Category: Uncategorized

There is a lot of uncertainty in healthcare today. Health plans like to know what the risk is and manage the risk. And when that risk is uncertain, it is challenging to run your business in that environment.

Many plans saw a drop in claims in 2020. However, the low level of claims will not continue indefinitely. Now, health plans must prepare for what is coming. Yet, uncertainty remains. It is still unclear how many people put off routine visits, as well as emergency care, and how that will impact healthcare costs post-COVID.

In the Annual Payer Index Survey: 2020 Report from Altruista Health, a HealthEdge company, the majority of the 177 respondents cited improving member outcomes as the top care management priority. And when asked about the effects they see with members who delayed medical care, “Forty-two percent reported member lapses in care for chronic conditions, and 26 percent saw preventable poor outcomes due to lack of routine screenings.” 

Should health plans prepare for an influx of treatment? Will costs go higher than expected due to more emergency room visits or inpatient stays? Or if it will spread out over time.

Industry consolidation is one of the biggest trends in the payer space right now. National health plans might acquire other regional plans or enter a new line of business, resulting in multiple claims systems and different point solutions. The challenge is, how do they serve their core mission with technology that isn’t necessarily made to work together?

There are dozens of steps in the claims processing workflow, and they may all use different software solutions. Suppose a health plan uses a specific solution for pricing, another for grouping and another for editing. In that case, all those applications could update at various times and communicate results differently, putting strain on internal resources to manage the workflow. And if something goes wrong, it’s incredibly challenging to pinpoint where the error occurred.

Health plans want to improve operational efficiency, but they will not get the desired outcomes with different point solutions and applications from separate vendors.

Health plans need a single solution with real-time data and analytics that provides cloud-based delivery of regular updates to ensure they have all the correct information. Take Medicare and Medicaid, for example; at any given time, something is updating somewhere in the country. Health plans need to be aware of the changes and have those codes up to date across all of their solutions.

Without a cloud-based solution, health plans need to figure out all of these changes independently, manually make updates, and manage the software on their own.

Cloud-based solutions, however, have the ability to remotely deliver updates to payment policies as they occur, arming health plans with the most up-to-date information needed to process claims accurately and efficiently. With a single instance of a solution that includes all the business rules on top of it, the entire health plan will have the updated information, no matter where they are calling it from across the whole ecosystem.

A recent study of 245 IT executives at leading health insurance companies revealed that larger health plans are interested in consolidating core systems to improve overall operations and cloud migration/technologies. The majority of respondents at larger health plans (61 percent) indicated that they plan to evaluate their core administrative processing system within the next two years.

In collaborating with health plans of diverse sizes and geographic spans, we find they all share similar challenges: improving member and provider satisfaction, cultivating brand loyalty, standing up new lines of business, staying on top of competitive pressures, improving operational efficiency, driving innovation, and maintaining regulatory compliance – all areas of opportunity given modern technology.

Where we find that plans differ considerably is in the approach, scope and dependencies involved in finding solutions to these challenges. The largest, nationally-focused health plans typically evaluate solutions from both local and global perspectives, looking at issues from the big picture within their organization alongside individual project requirements. While the immediate challenge being addressed may be highly specific to the needs of a geographic region or a line of business, they must take into account broader considerations such as corporate-wide IT initiatives, project prioritizations, resource allocation, existing technical debt as well as assets that could be capitalized on, the potential for solution application across other regions or lines of business, and more.

Whether on a broad national scale or in regionally-based health plans, data integration is also a significant opportunity when modernizing—for both internal- and external-facing purposes. From an internal perspective, key decision-makers require the ability to analyze comprehensive, up-to-date, well-structured data from across the enterprise in a single place to make business-critical decisions for the entire organization. From an external perspective, centralized access to real-time, accurate, enterprise-wide data is essential to creating a cohesive and meaningful customer experience across a health plan’s spectrum of products.

Due to their size, diverse regions and lines of business, and often a history of growth through acquisition, many larger plans have accrued numerous systems over time. These may include applications running on aging technology and/or requiring multiple surrounding point solutions to run effectively, creating all sorts of additional integration challenges. Maintaining this type of complicated ecosystem dramatically impacts the IT costs and resources required to keep all the components current and updated. The integration between these systems and solutions is crucial for delivering on innovation strategies and the overall success of the business. Today’s technology can solve these considerations – with the added bonus of agile implementations that require less time and disruption, which is to be expected compared to systems implemented 10-15 years ago.

In alignment with these findings and observations, we’ve found that while the pain associated with many of the challenges outlined can be more acute the larger the plan, all health plans need a highly interoperable, real-time technology platform that can handle multiple lines of business (LOBs), with the flexibility to react quickly to shifting market dynamics and the reusability to configure and streamline a diverse set of benefit plans and provider contracts. They also need the assurance that their leading-edge platform delivers scalability and versatility to extend across the business, using “Lego” like software that allows for reuse along with regional/LOB configurability. This provides the agility necessary to orchestrate technology implementations across regions and LOBs based on an organization’s unique drivers and dependencies.

Health plans need a technology partner with next-generation solutions that understands, appreciates, and can help to address the big picture.

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.