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.

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.