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Like any other organization, communication is crucial for health plans to serve their mission: deliver the best care for their members and improve health outcomes.

Every day, members with healthcare concerns work with their health plans; it is an incredibly personal, human interaction. While technology vendors like us do not interact directly with members, it’s important that we keep the human element at the forefront of our minds and focus our efforts on making the healthcare experience a better one.

One way we do this is by considering time as a critical factor when it comes to a member’s care. Health plans understand that they must treat health-related questions from their members with the same urgency their members feel. Working together, we help our payer customers leverage technology that can increase efficiencies, improve transparency with providers, and enable solutions that quickly meet a member’s healthcare needs.

As a technology partner for payers, it’s crucial that we’re precise and our documentation is clear. We also must communicate the right messages and information to the right people and always give notice of upcoming industry changes or other things that might impact our clients’ workflow. Sharing this knowledge allows health plans to prepare and make informed decisions for their business while providing efficient customer services that their members expect.

Our partnership approach was especially important over this past year when many people adjusted to working remotely, and regular communication became an additional challenge. Several of our clients, particularly in Q2 of last year, got pulled into different workgroups and tried to figure out how best to handle COVID-19, plan for additional changes, and keep the business moving forward amidst the chaos.

COVID-19 was just one example of how quickly things can change. While health plans grapple with becoming more agile, technology vendors, too, must anticipate change, adapt, and accommodate evolving customer needs. We value our client relationships and know that maintaining a strong, supportive partnership will ultimately help our health plan customers navigate uncertainty so that they can stay focused on their mission.

One of the biggest problems the healthcare industry must overcome is learning to communicate in a digital world. Our systems all speak in different languages, sometimes even behind the walls of the health plan, not to mention between providers and the health plan. At the end of the day, the member is left to figure out what it means.

Recent regulatory rulemaking is pushing the industry into the digital world, and there is no going back. Yet, the industry still struggles with the paradox of protecting members’ data behind firewalls and policies necessary under HIPAA and other rules and releasing it out to applications unknown. There are endless pockets of information, with no reasonable way for everyone to access the correct message at the same time.

Respondents in a recent survey of 220+ health plan executives cited lack of access to real-time data and information sharing as having the biggest negative impact on provider relationships.  The frustration comes when it takes so long for providers to get the information they need to care for their patients.

In an ideal situation, a provider would have real-time communication with the plan and know exactly what services are covered for a member and what requirements might be in place for preauthorization. With real-time information, a provider can resolve an issue on first contact—a member can go into their provider’s office and not have to wait three days or even five days to find out whether or not they can schedule an elective procedure.

Reaching this ideal state is not impossible. The technology that enables real-time information sharing has been around for a long time. Look at banking, for example—we have all seen the benefits of its evolution from paper to digital. People can transfer money in seconds on their phones. Ten years ago, someone would have to go into the bank, fill out paperwork, transfer the money, then wait (sometimes hours or days) for confirmation that the money was received. These steps are not necessary today. I cannot tell you the last time I went to an ATM, spoke with a teller, or even called the bank; even then, I probably used an automated system.

While healthcare is different than finance―we certainly don’t want to lose the personal touch―both industries are highly regulated with massive amounts of data that needs to be available and secure. By looking at the financial industry’s transformation, healthcare can solve many of the causes of frustration between the members, plans, and providers and evolve the relationship beyond just verifying information.

HealthEdge is looking at ways to create synergies between the traditional processes of the industry, the rapidly changing regulatory requirements, and the laws behind these rules to develop solutions that enable compliance and provide benefits to our customers and ultimately improve the overall health of the members.

Striking a balance between standards, process, and technology will enable all of the players to communicate digitally in a manner that benefits everyone.

11,000+ baby boomers turning 65 every day and become eligible for Medicare. The Centers for Medicare and Medicaid Services (CMS) predicts that Medicare enrollment will reach 72 million by 2025, and 99% of those beneficiaries have access to Medicare Advantage (MA) plans.

Medicare Advantage continues growing in popularity because it can achieve the triple aim of healthcare by keeping costs lower for patients, improving care while providing members with additional benefits that they value.

As the fastest-growing health insurance segment, MA presents more than $360 billion in market potential. So, it’s no surprise that according to an independent survey of health plan executives, 92% of health plans want to grow their MA membership more than other lines of business; and, 96% said the value-based model of MA significantly or moderately factors into that desire.

With 25% of Medicare beneficiaries having ten or more MA plans to choose from, health insurers need to keep pace and offer the most competitive benefits.

In an increasingly competitive market, how can health plans drive customer value and stand out?

According to HealthEdge Regulatory Compliance Manager Maggie Brown, “Baby Boomers are more digitally savvy than those who previously have aged into Medicare and Medicare Advantage plans. They want more information, and they want it now!”

Baby Boomers are looking for details about how to spend their dollars, which hospitals have better rankings or pricing, and which providers offer the best level of care.

Maggie continued, “The faster health plans embrace new legislation and regulations, the better off they will be, because even before a regulation mandates that health plans must provide a certain benefit to the Medicare population, Baby Boomers already want it.”

However, the majority of health plan executives say that technology and infrastructure that can’t keep up is the biggest challenge to staying compliant with CMS’s frequent changes.

Health plans need a core administrative platform that can easily create benefit plans and fee schedules to respond to constantly changing regulations and reimbursements. At the same time, the technology must enable the plan to maintain a quick turnaround time for processing claims with a high level of accuracy.

Payers are capitalizing on payment integrity trends more than ever before, but inaccuracies continue to plague the healthcare system—contributing to the estimated $760-$935 billion dollars in annual health system waste. Administrative complexities and pricing failures are expensive for payers and increase provider abrasion and healthcare costs for members.

The problem is multi-faceted, which is why most payers take a disjointed approach to solving the 5-8% of claim dollars paid inaccurately. Multiple departments within a payer organization may use various methods, investing in duplicative solutions with separate incentives. While this may address individual problems within a department, the larger issues of transparency for providers and solving for the source of inaccuracies remain elusive.

With reliance on multiple vendors (and instances) throughout the organization, several main issues contribute to miscommunications, lack of transparency, and improper payments:

Out-of-sync update cycles: Vendors often deploy update cycles at different times, resulting in policy and fee schedules that conflict. While sometimes entire teams at payer organizations are employed to manage and coordinate the multitude of updates, they remain daunting and disruptive.

Lagging updates: Payers routinely receive or make updates to policy and fee schedules after the regulatory deadlines with further delays due to IT implementation and testing of updates. This, of course, leads to claims being improperly paid and contributes to downstream payment integrity activities that could have been prevented with up-to-date data.

A complex, siloed stack of solutions: Many payers have spent 30+ years adding technologies and processes that lead to a tangled web of data compounded by vendor management challenges, conflicting results, and costly upkeep.

“The goal is to tie together disjointed components of the payment process so that complex communications can be translated into a common language.”  – Jared Lorinsky, Chief Strategy Officer, Burgess

Recognizing these issues, some payers with enough internal expertise, IT maturity, and certain provider characteristics, opt to insource payment integrity capabilities. While this approach removes the problems associated with reliance on multiple vendor solutions, it also eliminates the possibility for vendor insights and collaboration while taxing internal resources.

Alternatively, too much reliance on vendors often keeps payers focused on incremental savings and relinquishes control (and insight) of payment integrity functionality. This model continuously patches a broken system and hinders long-term business goals and opportunities for transformation.

As we move beyond interoperable systems toward the opportunity for complete digital transformation, the question remains: how can we walk a fine line that involves the right vendors for their expertise and insight without overcomplicating an already complex system?

Every day, the limitations of legacy systems cause health plans to waste money and time fixing improper payments, leading to strained budgets and relationships with providers and members.

According to a recent survey of more than 220 health plan executives, when asked what has the greatest negative impact on satisfaction, it comes down to underpayment/overpayment/delays in payment and need for access to real-time data for providers and surprise billing/difficult transactions for customers.

It’s clear that health plans want to create better experiences for their core constituents. The survey also revealed that increasing member satisfaction and improving provider relationships are the top two organizational goals for payers.

In fact, increasing member satisfaction has remained the top organizational goal since 2018. While executives remain focused on finding ways to gain approval from their members, we’ve seen more emphasis over the past year on improving engagement strategies as part of this focus.

However, for members, the transactions with health insurers do not feel natural—it’s completely different than any other transaction consumers engage with every day.

As HealthEdge CEO Steve Krupa said on the #HCBiz Show! Podcast:

The analogy that I often go to is Amazon. When we think about Amazon and its capabilities today, we see an awesome consumer front-end experience and a great supplier backend experience where suppliers can adopt the Amazon platform and use it as a place where they can do business. Those experiences are fundamentally enabled by an autonomous transaction engine. Amazon invested in [developing] the capability to manage transactions as close to real-time as possible … and the transaction engine produces data, information, and insights that have led to a very intuitive and efficient marketplace for customers and suppliers. 

More streamlined transactions are happening across every single industry. Consumers expect their interaction with the health system to resemble the customer service they’re used to, if not better.

If health plans want to create a similar experience for their members and providers, they need a next-generation core administrative platform with data-sharing capabilities that enables them to innovate their business models and push toward a better transaction process.

To improve provider and member satisfaction, health plans must invest in forward-thinking, next-generation technology solutions that offer a better experience with efficient and accurate payments – the first time.

The industry traditionally has addressed compliance requirements by solving for the Rule and waiting for specifics to come out of CMS, or other agencies, before taking any action. We need to stop solving compliance requirements for the moment and take a more holistic approach.

My personal mission is to change the mindset of health plans to use regulation as a springboard for innovation rather than a checkbox for compliance.

With any compliance mandate, there is a good intention behind it. Health plans should figure out the intent of the Rule, why are we doing it, and what is the best way to accomplish this that will benefit the entire healthcare ecosystem?

For example, take the CMS Interoperability Payer-to-Payer Exchange of Historical Data Rule, coming up in January 2022. The Rule allows for a member enrolling in a new plan to request that the plan from which they are disenrolling extract and send up to 5 years of historical data to the new plan; And the receiving plan must be able to accept that information. As a result, data will move with a member rather than being left behind.

The Rule just says what payers must do: send and receive the information, but the intent of the law is to use the data to improve care. The exchange of data is the “easy” part; the use of the data by the core administration systems to improve members’ overall health is the desired outcome of this and other compliance requirements.

At HealthEdge, we do not look at compliance simply as a check box. We are looking not only at how we support our customers’ ability to comply with the rules but also the why behind the Rule; Aligning the solution with the impacted business process in the best way to achieve the results we need in a highly regulated environment.

I want to help health plans go beyond achieving compliance.   I encourage you to look at compliance from the perspective of process re-engineering, considering the intent of the rulemaking, identifying the value it brings, and what benefits can be created as a by-product of the Rule.

In our digital world, this is where plans will distinguish themselves and create a reputation for partnering with members and providers to enable quality and affordable care that is member-centric.