As consumers of digital services in our daily lives, our expectations of personalized self-service experience have been set by the likes of Amazon, Netflix and others. We are very comfortable with transacting digitally for shopping, banking, and so many other activities. Interacting with businesses through apps or the web has become the norm.

The businesses who must provide this capability to their customers, typically have to go through a “digital transformation”. They must virtualize delivery of services and the key business processes that enable them. This is done through integrating their information systems and ensuring the right data is available at the right time.

In addition to having data available at the right time, it must be accurate, high quality and complete. High quality data is free from errors, not duplicated, contains all necessary fields and is up to date. Healthcare data is contained in several disparate systems, each used and maintained by separate teams. This leads to a challenge in matching data across systems with a unique identity. Names and addresses need particular attention to ensure that they are spelled and formatted correctly and are unique (consider combinations of initials, middle names and abbreviations).

A data quality program is essential to keep data accurate, by cleansing it of errors and merging from several sources. Errors in data can be prevented by employing a data governance program that prevents errors at data sources. An app user looking for a doctor should be able to see all the correct specialty, office location, hours and network information.

Digital transactions also need access to APIs and real-time data. Information such as eligibility, appointment schedules, payment status must be timely to be useful.

Incorrect or stale data makes for a poor digital experience, and reduces user confidence in the business. Customer experiences are key to retention. A foundation of trusted data as a basis for applications is the key. Good digital experiences demand good data.

The HealthEdge approach to enabling greater access to real-time data centers on three main principles:

– Accurate Data

– Organized Data

– Accessible Data

Learn more about how we are working to give our customers, our applications, and our partners’ unprecedented access to real-time data here.

Medicaid MCO claims management is complex and dynamic. The traditional approach to Medicaid payment policies and fee schedules is challenged by the increasing complexity of claims and dynamic state-by-state regulatory and payment environment.

Health plan leaders need to embrace technology solutions that enable accuracy while minimizing the lift for internal teams, especially with the variability in Medicaid. But what should you look for in your search for Medicaid Payment technology?

Top Features of Optimal Medicaid Payment Technology:

1. Cloud-based service – Enables automated, frequent Medicaid and CMS regulatory updates to eliminate IT lift
2. Depth of content – Includes reimbursement rates and payment policy for all care settings in each state, including facility and professional claims down to the provider level
3. Claims payment process unification – Complete editing and pricing before adjudication
4. Complete audit trail – Provides transparency that supports audits and improves provider relations

HealthEdge’s Source: Revolutionary Technology + Unique Depth of Content

With over 15 years of experience providing Medicaid and Duals support, our delivery of Medicaid pricing and fee schedules is unparalleled in the industry. As cloud-based platform, Source, is the only prospective payment integrity solution that natively brings together up-to-date regulatory data, claims pricing and editing, and real-time analytics tools into a single IT ecosystem. This transformational approach allows payers to make payments with total confidence and make business decisions with real intelligence.

The Value of a Great Vendor Partner

The ROI can be tremendous for health plans that find the right vendor partner. In one case a Source customer that processed 12+ million claims annually was able to reduce claim reworking by 40%, save approximately $6-12 per claim, and reduce IT overhead while gaining control of their workflow. The health plan improved CMS multi-state Medicaid program regulatory compliance, increased transparency on payment results, and spent less time preparing for audits, the latter of which increased staff satisfaction and retention.

Is a Traditional Approach to Medicaid Claims Payments Hurting your Health Plan?

Download our white paper Medicaid MCOs: It is time for a new claims management strategy to understand how our Payment Integrity solution, Source, is revolutionizing the way Medicaid claims are handled.

According to the Kaiser Family Foundation, there are over 280 Medicaid Managed Care Organizations (MCOs) that provide comprehensive managed care for over 55 million US adults, which is over 70% of all Medicaid enrollees. The diversity and economic status of the Medicaid population mean it can also be a more medically complex population than other payer sectors.

For health plan leaders that want to reduce these inefficiencies and drive down claims processing costs, they need to think differently and invest in solutions that lighten the load on internal teams while providing frequent and accurate data updates health plans need to succeed in managed care.

The typical release cycle for state Medicaid data varies from state to state, and updates can happen at any time. During natural disasters or events like the COVID pandemic, the number of updates to payment policies and fee schedules related to durable medical equipment and vaccine testing, for example, can increase dramatically. Unfortunately, since health plans typically only update Medicaid content at varying frequencies, improper payments are compounded during times of crisis, increasing the likelihood of rework.

In a typical large health plan, there may be 20-30 people managing the legacy process and increasing capacity means adding additional staff. Shifting from manually managing Medicaid MCO’s to cloud-based technology provides a myriad of benefits.

Six ways technology can lighten your team’s workload:

1. Process claims correctly the first time. Avoid errors with up-to-date pricing and important edits in each state.
2. Include all provider types and settings. Data that cover all providers in every care setting eliminate the need to piece together multiple data sources.
3. Automate updates and data loads. Reduce the need to manually update data sets, which can result in delays and human error.
4. Update more frequently. Quarterly updates can be too slow for an organization that wants to react quickly and remain agile.
5. Keep an audit trail. Automate the audit trail so teams do not need to rely on incomplete archives that place the burden on the user to prove and support claims pricing results.
6. Eliminate costly infrastructure. Moving to a cloud-based solution can reduce demands on internal IT and business teams as well as eliminate maintenance of costly legacy software.

By implementing a cloud-based claims processing solution that automatically updates the latest regulatory and pricing content, eliminates the need for infrastructure support, and maintains audit data, many of these talented individuals previously used to support the legacy system can be redeployed to more value-added responsibilities.

Download our white paper Medicaid MCOs: It is time for a new claims management strategy to understand how our Payment Integrity solution, Source, is revolutionizing the way Medicaid claims are handled.

“Variability in Medicaid is the rule rather than the exception. States establish their own eligibility standards, benefit packages, provider payment policies, and administrative structures under broad federal guidelines, effectively creating 56 different Medicaid programs—one for each state, territory, and the District of Columbia.”

– Medicaid and CHIP Payment and Access Commission (MACPAC)

Understanding Medicaid MCO Claims Management Risks

What does this mean for the 280 Medicaid Managed Care Organizations providing comprehensive care for over 55 million US adults? The complexity and variability in state-by-state regulations have health plan executives scrambling to keep up with each state’s latest Medicaid payment policies and fee schedules.

Within each state Medicaid program, there are numerous pricing models that may be based on patient population or geography. For the same procedure on a similar patient, a hospital in Stockton, California may have a different pricing model than a hospital in Sacramento. The diversity and economic status of the Medicaid population mean it can also be a more medically complex population than other payer sectors.

With the increasingly complex and dynamic state-by-state regulatory and payment environment, it has become nearly impossible to keep up to date with and adapt to the constant and nuanced changes in Medicaid payment policies and fee schedules.

But what are the real risks of not keeping up to date with the rapidly changing, dynamic world of Medicaid pricing? When fee schedules and configuring payment policies aren’t updated in real time?

1. Health plan waste – Internal team is responsible for updating content, leading to high overhead, inaccuracies, and significant effort spent on IT infrastructure and maintenance
2. Provider abrasion – Slow and inconsistent payments and repeated overpayment recovery strain payer-provider relationships
3. Competitive disadvantage – Inaccuracies, lag, and strained provider relations can impair a health plan’s chances of contract renewals and winning bids.
4. Overpayments – Using the wrong edits and price increases the risk of overpayments and downstream recovery
5. Denials & Rework – Delayed fee schedule updates can lead to inaccurate claims. Payment policy and fee schedule as an incorrect fee schedule will likely not deny a claim.
6. Missed Reimbursements & Incorrect Payments – Incorrect claims drive missed reimbursements & inaccurate payments
7. Lost Time Resolving Payments Disputes – Payment disputes take up precious time

These factors highlight the Medicaid MCO Claims Management Risks and show the traditional approach of Medicaid MCO Claims Management is inefficient and drives unnecessary costs for the health plan. For health plan leaders that want to reduce these inefficiencies and drive down claims processing costs and medical waste, they need to think differently and invest in solutions that lighten the load on internal teams while providing frequent and accurate data updates health plans need to succeed in managed care.

Download our white paper Medicaid MCOs: It is time for a new claims management strategy to understand how our Payment Integrity solution, Source, is revolutionizing the way Medicaid claims are handled.

Through value-based care arrangements, health insurance companies have the opportunity to share the burden of care delivery costs and rewards of high-quality care with their provider networks, so it’s no surprise that many organizations are headed that way. However, due to disjointed systems and siloed data sources, most payers are still restricted to small pilot projects that are limited in scope and impact. Very few payers have been able to launch large-scale value-based initiatives that deliver on the promise of true value-based care.

The Journey to Value

One could argue that health insurance companies have been on a journey toward value-based care since the 1990s when capitated rates were first introduced. But as CMS motivated providers with federal incentives to digitize their operations and move to electronic health record (EHR) systems through the Affordable Care Act, massive amounts of clinical data became available. At the same time, electronic claims became more prevalent, and the stage was set for what we now call value-based care.

The vision of being able to leverage claims and clinical data to reduce the cost of care, improve patient outcomes, and increase member satisfaction was formed. However, most of the clinical data remained locked within the systems that generated it. Claims data also sat idle and stuck within the core claims administration systems that produced it. Plus, non-medical data, such as social, economic, and behavioral data was available but highly unstructured and therefore largely unavailable for inclusion and analysis.

Disparate data and disjointed systems presented significant barriers to health insurance companies’ ability to execute value-based, risk-sharing arrangements rapidly and successfully. For payers that are operating on outdated systems, those barriers still exist today and pose significant threats to their ability to compete in the future as the industry moves away from fee-for-service toward value-based care models.

Modern Technology Breaks Down Barriers

While progress has been made among the provider, payer, and vendor communities when it comes to exchanging data through standard interoperability protocols, those payers who are equipped with modern systems on modern architectures are better positioned to succeed in a value-based care environment. Why? Because to achieve true value for the payer, provider, and member, the claims management, care management, and member engagement systems must work together seamlessly.

With modern technology solutions like those from HealthEdge, exchanging insights and integrating workflows across the entire spectrum is possible. This vision of end-to-end automation with the exchange of real-time data that can equip care managers, providers, and plan administrators with the right information at the right time to make the right decisions form the basis of HealthEdge’s recent acquisitions and product investment strategies. In the HealthEdge ecosystem, best-of-breed systems share real-time data across functional business processes, no matter where the data or the system functionality originates.

A HealthEdge Example

One health plan that is making great strides with value-based care models is Independent Health, a New York-based, not-for-profit organization serving more than 375,000 members. The leadership team wanted to transition from the traditional fee-for-service (FFS) model to drive down soaring costs and positively impact patient outcomes, and they chose HealthRules Payor to help them make the transition.

The secret? Building strong relationships with their providers based on data, which could be easily shared from the system.

“When we give providers data that show how they are performing relative to required or recommended services for members within various demographics and disease states, we’re doing so with the ability to drill down to the individual patient level,” explains Dave Mika, vice president, Enterprise Core System Operations at Independent Health. “When we understand where a single patient stands relative to utilization of inpatient and outpatient services, we can offer clarity into everything from who needs to be more active in managing their own care to how cost calculators and digital health tools can be better utilized – by providers and their patients.

The results were impressive. In one use case, Independent Health targeted a series of approximately 5,000 patient encounters with the goal of reducing wasteful practices in a post-acute setting – including readmissions and avoidable admissions. The result: a savings of $14.8M, which represented a cost reduction of 10 percent.

Independent Health reports that 98 percent of primary care practice members are now in full capitation contracts, with solid alignment of goals between Independent Health and its providers. Pay for value has improved patient outcomes and lowered healthcare costs, all the while increasing customer satisfaction and overall health in the community.

Many Approaches. One Solution.

Payers are approaching value-based care in different ways, and different aspects of their businesses are typically further along than others. Whether the organization is focused on improving clinical care to improve member outcomes or more focused on containing costs through creative pricing programs, the HealthEdge portfolio of solutions can pave the way.

“Value-based care comes in many different forms, but it’s really based on how health plans reward providers for delivering good service and good care to the member. We are helping our customers take a more member-centric focus and contract with providers who share their common vision.”

– Steve Krupa, CEO HealthEdge, IMPACT 2021 Customer Conference

The HealthEdge integrated ecosystem of products and partners work together seamlessly to help health plans accelerate the pace by which they can create and implement successful value-based care programs. As plans seek to align with provider partners who can share the responsibilities of care delivery costs and high-quality care, now is the time to embrace modern technologies that can help bring true value to value-based care.

To learn more about how HealthEdge can help your organization embrace value-based care arrangements with greater confidence, visit www.healthedge.com or contact us at [email protected].

Download the rest of the series here: 

The Foundation: End-to-end Business Automation

The Digital Transformation Journey: Real-Time All of the Time

Opportunity is the Name of the Game in Today’s Health Insurance Market

As the 2022 open enrollment period comes to a close, health insurance industry leaders are facing a year of unprecedented change. For some, these changes are being embraced and viewed as an opportunity for growth. For others, the rapidly changing market dynamics will have them falling further and further behind. The difference? It’s all in the technology. IT systems that combine best-of-breed solutions with modern technological advancements that facilitate easy integration, fast implementations, and effortless upgrades will separate those who thrive and those who barely survive in the new year.

Growth in the Midst of Chaos

According to AHIP, the health insurance industry is experiencing significant growth as we look to the new year:

• 12.2 million Americans will buy coverage through the Affordable Care Act’s health insurance exchanges this year, the highest number of individuals since the program began.
• 213 health insurance providers will participate in the federal exchange this year, an increase of 15% from the previous year.
• 27 million Americans are now enrolled in Medicare Advantage plans, which represents the highest percentage of Medicare beneficiaries to date.
• 180 million Americans now receive their health coverage through employer-based health plans.
• 40 states have now chosen to partner with Medicaid MCOs and more than 75% of Medicaid enrollees are served by Medicaid managed care (MMC) programs.

In addition to evolving consumer behaviors, legislation regarding interoperability and transparency is gaining momentum. In 2022, payers will be required to focus on the implementation of foundational transparency requirements, such as the Machine Readable In Network and Allowed Amount Files, and the No Surprises Act consumer protections. Payers will also be required to collaborate on the method and standards for the Advanced Explanation of Benefits and Pricing Comparison Tools. The technology advancements required to ensure compliance may be leveraged, since the increased access to information and the implementation of standards provides new insights into member health, risk scoring, and health equity gaps.

Increased Choice = Increased Competition = Increased Opportunity

As the numbers above show, consumers now have more choices than ever before. As a result, health insurance providers now have more competition than ever before. For example, AHIP tells us that the average number of options individuals had to choose from in this year’s federal exchange was six to seven options, up from four to five just last year.

For those organizations that have embraced modern technologies, this competition is a welcome opportunity to gain market share and grow their lines of business. For those still burdened by legacy core claims, admin systems, and manual-dependent care management platforms, this competition creates new risks of being left behind in a market that appears to have no intention of slowing down.

Over the past several years, the complexities that health insurance business leaders must address have grown exponentially. From regulatory requirements embedded in the 21st Century Cures Act to consumer demand for greater transparency and more control, leaders now recognize the critical role their technology stacks play in the ability to keep pace with change.

At the same time, technology companies that have mastered automation in other industries such as financial services and manufacturing have set their sights on modernizing the healthcare industry. Companies like Microsoft, Amazon, and Apple have moved into healthcare, bringing with them powerful new data sources that legacy health systems cannot absorb and new approaches to solving age-old problems.

Modern systems, like those from HealthEdge’s next-generation solution suite, can help health plans embrace change and leverage the opportunity to become more nimble, more efficient, and more consumer-centric as they explore new markets and pursue new payment models with greater confidence.

Eric Decker, Senior Vice President of Information Technology and Chief Information Officer, Independent Health, noted, “About ten years ago, the Affordable Care Act created uncertainty as to whether our legacy [core claims administration] system could manage things like member-level benefits, or how it would perform and integrate with exchanges. We closely evaluated different products in the space at the time and immediately realized HealthRules® Payer enabled us to significantly cut down our new product development time. Now, what used to take weeks and months actually takes hours or days.”

Speed to Market Matters

With the right systems in place, health plans can not only better identify opportunities for growth and better member outcomes, but they are also able to act on those opportunities with greater speed and more precision.

For example, health insurance companies who leverage the integrated HealthEdge solutions, which include best-of-breed core claims processing, care management, payment integrity, and digital health management systems, are uniquely equipped to bring innovative plan designs and benefit configurations to market faster. HealthEdge customers can easily expand into new geographies and reach new populations with next-generation products that are highly configurable.

This new level of nimbleness that modern technology platforms bring to the table in 2022, will be the difference between those who grow and those who fall further behind.

How It Works

Organizations that use HealthEdge products can take advantage of flexible configurations, customizable workflows, and automated processes.

For example, the English-like language capabilities used in HealthRules Payer make it easier for health plans to design and bring new benefit products to market faster. That’s because it has been designed in a way that a benefits person thinks, not the way a core admin system works.

With HealthEdge Source®, health plans receive automatic updates on important data, such as fee schedule changes, rates, payment policies, and provider-level data, every two weeks instead of having to wait months to receive now-outdated information. GuidingCare®, HealthEdge’s care management platform, streamlines clinical workflows so care managers easily create care plans and ensure that members follow the plans for better outcomes.

“[With HealthRules Payer], we’re able to complete the solution design process as a series of benefit objects, so we don’t have to rebuild over and over again at the risk of increased costs and errors.”

– John Janney, Senior Vice President of Transformation at AmeriHealth Administrators

Lifting the IT Load

The features and configuration capabilities of the software system are only part of the speed equation. The ability to easily integrate best-of-breed solutions with other systems in a seamless manner eliminates the IT burden that often serves as a barrier to change among health plans with legacy claims processing and care management systems. The business can only move as fast as the systems can manage the changes.

Similarly, implementations of monolithic systems needed to support new lines of business or new markets can dramatically slow down the health plan’s ability to pursue new opportunities. Upgrades with new features create similar IT challenges and have the potential to disrupt business operations.

“[GuidingCare] was an incredible partner, great collaborator, and provided great teamwork. I have great appreciation for that. We have no regrets about choosing GuidingCare.”

– Clinical Director, 1M+ member health plan that was able to replace its legacy system with GuidingCare in three stages across its entire business in only nine months

With modern technology and proven processes, health plans have the opportunity to expand into new markets and drive new business opportunities without worrying about how to fit projects onto an already overloaded IT list.

“Adaptability in terms of the benefit configuration and allowing us to roll out new products without having to do massive coding projects is a big deal that we don’t have today (with HealthEdge).”

– Eric Decker, SVP of IT and CIO at Independent Health

Get Ready to Grow

Advancements in modern technology, like those from HealthEdge, are helping health insurance companies keep pace with the ever-growing demands from regulators and consumers. But the pace of change in 2022 will require health plans to accelerate their digital transformation journeys if they want to capitalize on growth opportunities.

Our product investment strategy at HealthEdge is focused on helping our customers migrate to more modern, interoperable, and composable systems that allow them to grow in the ways they want and when they want to.

To learn more about our best-of-breed solutions and how they work together with our broader ecosystem of solutions and partners, visit www.healthedge.com or contact us at  [email protected].

“HealthEdge allows us to achieve speed to market with our products in the rapidly changing healthcare environment, with the capability to configure and implement products quickly and on the fly.”

– Dave Mika, VP, Enterprise Core Systems Operations, at Independent Health and user of HealthRules Payer