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States have been passing legislation in recent years to address the complaints of providers that they are subject to too many prior authorization requirements in advance of patient treatment. This provider abrasion is something health plans are seeking to reduce independent of any legislative initiatives because it can be a labor-intensive process to assure medical necessity. Most requests are eventually approved.

While some states have mandated that payers provide electronic submission options with established turnaround times, Texas and West Virginia are two that have passed “Gold Card” laws using a different approach. At least seven other states are discussing similar legislation.

The gold card method in Texas mandates that over a specified period of time, providers achieving a 90 percent approval rate for prior authorizations achieve special status that waives the need for further approvals on those services for the next year.

HealthEdge has tools in place to meet the challenges of this and other new state laws. For one thing, GuidingCare rolled out an electronic Prior Authorization Portal that was developed in conjunction with both a customer payer and its system providers in 2021. Through this portal providers receive authorizations in a matter of moments, allowing more complex requests to be quickly routed for review of medical necessity. The portal features one-click messaging and eliminates the need for concurrent reviews during inpatient stays. GuidingCare also supports the rules that determine when a provider has reached the threshold for a gold-card status.

HealthRules Payor can easily be configured to waive prior authorization requirements when processing claims for providers who have reached a threshold. This interoperability between HealthRules Payor and GuidingCare is just a preview of what platform integration promises with new companies brought under the HealthEdge banner in the last two years.

Payers disagree even among themselves as to whether gold-card practices are effective, and provider organizations also disagree among themselves. Either way, HealthEdge is ready to support customers in meeting the requirements known to date.

Learn more about Reducing Incorrect Payments Between Payers & Providers in a Claims Wasteland here.

A successful implementation of our products begins with a strong foundational relationship between our health plan customers and HealthEdge. Our goal is for customers to leverage the power of our products to gain competitive advantage, grow their business, lower costs, and improve member and provider satisfaction. Based on HealthEdge’s extensive experience in implementing our solutions with health plans of all types, sizes, and lines of business, our staff is equipped with best practices and lessons learned – and also the biggest risks to avoid. Successful implementations result from shared goals, clear governance, designated team, and a collaboration mindset to drive change through your organization.

Make sure to avoid these 7 critical implementation risks:

1. Unclear Governance

Transparency across all levels of the project team is important to understand blockers, drive quick decisions, maintain timelines, and budget. Poor governance at the project and executive sponsorship levels can cause delays in addressing project roadblocks and making critical decisions in a timely manner.

The HealthEdge ‘Transform’ implementation methodology includes daily stand-up meetings for each implementation workstream, weekly program management, and monthly executive sponsorship meetings to ensure issues and risks are addressed timely and the project is progressing to achieve the scheduled milestones and program budget.

2. Team members pulled in too many directions

Team members assigned to an implementation project are typically the most knowledgeable and valuable to daily business operations. These individuals are often pulled in multiple directions trying to keep the trains running while designing and implementing the new system.

When key resources continue to have responsibilities to the current business, issues can arise with the implementation project. These issues can include lack of timely decision making, poor design due to missing input from key business partners, and insufficient test cases.

The client executive sponsor needs to provide relief for the key resources to focus attention on the implementation project and allow others to manage the existing daily business.

3. Multiple Methodologies

Clients unfamiliar with Agile methodology can struggle with the structure and pace. Especially when their other projects are run with a different methodology.

HealthEdge Professional Services has refined the ‘Transform’ methodology approach based in Agile principals. A single tracking tool and methodology is required to truly track the burndown and progress of the overall project to recognize and avoid issues.

4. Insufficient Testing

We often have clients that cut testing time or try to take shortcuts in an attempt to meet milestone deadlines. Issues are identified late in the project and require rework and disruption to the project. This causes project delays and lack of confidence for subsequent phases.

The Transform methodology is based in Agile principals. A main principal is a test first approach. Test suite creation must be prioritized and the various levels outlined in the project must be adhered to.

5. Zero Training

Training can be a difficult area to fit into project timelines. Some clients have only had a handful of the project team take courses and rely on the ‘on-the-job’ training from the HealthEdge team throughout the project.

As a result, client team members struggle with the concepts and terms of HealthEdge products. And the project heavily relies on the HealthEdge team to build the configuration which leads to downstream issues when the client takes ownership after go-live.

The team engaged in the implementation project should take the recommended product training courses to understand the core concepts of the HealthEdge system.

6. Holding onto the Past

Many client team members have been the heroes in creating wrap-around processes or systems to cover legacy system issues. These creative approaches have been in place for 10-20 years and have been designed specifically for that client’s business. Clients try to replicate or hold on to these processes in the HealthEdge design.

The HealthEdge features/ functionality can improve the overall efficiency and business processes. However, this requires the organization embracing the change and adopting the new system – not just trying to make the HealthEdge products do what the legacy system did.

7. Moving the Goalposts

Throughout an implementation project, client teams will try to add new items to the scope. Addition of scope from the initial state of work, regardless of big or small, can add up and cause project delays and/or budget overages.

Strong discipline to the core objectives and timeline is critical to keeping the project on track. Although tempting, new scope should be deferred to a subsequent implementation phase whenever possible.

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

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.

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.

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.