the needs of state-sponsored programs serving the most vulnerable and high-risk populations.

Nationally, 1 in 5 Medicaid members are managed on GuidingCare. GuidingCare is currently live in 35 states for Medicaid, 29 states for D-SNP, and 14 states for LTSS. Learn more about how GuidingCare supports D-SNP populations here.