Category: Uncategorized

Background

Many health plan customers have historical workflows that rely on batch processes – file a claim on Day 1 and the results are available on Day 2 (or 3 or 4). Because of limitations with compute, storage, and network performance years ago, the idea of processing a piece of information in milliseconds was unheard of, primarily since it was not technically feasible to do it in a cost-efficient manner. However, in 2022, real-time, scalable, and global systems are commonplace.

Innovative companies across industries have taken advantage of these disruptive trends to deliver seamless, digital experiences that we take for granted today -– when we buy with 1-Click on Amazon or watch our Uber driver inch his or her way along the map on the way to pick us up. These become the baseline expectation. If you are the consumer of health insurance, you also expect to participate in these experiences. If you are the provider of that health insurance, you are expected to deliver this experience.

Real Time APIs (for Business Outcomes)

HealthRules Payor (and all HealthEdge products) are designed with real-time APIs. It is one of the reasons why Payor continues to be a Gartner Next-Gen solution for the Core Admin Processing Systems market. This is now table stakes for participating in this market and the baseline of our customers, who are modernizing for the coming decade.

Real-time APIs are the product that close the gap between various cloud-based health systems (CAPS, EHR, Pop Health, Portals, Mobile) and enable new experiences for members, providers, and users of these systems. Today, customers leverage the rich suite of real-time APIs to power member portals, send out correspondence, or determine member costs before they go to the hospital for a procedure. For example, HealthRules Payor real-time Trial Claim API allows for health plans to meet the government mandate for member specific pricing and cost sharing through the price comparison tools, as well as the AEOBs (Advanced Explanation of Benefits)

Real Time Events (for Business Outcomes)

The next stage of evolution for HealthRules Payor’s (HRP) integration capabilities is real-time event streaming, which is sometimes called stream processing. It sounds technical – but is conceptually easy to understand – and it solves some of the challenges that current businesses require to be even more responsive to customers. Created by LinkedIn over a decade ago and managed, now, as open source by Apache, Kafka is a technology used by most Fortune 100 companies to help with business events that occur thousands, millions, or billions of times per day (e.g., data from IoT (Internet of Things) device, a new member enrollment, LinkedIn message posts).

To achieve this, Kafka uses what is called a publish-subscribe messaging architecture. At the core of Kafka (and event streaming in general) is the concept of an “event” – i.e., something happened. It could be that a member got enrolled, a claim has been paid, or a heartbeat on a heart rate monitor exceeded a threshold. These events in small quantities or millions are “published” by applications (also called “producers”) and are “subscribed” to by downstream applications that need this information (also called “consumers”). And these events can be organized into logical “topics”. So, events related to enrollment go in one stream and events related to billing, perhaps, another. If each published event were a 3×5 card with information, those events are placed on to one of many user-defined conveyor belts in time order with each conveyor belt reflecting that different topic.

As a concrete example, an event could be a new member has enrolled for health coverage. As the source application, HRP “publishes” this event to the “Membership” topic. Any downstream application such as a correspondence solution for member ID cards or a member portal can “subscribe” to this topic. A depiction of this architecture is given below. If you want the fun, non-technical, children’s storybook illustration of how this works, please check this link out. It’s very well done.

Source: https://www.slideshare.net/KaiWaehner/the-rise-of-event-streaming-why-apache-kafka-changes-everything

HealthEdge’s objective with creating a Kafka-based event streaming architecture is to help our customers achieve digital transformation by democratizing the data in the HealthRules ecosystem, allowing them to leverage the power of “real-time” healthcare data to build modern, digital, world class experiences for their members.

Unique Capabilities and Use Cases

Because health plans are an ecosystem of integrated solutions with a CAPS at the core, there are some distinct advantages of this real-time messaging system that are especially relevant for payers:

Fault Tolerance – Because event producers and consumers are effectively de-coupled through this event streaming service, HRP can continue to publish events even if consumers are not online and vice versa. The events are backed up and consumed when the consumers come back online.

Performance – Kafka is extremely low latency (fast) and scales (powerful) to support millions or billions of events without impacting the core performance of HRP. Customers can continue to add events and topics with any number of consumers downstream and not impact HRP’s performance.

Highly Configurable – Instead of each additional use case for real-time data from HRP (and other HealthEdge products) needing an integration project or custom APIs, customers can use (and re-use) the same topics and published events across various consumers and configure these streams through a web UI.

Healthcare payors can configure and consume different data streams for a wide variety of use cases … use cases that we’re familiar and newer ones afforded by the performance and reliability:

Connecting with enterprise apps or other internal systems – Payors can use these data streams to connect to customer/provider service apps (enabling real-time response to customer and provider issues) or CRM (Customer Relationship Management) systems like Salesforce or to power new-age apps like chatbots.

Power their own AI/ML algorithms – The scale and reliability of these data streams enable payors to use them to power their custom ML models for complex use cases like fraud detection.

Analytics or dashboards – Customers with their own centralized analytics and dashboard capabilities can use the data streaming through topics to power these dashboards in real-time with claims, member and other HRP data.

A Step Ahead

Real-time experiences for members and providers are both here today, but also growing in sophistication and complexity to push the art-of-the-possible. HealthEdge is committed to keeping our customers a step ahead in delivering these experiences through evolving technologies applied to business outcomes.

Learn more about HealthRules Payor here.

Over the last 3 years, I’ve helped new HealthEdge clients implement our software. During that time, I’ve learned countless tips and tricks to improve the implementation experience.

There’s the technical software implementation, but today we’ll be looking at the people side of implementation. The team members who will be sunsetting the old software, implementing the new software, and linking it into the ecosystem.

These are my top 3 tips for a smoother software implementation:

1. Create a shared vision of the future

Even with the best possible outcome – change is hard. The people on your team are grappling with all the balls they’re currently juggling plus trying to learn this new system and get it plugged into your ecosystem. It’s natural to resist change and cling to the status quo.

The key is to create a vision of the future that’s so exciting and engaging your team can’t help but get pulled into the possibility of this amazing future state. Make the vision so compelling your team can’t help but be intrigued by the new software – even with the imminent growing pains.

For example, a health plan that implemented our product Source, achieved an amazing ROI after implementation:

• Decrease of 800,000 erroneous claims per year for an estimated savings of $4M/year
• Automated claims process saving approximately $6-12 per claim
• Reduced IT overhead, saving $350-500K annually

By getting your team excited about the possibilities and demonstrating how amazing the future can be AFTER the change, you get them engaged at the onset of the implementation.

2. Begin with the end in mind: workflow & operating procedures

It’s so easy to take a new piece of software and try to adapt it to the old way of doing things. This leads to recreating old systems, riddled with workarounds, and partial functionality. It’s a surefire way to get your team feeling frustrated and disappointed with the new software.

One of the things we focus on in HealthEdge’s Education Services is analyzing business scenarios. And then, we optimize workflow and operating procedures for those scenarios.

Encourage blank space, white board thinking – how can we leverage this innovative technology to optimize and enhance our way of work?

3. Customize training and onboarding

Each of our customers has a different business need for their implementation, and their team members have different roles and responsibilities. Custom instruction that is tailored to your needs is vital to engaging your team because each person who will be interacting with the new software wants to know, What’s in it for me? What do I need to know to be able to do my job well in this new environment? We don’t want to bore experienced analysts or overwhelm team members with less experience.

Unsurprisingly, the confidence gap is a huge barrier to software acceptance. Providing customized training and onboarding helps employees feel confident using the new software. There’s a direct correlation between new software training and new software optimization and acceptance.

HealthEdge Education Services

HealthEdge has a team dedicated to education and implementation success. I’m proud to be a part of our Education Services and help our new customers successfully implement our suite of products. Learn more about our Implementation Services here.

To remain competitive in today’s rapidly changing healthcare market, health plans need a modern solution that can easily integrate across their enterprise to infuse more accurate and timely data into every corner of their organization. There is no better place to expose the implications of bad data than claims payment administration process. This article drills deep into the importance of having consistent, accurate, and transparent data.

The Current State of Data Among Health Plans

Health plan leaders must challenge the inefficient status quo that comes with legacy claims processing systems and invest in modern technology that enables data consistency, accuracy, and transparency, which will result in greater operational efficiencies and more informed business decisions.

Today, bad data is estimated to cost the healthcare industry $314B annually and negatively impact an organization’s revenue by 10-25%. The case for more accurate data has never been stronger, given the rapidly changing dynamics of the Medicaid system and the reality of the waste:

• 5.8% expected annual Medicaid enrollment growth
• 9.5% claims payment error rate
• $25B approximate annual MCO Medicaid spend on admissions functions
• $36B improper Medicaid payments in 2019

Good Data Means Good Business

The implications of having good data flowing into and out of your organization’s systems has implications across the entire business. In particular, the claims payment processing team depends on good data for its daily functions, such as claims edits, audits, pricers, analytics, and even contract terms and negotiations.

In addition to the efficiency gains, good data also drives more informed decisions, because data is the foundation on which business assumptions and decisions are made. Provider relationships improve due to the reduction in payment recovery activities. Plus, when it comes time to respond to a CMS audit, having good data means the difference between dedicating valuable resources for days on end vs. having a few resources respond quickly and confidently to address the requests.

When good data is driving the business, health plans are able to:

• Lower operating costs: Payers reduce FTE time dedicated to overpayment recovery and redirect the resources to more productive analysis.
• Decrease operating risks: Automating claims processing reduces the chance for human error that can occur when using spreadsheets or manually updating data when using disparate systems.
• Improve provider relationships: Increased transparency and fewer overpayment recoveries will help ease provider abrasion, and the partners will recognize clerical time reduction in deadline with payment issues.

A Fresh Approach to Good Data

To achieve long-term goals of consistent, accurate, and transparent payments, successful organizations have focused on:

• SaaS technologies
• Integrated ecosystems
• Centralized data

As a SaaS-based solution, Source is empowering healthcare payers who have Medicare, Medicaid, and commercial lines of business to leverage a single, unified platform that natively brings together up-to-date regulatory data, claims pricing and editing, and real-time analytics tools. These payers have a single source of truth and a single point of accountability.

More specifically, Source’s transformational approach to payment integrity allows payers to deliver accurate, defensible payments to providers in a single pass with precise audit trails and business intelligence tools that help payers model and forecast scenarios with total confidence.

But it doesn’t stop there. Source works seamlessly with a wide range of data and solution providers, including its sister solutions: HealthRules® Payer core administration system and GuidingCare® care management solution, to leverage the power of more accurate data.

The Business Case for Good Data

When evaluating the return on an investment of a recent Source-powered health plan, the results are undeniable:

Financial Impact:

• Decrease of 800,000 erroneous claims per year for an estimated savings of $4M/year
• Automated claims process saves approximately $6-12 per claim
• Reduced IT overhead, saving $350-500K annually

Customer Service Impact:

• Higher regulatory compliance and consistency
• CMS audit support
• Increased transparency on payment results
• Actionable data for improved business intelligence

Learn more about good data

Check out our latest white paper that discusses the complexities of healthcare data and how bad data can lead to inaccuracies and waste. Using technology solutions to address this issue, payers can harness data as a strategic asset and create positive change across their organization and for providers and members. Read now.

Sources:

1 https://www.cms.gov/newsroom/press-releases/cms-office-actuary-releases-2017-2026-projections-national-health-expenditures

2 National Health Expenditure projections, 2017-26: Despite Uncertainty, Fundamentals Primarily Drive Spending Growth; Centers for Medicare & Medicaid Services, Office of Actuary, National Health Statistics Group

3 https://www.forbes.com/sites/adamandrzejewski/2019/03/23/federal-agencies-admit-to-1-2-trillion-in-improper-payments-since-2004/?sh=64484646352a

4 https://www.forbes.com/sites/adamandrzejewski/2019/03/23/federal-agencies-admit-to-1-2-trillion-in-improper-payments-since-2004/?sh=64484646352a

The non-profit organization CAQH® has been issuing a steady drumbeat of reports over the years about how much money and time could be saved across the healthcare industry by switching transactions from paper-based to electronic. It’s fascinating to see the progress over the years as the industry transitions, yet despite obvious savings, many think progress is still much too slow. The 2021 CAQH Index is just out in early 2022, reporting that important shifts have taken place in healthcare administrative operations during the pandemic. These are hopeful indicators.

Prior authorization is an area that changed dramatically during the pandemic, as the requirements were mostly suspended or waived during the urgency of providing care to jampacked healthcare facilities. The volume of elective procedures also decreased as consumers shied away, lowering the rate of prior authorizations by 23 percent. Automation of prior authorizations in general also lowered the time providers spend on this process. Overall automation of prior authorizations has increased from 21 to 26 percent, lowering the cost to the system by 11 percent to $686 million.

Prior authorizations help providers and health plan members stay within the rules and criteria governing their plans. They ensure that providers operate within the most up-to-date and respected clinical decision-making criteria. But they do create payer-provider friction that can ultimately filter down to health plan members in some form.

Last year, the GuidingCare business unit of HealthEdge worked with a valued customer, Priority Health, to develop an automated prior authorization process under a unique set of circumstances. Priority is part of the Spectrum Health System, which means that the GuidingCare® implementation team was able to solicit the direct and specific input of Spectrum physicians as to what would be most helpful in a portal for prior authorization. The teams worked together to create a provider-friendly solution that dramatically reduced the time spent on prior authorizations. The portal allows providers to receive authorizations in a matter of moments, allowing more complex requests to be routed quickly for review of medical necessity. One-click messaging offers document and image upload on both ends. With 80 percent of requests being approved at some point, valuable data is being generated about which prior authorizations could be eliminated altogether.

The power of automation and data are changing the landscape. Payers and providers both need to jump on board and help CAQH turn out an even more encouraging reports in the future.

Learn more about GuidingCare here.

We all know at this point we are experiencing a never-before-seen shift in what employees expect from their employers. These changing expectations are especially true for managers. Belonging and connectedness with other people, primarily one’s manager, is one of  the most accurate predictors of whether someone stays or decides to leave. You expect them to do their absolute best for you, are you giving them your absolute best?

This is not a “how-to” article or a list of the “top ten things” to make you a better leader. This is a call to action to shift how you think and approach managing your team from a lens of humility. Great leaders are humble. But being humble doesn’t mean you are weak. It means you are willing to admit that you still have things you can learn, it means you can ask for feedback from your team, and it means you never want to stop growing and raising the bar for yourself and ultimately for your team.

It has been proven time and again that top performers do not leave organizations as much as they leave…. poor managers! A top performer who reports to a strong and encouraging leader that brings out the best in them will NOT want to leave. Are you that leader? If so then I encourage you to keep reading as I do have some strategies that can help you retain your best people.

400% Better: The secret of high performers

Author, researcher, and coach Dr. Ruth Gotian says “high performers perform 400% more than the average employee.” Let that sink in. This means the employees you rated as “Exceeds” on their performance review are doing 4x as much work as their colleagues who were rated “Meeting Expectations”.  We owe it to them to show up as our best selves and provide the very best employee experience.

Be the example of what you expect. Every day you have an opportunity to show up as the leader with a smile on your face and make sure that you give everyone the same feeling of importance. Create an environment where people feel heard and can contribute.

Motivation & Feedback

Managers often spend time focusing on their underperformers thinking it’s their job to help motivate them to do better. Do not ignore your top performers and think that their level of self-motivation and commitment to excellence is enough and they do not need you. They do! Make it a priority to give them clear and candid feedback about how they are doing and how they can improve.

Purpose & Meaning

Give them a sense of purpose in the work they do. Show them they are important by challenging them, asking more of them, giving them stretch assignments and projects that have clear visibility to higher-ups and key-decision makers.

Make sure your best people feel valued and appreciated by providing timely and meaningful recognition. This is not just about money, which is very important, but often secondary to that sense of pride when you, as their manager, recognize them for great work. This can be as simple as a thank you, an acknowledgment during a team meeting, a call-out on Slack, or special assignments. It’s very important that you understand how someone wants to be recognized as this shows you care about what is important to them.

Autonomy & Flexibility

Workplace flexibility is essential in organizations today and that does not just mean working from home. Where possible, give autonomy when it comes to work schedules, time off, taking breaks, and caregiving leave. Our home lives and work lives are intertwined and finding that balance is necessary for both employers and employees.

Communication

We think we are good communicators but in fact we have a lot of work to do in this area. Working in a remote environment has made the mastering of great communication skills imperative to organizational success.  A recent Harris poll found that 69% of managers are uncomfortable communicating with employees and 37% are uncomfortable giving direct and constructive employee performance feedback. What kind of communicator are you? Don’t know? Ask your team.

Leading people, leading teams is a privilege

If all of this feels like work to you, it is but leading others is a privilege, and you have this incredible opportunity to change someone’s life every single day. It’s time to start showing up like it matters to you. Invest in your development, create a team environment where people feel heard, invest in your employee’s development, take the job of being a leader seriously. We need you!

 

Sources:

Resource: Coaching for Leaders with Dave Stachowiak podcast, How to Lead and Retain High Performers, February 13, 2022

Alan Collins, Success in HR, https://successinhr.com/newhrleader

Blog: Good Managers are Great Communicators

In my prior role as a health plan CIO, one of my responsibilities was to evaluate, select, and justify software solutions – and often to prepare materials to seek funding and/or approval from a Board of Directors.  HealthEdge helps to arm health plan CIOs and other health plan leaders with the information necessary to justify selection of our software solutions.

While no two boards are the same, these tips have helped me achieve success most often.

1. Understand group dynamics and individual personalities

One of the most important things to know and understand is that boards are made up of individual personalities – and that their collective presence has a group dynamic. The key is to understand the fabric of your particular board and the individual personalities.  Some things to discover are their individual backgrounds, their current career and aspirations, their passions, their relationships in the industry and community.  What are their individual and group goals?  What does success look like to them?  What information do they require to feel confident making a decision?

And, very important – be sure to anticipate each board member’s questions for every topic or decision put to them.

Understanding your unique board and board members ensures you can tend to each board member the right way.  Once you understand your audience, you can come fully prepared to answer questions they are likely to ask.  With that understanding and preparation, you may even get lucky and win their approval with few questions.

2. Build Trust.  Be Transparent.

A savvy board of directors can sniff out an unprepared presenter easily.  It’s important to respect their time.  In my experience, the majority of boards (and most others) appreciate honesty and transparency – whether bad news or good.  They will respect the candor.  They generally do not respond well to being served what could be perceived as a “sales pitch”.  They may even cringe at a lengthy slide deck.  A lot depends on the board personality.  Whether sharing good news or bad – the direct approach is best.

Once the board becomes familiar with your transparent and honest approach, the building blocks of trust start to accumulate.  This doesn’t happen overnight but is the critical foundation of a solid relationship with the board.  The ability to connect with the board and influence change hinges on this relationship and the trust you build.

I recall a memorable board meeting that was a turning point in a trusted relationship.  As I stepped to the podium to present my information and request funding – I examined their faces and gambled.  They had seen and read my advance material – they seemed anxious to not have a lengthy meeting.  In that moment, in reading their body language, I asked if they’d rather I run through my presentation or simply respond to their questions.  The board members looked back and forth at each other, asked two questions, voted in favor of funding the initiative – and then thanked me for my brevity.  Trust had been established.  This never means that one should become overly confident and comfortable.  Board members often rotate in and out, sometimes on a regular schedule – and that trust foundation must be continually maintained.

3. It’s more than just cost

When you think about implementing a new software solution, cost is obviously a significant consideration.  As you well know, there’s more to a selection than cost.  It’s advisable, in most cases, to have a consistent evaluation and scoring approach to document the selection.  Cost is one criterion, as are these items below:

• Competition: Who are the competing vendors?  How do their solutions compare and contrast?  How are they aligned with your needs as well as your mission and vision?
• Experience: how much experience do the software vendors have?  How much with companies like yours?
• Reputation:  What is each vendor’s reputation within the industry?  What do industry experts say about each (e.g. Gartner, Forrester, etc.)?  What do references say?
• Software development/maturity: Has the software been fully developed to the level your organization needs?  What is on the product roadmap?
• Implementation: What does implementation look like (duration, process, etc.)?  How much time commitment is required of your team?
• Partnership/Trusted Advisor: Is the vendor capable of being direct, telling it like it is, and being a true advisor?  Do they provide experts in your industry who can advise you?  Can they be a true partner, not just a “vendor”?  Can they clearly demonstrate an understanding of your business needs, where you’re coming from, and how they intend to help you get to where you want to go?

4. Be Concise but Thorough

There is a significant volume of information that contributes to the ability to select a new software solution.  The personality and dynamic of the board, and your knowledge of them will help determine how much of that information is needed for their approval – and in what format it should be presented.   In many cases, the board won’t need or want all the details.  Based on your understanding of the board, determine what they need and how best to present it.  An evaluation matrix can be helpful to succinctly address the areas mentioned above – and allow for questions.

5. Be prepared – common questions to have answers at the ready

While no two boards are alike, there are common questions. Make sure you have answers to these available.

1. What is the problem we are trying to solve?  What is the business need?
2. What is the technology need or impact?
3. How much is this going to cost?
4. How long is it going to take to recover the cost?  What is the ROI?  How has this ROI been proven in the past?
5. What are we going to get out of this?
6. How was the recommended solution evaluated and selected?  Why was that solution ranked #1 – and is #2 a valid backup plan?
7. Is it the right time to do this?
8. Would it have been less impactful if we had made this decision a few years ago?  Or are we late and need to do this as soon as practical?
9. How long will the new solution last?
10. What are the ongoing maintenance costs?

Hopefully something from this short blog will be helpful the next time you are presenting to your board. When you are ready to select a HealthEdge product, we are here to help you prepare for your Board meeting.