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I’ve worked in the healthcare industry for over 30 years and with Burgess for a little over ten years. At Burgess, we strive to anticipate the clients’ needs before they are even aware they have the need. We’re always looking for the next problem to solve to make the clients’ experience better and ultimately shift the overall healthcare system forward into the future.

We value our customers’ input. Getting client feedback is important and allows us to build a better product. When we introduce a new feature, we love to get positive reinforcement from our clients because it confirms that we’re hearing them, understanding them, and building and delivering the right solutions.

On the other hand, if we receive not-so-positive feedback, we always turn that into an opportunity to improve the product and make the customer’s experience better.

While there are certain problems that all of our clients share, each company experiences unique challenges; this requires us to detect those nuances and dive deeper to understand the client’s specific needs, what they want to achieve, and how we can find a solution.

Several capabilities we’ve built into the product over the years have started with one client’s particular need. For example, one of my customers recently had a special need for pricing a provider contract provision. Coincidentally, one of my colleagues on the service delivery team was working with a different client that raised the same issue three days earlier. This immediately signaled to us that this function was not just a “nice to have,” but could offer value to a range of clients. Through ongoing collaboration by listening to and sharing our clients’ feedback internally, gave this enhancement―and other features in the past― the traction and attention it needed to move forward.

The best part of my job is working with our clients. I enjoy helping our customers improve their workflows and processes, do things more efficiently and cost-effectively, and achieve their goals.

HealthEdge CEO Steve Krupa and I both graduated from The Wharton School at the University of Pennsylvania. Benjamin Franklin, who founded the institution that became the University of Pennsylvania, advised Americans to “do well by doing good,” an early and broad expression of stakeholders. He founded the Colonies’ first subscription library, a volunteer fire department, and a property and casualty insurance company to spread catastrophic risk along with founding his adopted colony’s leading educational institution. It was a mix of profit and non-profits exhibiting an advanced view of how individual success and the success of your community are inextricably tied together.

Historically, there has been a view that in order to do good for society, one must work for a non-profit, work in government, take a vow of poverty, or work in some bureaucracy. However, business is also part of the answer to creating social change.

Through Wharton and its other schools, UPenn has begun to offer programs to build the skills for social entrepreneurship, where students can learn how to develop business plans for both non-profit and for-profit ventures that contribute to social change.

Dr. Ariel Schwartz, Post-Doctor Fellow at UPenn’s Center for Social Impact Strategy, said, “the activity of any sustained venture—a business, a non-profit, a government, a university—has an effect on the world. And the effect of any organized action that systematically engages with the market or a group of people in society can be positive or negative…With careful planning, any venture in any sector can use its financial, social, technological, and knowledge resources to leave a lasting systematic positive mark on the world.”

HealthEdge values social entrepreneurship and aligns our company’s goals with what is good for society to contribute to positive social change through our business. We recognize that capitalism and social equity can work together to make the world a better place.

An example of someone who is doing well by doing good is Ric Geyer, my former grad school housemate, and fellow Wharton alum. Ric created a for-profit venture, Triangle Arts, that supports social change in Macon, Georgia.

HealthEdge promoted our values by promoting and sponsoring Triangle Arts and its mission at a recent Wharton Graduate School reunion program. The video and subsequent speech were intended to make people aware of social entrepreneurship and social ventures. Passionate about building strong communities, Ric has held various urban development roles in both Detroit and Atlanta.

Most recently, Ric was at the forefront of the urban exodus, moving an hour from Atlanta to Macon, Georgia, a city of about 150,000. While we have seen an increasing amount of people moving out of major urban areas to anything from mid-sized cities to small towns, COVID-19 accelerated this trend.

Recognizing that people still want a sense of community, culture, and connection, Ric’s company, Triangle Arts, brings the arts to Macon and combines with urban redevelopment to revitalize parts of the city with economically challenged populations.

Triangle Art’s mission ties directly to our mission at HealthEdge. Today, Triangle Arts Macon lifts up the voices in the community, creating an environment where people feel both safe and empowered. That uniquely aligns with our vision at HealthEdge, which is to innovate a world where healthcare can focus on people and not process.

At HealthEdge, we’re focused on promoting good health, working with our health plan customers to enable them to be more efficient so they can focus on providing access to quality care and creating healthier communities across the country.

As a nurse, my passion and purpose have always been to make healthcare more accessible and improve the overall health of the communities I serve. And I know social determinants of health (SDoH) are crucial for a person’s well-being. I’m always looking at what support system does a person have? Do they have access to adequate food? Transportation? To improve the health of an individual or community, we must look at these factors.

Twenty percent of healthcare costs are clinical or medical services, and the other 80 percent is around the community. I have been thrilled to see more health plans embracing social determinants of health (SDoH) and creating community-based programs that address these factors.

And at work, we are all part of a community. In addition to focusing on members’ health, as employers, health plans should prioritize their employees’ health and well-being. Health plans must consider how to make employees’ work purposeful, meaningful, and engaging.

Focusing on your employees’ well-being and creating a sense of purpose and connection is not only good for their overall health, but it’s also good for the business.

Suppose employees are not passionate about what they do or don’t think their job delivers meaningful value to an organization. In that case, it’s much more challenging to wake up every day and be purposeful about their work. There is a link between meaningful work and professional effectiveness that drives success for the entire organization.

When it comes to successful innovation in health plans, technology is the enabler, but people are drivers. Often, implementing the technology is not what causes delays; it’s getting people to adopt and use it.

An organization can invest in a technology solution, but without a purpose-driven goal, why would the employees take time to learn a new tool, configure it, and begin using it in a way that transforms the business? The health plan must provide context to how each employee is valuable and their experience and insight play an essential role in transforming the organization.

To make real change, there must be buy-in and collaboration amongst an entire organization. Employees must know how they fit into the big picture and their purpose. For health plans that focus on creating a strong community that supports employee well-being will drive business transformation.

When it comes to business transformation, the biggest roadblock is often resistance to change.

In a former role, prior to working at HealthEdge, I was among 30 consultants hired to tackle a company’s backlog of work. The client did not ask about our individual experience that they could tap into or recommendations for improving the process. The project was incredibly inefficient. We all had different skills and knowledge to help move their project along faster, but we faced resistance. The client wanted to keep the process as it was, having all 30 consultants working on the exact same tasks.

It was clear that everyone was working at different speeds. Some people were fast but had a few errors, while others were slower yet analytical. I recommended that we push to have a tiered system― the tier 1 people would quickly work through the backlog, tier 2 people audit the work, catch any mistakes, and tier 3 people focus on any complex issues that arose. Leveraging our talent in a different capacity, this process would allow our team to meet the production schedule, reduce errors and ultimately boost morale.

I finally convinced the client to let us try something new. We assigned people to the tiers where they would perform best and set up a model so that the process wouldn’t get caught in a bottleneck. As a result, we took care of the backlog that had been accumulating for months in less than 30 days.

With a fresh perspective, we implemented a new process that capitalized on the strengths and expertise of our people and allowed the company to transform and gain productivity moving forward.

That’s just one example; not every project is the same. To transform your business, it’s always key to revisit and improve processes, leverage the vast experiences of your people and find the right technology partner.

When it comes to software, it’s important for the company’s technical side and business side to work together and collaborate. When IT and business join forces, they can achieve so much more and faster.

HealthEdge, in partnership with independent market research firm Upwave, recently conducted a survey of more than 220 health plan executives across the country; results revealed that increasing membership is a top organizational goal for payers.

With increasing demands to grow membership, market pressures are changing how health plans invest the resources made available from lowering costs and increasing efficiencies― top responses included consider new partnerships or acquisitions and invest in a new geography or line of business.

This year especially, payers are facing unique pressures to grow. Many health plans lost a lot of membership due to COVID-19 and businesses closing. As the economy opens back up, health plans will focus on different ways to establish themselves and attract members as consumers re-enter the market.

We’ll see large nationals strategically entering into new geographies and product lines to expand their market share. As a result of acquisitions, large national plans also often have multiple legacy systems. I also expect to see increased due diligence in potentially consolidating those systems to cut administrative costs and have a best-in-class ecosystem. Provider-owned regional plans, which were particularly hit hard in the last year financially, will also expand new product lines and focus on member retention. Overall, innovation in consumerism will be essential across the board.

The executive survey also revealed that one of the top challenges to acquiring new members is offering the variety of plans necessary to satisfy members. In order to create new plans that appeal to the consumer, health plans must make strategic business decisions; this requires the ability to model new benefit plan design and quality-based pricing in their system against real-utilization data to understand outcomes and predictability.

Additionally, with COVID-19 and society in general, we’ve seen an increased emphasis on behavioral health. This increased prevalence will certainly impact benefit design going forward, especially with new models to reach consumers, like telehealth.

Whether through new geography, line of business, innovative offerings, or acquisitions and partnerships, health plans today want to take advantage of all available resources to expand in the current landscape.

We had three very significant Final Rules in play at the end of last year. The first one, the CMS Interoperability Final Rules, was back in May. The Transparency in Coverage Final Rule came through in November, followed by the Consolidated Appropriations Act, which included the No Surprises Act and several Transparency items signed in the last few days of 2020.

Many of the components in the No Surprises Act have a January 1, 2022 implementation date. In the middle of all of this, any solutions developed for 1/1/22 will likely coincide with the Medicare Advantage annual enrollment period, so things will get a little hectic.

To start things off, on July 1, 2021, Medicare Advantage (MA), Medicaid, CHIP, and Qualified Health Plans (QHP) on the federally facilitated exchanges (FFEs) must implement the Patient Access and Provider Directory APIs from the CMS Interoperability Rule.

HealthEdge has created a Patient Access Data Mapping. The Data Mapping uses the Common Payer Consumer Data Set (CPCDS) to bridge to the FHIR Profiles, which will be exposed to the member selected application via the Patient Access API.  We have collaborated with several customers and will finalize the draft by the end of this month.  Of course, the mapping is subject to change because this is an evolving process. We had HIPAA back at the beginning of the century, and ten years later, the Affordable Care Act came and shook things up. I think interoperability and transparency is the next big wave in healthcare.

On January 1, 2022, the Payer-to-Payer Historical Data Exchange under Interoperability also becomes enforceable.  Members can request up to five years of historical data to be sent from their previous plan to their new plan, and the new plan must be able to ingest the historical data.

Consolidated Appropriations Act’s No Surprises Act, effective for plan years beginning on or after January 1, 2021, comes into play.  Many states already have no surprise billing rules; however, this is the first at the federal level.  While we await rulemaking by the tri-agencies, we can get started on what we know from the legislation. Insured, Self-Insured, and Individual Plans that provide in-network emergency coverage must provide out-of-network emergency services coverage without preauthorization requirements and with the same cost-sharing amounts as in-network.  The same applies to when non-emergency services are received without notice by an out-of-network provider at an in-network facility.  There are also provisions addressing Air Ambulance.

For these situations:

• Cost-sharing must be applied to both in-network and in-network out-of-pocket maximums and is calculated as if the total charge is:
  • The amount required by state law; or if none
  • The median contracted rate of the plan sponsor (or issuer) for the same or similar item or service in the same geographical and the same market as of 1/30/2019 (increased by CPI-U)
• Initial payment or issue of denial within 30 of claim receipt
• Arbitration is available to resolve disputes between the Provider and Plan.

Meanwhile, providers may not balance bill except ancillary services with prior notice and consent.

Also beginning January 1, 2022, the Transparency in Coverage Rule requires virtually all non-grandfathered plans to post three machine-readable files (MFRs) to their public website every month.

The three files include the In-Network Rate File, which is the negotiated rates based on the benefit plan, provider, and service code with the rate expressed in dollars. The Allowed Amount File which is basically the out-of-network payments. The file is created from claims experience, using data beginning 180 days prior for the first 90 days of that period, where there are 20 or more claims found for a reported service code. The machine-readable file must contain the billed and the allowed amount attached to that benefit plan, provider NPI, and service code. The third file is for the Prescription Drug Coverage File.  This is out of scope for HealthRules Payer. A high-level requirement has been completed for the In-Network Rates and the Allowed amount Files and is in solutioning.

Additional items under the Consolidated Appropriations Act (CAA), all converging on January 1, 2022, include:

The Advanced Explanation of Benefits (A+EOB)

When a provider notifies the insurer or group health plan that an enrollee is scheduled to receive a health care service and provides a “good faith” estimate of charges, the plan must send an “Advanced” Explanation of Benefits (A+EOB). This advanced explanation of benefits must indicate if the provider is in-network or out-of-network, include the good faith estimates of costs and the required disclaimers.

Price Comparison Tool

The group health plan must make a price comparison tool available to members, online and by telephone. The tool compares the cost-sharing amounts that members would be responsible for paying different providers for the same service.

ID card requirements

All plan ID cards, Hard Copy, and Electronic must include the in-network and out-of-network deductibles and out-of-pocket maximums printed out.  Along with a telephone number and website for assistance.

Provider Directory Provisions

All provider directories must be verified and the information updated every 90 days. Plans must respond to member inquiries regarding a provider’s network status within one business day and then keep a record of that for a minimum of two years. The plan must also establish a database of network providers. And lastly, the plan must not impose out-of-network cost-sharing if directory or response indicated the provider was in-network as of a relevant date.

Looking ahead, most group health plans and health insurance issuers in the individual and group markets must offer an online shopping tool under the Transparency in Coverage Final Rule. This will allow consumers to see the negotiated rate between their provider and their plan, as well as a personalized estimate of their out-of-pocket cost for 500 of the most shoppable items and services, beginning January 1, 2023. The online shopping tool becomes all-inclusive on January 1, 2024, expanding to drugs, DME, and all other items or services covered by the plan.