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With the Omicron variant starting to recede and political pressure starting to build to end the Public Health Emergency (PHE), various sectors of healthcare are starting to prepare for the end of the emergency period. Currently slated to come to a close April 16, the PHE has been extended eight times since it was declared in January of 2020 and could very well be extended again for three months at a time. However, the end is in sight and the pressure is building. The implications to the larger economy and the healthcare system are significant. Payers will see a shift in their member mix due to Medicaid disenrollment, among other changes.

A feature of the PHE was to halt all Medicaid disenrollment, regardless of changes to member eligibility. Those covered by Medicaid who are no longer eligible due to changed circumstances stand to be disenrolled when the PHE expires. One estimate reckons 15 million people younger than 65 could lose coverage, even though some will become eligible at the same time for Exchange plans or other programs. However, the educational task to convey this is huge with this traditionally difficult-to-reach audience because of SDOH barriers. Many who qualify for Medicaid often fall off the rolls because they cannot or do not complete the renewal process. Changes of address, disability, illiteracy, language barriers and other challenges contribute to incomplete renewals.

The Centers for Medicare and Medicaid Services (CMS) has issued guidance for states on “unwinding” the requirements and sorting out who continues to be eligible among 76.7 million currently enrolled individuals – nearly one in four Americans. The federal money allotted to maintain continuous coverage is likely to run out before this task is completed, even with the current administration allowing states a year to finish redeterminations. States will be under significant budgetary pressure.

The industry will get 60 days’ notice before the PHE ends, according to the U.S. Department of Health and Human Services (HHS). The agency often waits until just a few days before the expiration date to extend the PHE, shortening the window for state agencies and others to notify beneficiaries that their coverage may end.

Medicaid disenrollment is just one challenge of many ahead, as grants to local governments, providers and other groups dry up. With an unprecedented worldwide pandemic in modern times, the after-effects are bound to be significant and long-lasting, but may reveal opportunities to improve the system.

“How much should a healthcare provider be reimbursed for the services they provided our member?”

While a seemingly straightforward question, the answer, unfortunately, continues to elude payers. And mistakes made while trying to answer this question contribute over $200 billion to the annual cost of healthcare in the United States.

I have spent the past 8 years in the payment integrity industry, working to address this question in some way, shape or form. But it wasn’t until I joined HealthEdge that I saw how radically different things could be.

With Source, our answer to this question was to build a solution from the ground up with the simple mission to enable customers to pay claims accurately, quickly, and comprehensively – however it is our vision and approach that will redefine payment integrity.

The payment integrity market is chock-full of vendors operating the same way they were a decade ago. They are using an outdated approach to solve for increasingly complex problems that limit visibility for the healthcare payer and hamstrings their ability to meet the increasing demands of their members and transparency in the industry. This “black box” approach enforces competition between the payment integrity vendor and the payer—where the vendor continuously profits off mistakes without addressing root cause issues for the payer.

But what if instead of competing for profits and benefiting from mistakes—which ultimately impact members, we partnered with payers to truly understand their pain points—and helped solve them?

At Source, we do not want to be just another vendor in a Payor’s complex web of payment systems. We have built an end-to-end payment and editing platform with the vision of deep partnership and moving the payment integrity industry from a black box to an open book. We do not wish to compete with a Payor and profit off mistakes, but rather partner to truly understand pain points and solve them at the time of adjudication.

We’re calling this the “Open Book” approach, where we provide the technology for payers to gain control over their IT ecosystems, address root cause issues, and ultimately cut costs that contribute to member savings.

With Source, you not only have complete control and visibility over your payment lifecycle in one place, but a dedicated partner who wants to help solve your largest and most complex payment challenges. We want to eliminate administrative waste and provider abrasion so that the Payor can focus on what matters most—their members.

We’re on a mission to challenge the payment integrity industry to do better by empowering payers with the technology and partnership they need to make healthcare better for everyone.

Learn more about Source payment integrity here. 

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.