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When it comes to claims processing, it’s easy to look at an error rate of 3-7% and be satisfied with your progress. But if you dig deeper, you may see a different, more concerning picture. Every year, health plans lose an estimated $86.49 billion dollars due to incorrect payments. Don’t get stuck spending valuable resources on just managing and reconciling data.

Ensuring payment integrity in healthcare is essential, but the process is full of hurdles and can be costly. You might find your health plan fighting against outdated or inaccurate edits, depending too heavily on external vendors, held back by a lack of customization and flexibility in your payment processes, and stuck in slow development cycles. These issues aren’t just annoying—they can lead to mistakes, inefficiencies, compliance risks, and a lot of frustration for both your members and providers.

Common Claims Editing Challenges for Health Plans

In a recent webinar, a HealthEdge® expert discussed how health plans can take control of business rules and create their own edits to improve claims processing. During the webinar, our audience reported that some of their biggest challenges include: relying on external partners, billing errors, and keeping up with regulatory changes.

These responses demonstrate health plan needs for more adaptable solutions, less reliance on third-party vendors, and staying up-to-date with regulatory changes.

We also found that 84% of the webinar participants heavily depend on external partners for managing intellectual property (IP). Relying on third-party vendors for important tasks like editing and rule creation can lock health plans into external systems and processes—making it more difficult to adapt to meet new regulations or adopt new systems.

Involved third-party partnerships can also become less cooperative, leading to external vendors benefiting from recurring problems instead of working together to solve them. Plus, depending on external vendors can be more expensive and introduce security risks over time.

 

 The Advanced Custom Edits (ACE) solution from HealthEdge Source™ puts the power back in your hands by offering an advantage over traditional approaches to payment integrity. With ACE, your health plan can create edits that are tailored to specific organizational policies and data. This means you won’t have to wait through lengthy development cycles or use more of your budget for external help. Plus, you have complete control over the final product, ensuring it aligns perfectly with your plan’s unique needs.

No one knows your data and policies better than your team. The ACE solution recognizes this and provides the efficiency and flexibility your plan needs to take ownership of your payment integrity processes. By empowering your team to create their own edits, ACE fosters a more collaborative and solution-oriented approach that leads to greater accuracy, efficiency, and cost savings.

Benefits of Advanced Custom Edits from HealthEdge Source™

HealthEdge Source™ is the ultimate solution for payment integrity. It seamlessly integrates with existing adjudication systems, providing a centralized platform to manage all your health plan’s editing requirements. Whether you require standard, custom, or third-party edits, Source efficiently handles them all with speed, accuracy, and transparency. Additionally, Source offers powerful analytics and reporting features to monitor your payment integrity performance.

Advanced Custom Edits are accessible through the Source user interface, equipped with all the familiar functionalities of Custom Edits. This point-and-click tool allows you to effortlessly create complex edits in the user interface, test the edits, and activate them in just minutes. Whether you need to rectify billing errors, modifier abuse, frequency limits, duplicate claims, downcoding, or any other payment integrity issue, you can accomplish it all with ACE.

The Advanced Custom Edits tool is here to put control back in your health plan’s hands. Some of the primary benefits of leveraging ACE include:

• Build edits based on your specific policies and data without waiting on external vendors or paying hefty fees.
• Create and update edits in minutes, without involving IT resources, to keep pace with changing regulations and policies.
• Ensure your edits are tailored to your health plan’s exact needs, minimizing errors and ensuring compliance.
• Prevent overpayments, underpayments, and fraud, saving you time and money.
• Easily understand how your edits work and share them with your team for better collaboration.

Benefits of Advanced Custom Edits from HealthEdge Source™

While there are many benefits of leveraging Advanced Custom Edits, we gathered three of the most valuable ways the tool impacts payment integrity processes for our health plan customers.

Reduce Duplicate Claims

Duplicate claims occur when the same service is billed more than once, either by the same or different providers. This can happen due to errors, miscommunication, or fraud and cause issues like overpayments, underpayments, or unnecessary costs.

With Advanced Custom Edits, health plans can create a duplicate edit that checks or compares any selected field, such as date of service, provider, CPT codes, modifiers, charges, and more. Users can also deny, adjust, and append claims as well as make a simple or complex duplicate edit.

Create Frequency Limits

Frequency limits restrict the number of units, visits, or services that a member can receive in a certain time period. They are based on medical necessity, clinical guidelines, or contractual agreements and can prevent overutilization, waste, or abuse.

With ACE, you can create a frequency edit to identify claims that exceed your frequency limits based on internal policy and data. Users can filter by fields such as CPT codes, modifiers, revenue codes, and providers, in addition to using different operators, such as equals, less than, greater than, etc.

Identify Downcoding

Downcoding is a practice where a provider bills a lower level of service than what was actually provided, or what was documented in the medical record. It can happen due to errors or misunderstanding. It can result in underpayments, compliance issues, or quality concerns.

With ACE, you can create a downcoding edit that detects claims that have a mismatch between the facility and the physician level of service, based on your policy and data. Like with Frequency Limits, users can filter by CPT codes, modifiers, type of bill, providers, as well as operators like equals, less than, or greater than.

Frequently Asked Questions about Advanced Custom Edits

How do users test the edits that you create with ACE?

Users can test the edits in several ways:

• Monitor Mode: Observe how your edits perform on live claims without affecting the adjudication process.
• Batch Processing: Run claims against your edits in bulk.
• Manual Claim Portal: Enter claims manually to see the results.
• Analytics and Reporting: Track and measure the impact of your edits.

How do users document or share the edits you create with ACE?

Use the notes feature within the tool to document or share edits:

• Add Notes: Include links, references, or any other relevant information.
• View Notes: See notes added by other users, including the date and user name.
• Audit Trail: Create a detailed audit trail and collaborate with team members and stakeholders.

Are there limitations or special permissions needed to access ACE?

There are no specific limitations or special permissions required to access Advanced Custom Edits. It is designed to empower teams to manage their own content and intellectual property.

Can you provide more information on how advanced custom edits can help reduce dependency on external partners?

The ACE tool reduces dependency on external vendors by allowing teams to enact their own policies, create custom edits specific to their needs, and centralize the payment integrity process by eliminating the need for new editing and post-pay vendor solutions.

Is ACE a replacement for existing custom edits or a new separate feature?

Advanced Custom Edits is a new feature developed to provide advanced custom editing capabilities. It enhances existing custom edits by offering more control and customization.

The recent HealthEdge webinar provides valuable insights for health plans seeking to improve payment integrity and reduce dependence on external vendors. The session provided information on payment integrity topics vital to many health plans, such as billing errors, modifier abuse, frequency limits, duplicate claims, and downcoding.

To discover how ACE can benefit your health plan’s payment integrity efforts, watch the webinar recording.

The traditional post-pay model has long been the standard in healthcare claims adjudication. However, it can result in significant administrative burdens and increased costs for healthcare payers. Providers are left to deal with the impacts, such as claim rejections that lead to financial setbacks and strained relationships.

A pre-pay model offers a solution by resolving errors before claims are paid. This proactive approach reduces costs and enhances the experience for payers and providers. By streamlining workflows and implementing robust pre-payment processes, health plans can expedite claims processing while reducing unnecessary payments and appeals.

Industry Trends Driving the Shift to Pre-Pay Review

As an industry, the increased focus on care quality and efficiency is changing how health plans deliver and reimburse for care services. As payers and providers strive to improve outcomes without increasing costs, 4 key components have emerged as most influential in supporting pre-pay initiatives.

• Value-Based Care: The shift toward value-based care models from fee-for-service highlights the need for accurate and timely payments. Pre-pay review supports this trend by making sure that providers are fairly compensated for the value of the care they deliver—thereby helping improve outcomes while controlling costs.
• Risk Adjustment: Risk adjustment models are becoming increasingly complex, making accurate coding and documentation crucial for maximizing revenue. Pre-pay review helps identify and correct coding errors before claims are submitted.
• Advanced Analytics: The availability of data and advanced analytics tools allows health plans to identify potential issues with claims more efficiently. This powers predictive models that can flag high-risk claims for pre-pay review, enabling health plans to address problems before they escalate. This proactive approach reduces the likelihood of claim denials and rework.
• Regulatory Compliance: Healthcare payers operate within a complex regulatory environment. Pre-pay review helps health plans ensure compliance with fraud, waste, and abuse regulations. By addressing issues upfront, health plans can avoid costly penalties and maintain a high standard of integrity.

Benefits of a Pre-Pay Model

A pre-pay model facilitates accurate claims reimbursements, helping payers accelerate transactions, identify root causes of incorrect payments, and decrease claim denial rates. It is a step forward in creating a more optimized and cost-effective payment ecosystem. Primary advantages of a pre-pay model include:

• Claim Accuracy: Reduces errors and denials by proactively verifying eligibility, medical necessity, and authorizations before payment.
• Administrative Efficiency: Minimizes manual intervention and risk of rework by identifying and addressing issues before claim submission.
• Cost Control: Prevents unnecessary services and detects fraud early, which can lead to substantial cost savings.
• Provider Relationships: Timely claim payments, fewer denials, and transparent communication foster trust and build strong provider relationships[AM2] . Health plans that prioritize accuracy and efficiency in claims processing are more likely to retain high-quality provider networks.

Challenges with Implementing a Pre-Pay Model

Implementing new processes and solutions can be complicated. From earning team buy-in and managing expectations to training and adoption, there are several hurdles health plans might face. But the right technology partner should be able to answer your questions and support your organization throughout the implementation process.

Data Integration

Integrating different data sources can be a major obstacle in implementing a pre-pay model. Health plans often rely on outdated systems that struggle to communicate with each other, impacting the accuracy and speed of pre-payment claim reviews. Leveraging an integrated payment integrity solution can facilitate data-sharing and claims processing.

Technical Barriers

Setting up and configuring new systems can be cumbersome and time-consuming. Upgrading infrastructure, implementing advanced analytics, and retraining staff require significant financial and time investments. Organizational buy-in is crucial to overcome adoption roadblocks.

Financial Considerations

Shifting to pre-payment requires upfront capital for new systems and ongoing operational costs. Despite the promising long-term benefits of a pre-pay model, health plans must carefully consider the financial implications of such a transition and prioritize their adoption timelines accordingly.

Cultural Transformation

Implementing a pre-pay model requires a cultural transformation within the organization. Employees must adapt to new roles and responsibilities, and health plans must foster a culture of continuous improvement and innovation. Effective change management strategies from the beginning of the process are vital for maintaining long-term commitment.

Prospective Payment Integrity Solution for Pre-Pay Accuracy

To make this transition easier, we have designed HealthEdge Source™, an integrated prospective payment integrity solution. Source can support payers across all lines of business, providing real-time claims audits and analytics while addressing common challenges associated with pre-pay implementation.

The Source platform can enable the transition to a pre-pay model through:

• Data Integration and Standardization: Leverage up-to-date information from claims, members, providers, and contracts—all seamlessly combined and standardized accurate analysis.
• Comprehensive Content Library: Access the latest clinical, coding, and payer guidelines, updated bi-weekly to ensure claim accuracy. This comprehensive content library helps health plans stay current with industry standards and best practices.
• Advanced Automation: Accelerate claim processing through real-time, cloud-based editing and pricing features that reduce manual intervention.
• Robust Analytics: Identify trends, patterns, and anomalies across your payments data to inform data-driven decisions and workflow optimization.
• Flexible Configuration: Adapt to your health plan’s unique needs with flexible and user-friendly configuration options.
• Reduced Vendor Dependency: Manage edits in-house and increase how much control your plan has over payment integrity.

How HealthEdge Source Supports Pre-Pay Review

Identifying Potential Issues Early

By applying comprehensive edits and analytics, Source can flag claims with potential errors before payment is issued. This early identification helps prevent costly mistakes and reduces the need for rework.

Improving Claim Accuracy

Addressing upfront issues helps reduce claim denials, appeals, and rework, leading to increased claim accuracy. Health plans can ensure that claims are processed correctly the first time, enhancing overall efficiency.

Enhancing Operational Efficiency

Automation and streamlined workflows contribute to faster claim processing and reduced administrative costs. Health plans can allocate resources more effectively, focusing on strategic initiatives rather than manual claim reviews.

Supporting Data-Driven Decision-Making

Source provides valuable insights into claim trends and performance metrics, enabling data-driven improvements to the pre-pay review process. Health plans can use this information to continually refine their processes and achieve better outcomes.

Adopting a new payment model comes with distinct challenges, but your health plan doesn’t have to do it alone. HealthEdge Source offers more than just a solution for payment integrity—it helps drive enterprise-wide transformation. By optimizing workflows and establishing strong pre-payment processes, health plans can expedite claims processing while minimizing unnecessary payments and appeals.

To learn more about how a regional health plan partnered with Source to improve efficiency and reduce payment complexity, visit our case study.

In a dynamic marketplace, member engagement helps strengthen healthcare market competitiveness for healthcare payers. Health plans that leverage digital engagement solutions can enhance their appeal to employer groups and members across lines of business while achieving substantial cost savings. 

According to the 2024 HealthEdge® Consumer Survey, one-third of health plan members are “very likely” or “likely” to switch insurance plans in the next year. Personalization, transparency, and convenience topped the list of factors most influencing member satisfaction.  

Use Member Engagement for Marketplace Differentiation 

Digital solutions like Wellframe can amplify the impact of healthcare interventions, increasing workflow efficiency and broadening member reach. Wellframe enables health plans to distinguish themselves in a crowded market by offering an integrated, enhancing healthcare market competitiveness by offering an integrated whole-person platform that streamlines workflows and reduces reliance on point solutions. Members can directly engage with their health plan and providers, simplifying the user experience and improving benefits access. 

Health plans that utilize Wellframe have reported significant improvements in member satisfaction, engagement, and clinical outcomes—which contribute to higher retention rates and a stronger market position. Plus, payers can leverage their integrated Wellframe offerings as a value proposition during the RFP process and open enrollment to attract new business. 

Deliver Comprehensive Benefits for Employer Groups 

Employers are increasingly looking to provide their employees with comprehensive benefits that directly affect health and wellness. Wellframe addresses this need through a range of accessible features designed to help health plans achieve organizational goals, such as cost savings, improving satisfaction rates, and reducing vendor reliance. 

Cost savings: Coordinated care management drives cost savings, reducing overall healthcare expenses. The Wellframe solution offers up-to-date information on members’ unique health needs, making it easier for care managers to prioritize outreach and deliver proactive support that lowers long-term care costs. 

High satisfaction rates: Wellframe’s staff dashboard offers tools that enable decision support and facilitate member engagement. Care managers receive alerts based on member risk data, and a HIPAA-compliant chat feature allows them to send messages for members to respond to on their own time. By offering an intuitive and accessible platform, Wellframe increases member satisfaction and engagement with their health benefits.  

Vendor Reduction: Managing multiple vendor relationships and coordinating between multiple systems can be a logistical challenge for employer groups. With more than 70 digital care programs, Wellframe eliminates the need for distinct point solutions by providing an integrated platform that supports a broad spectrum of acute and chronic conditions. The Wellframe solution streamlines administration and reduces the complexity of managing employee health benefits. 

Retain and Win New Members Across Lines of Business  

Wellframe’s platform provides a strategic advantage for retaining and attracting new members across lines of business, including Medicare, Medicaid, and Commercial populations. 

Government Lines of Business 

Achieving high member satisfaction is critical for favorable Consumer Assessment of Healthcare Providers & Systems (CAHPS) scores, which, in turn, contribute to a plan’s Star Rating. Improved Star Ratings not only enhance a plan’s reputation but also lead to increased federal bonus payments and boosted member enrollment. Wellframe’s digital engagement solutions help health plans improve CAHPS scores by providing personalized, consistent support to high-risk and rising-risk members. 

Commercial  

For commercial populations, high rates of member satisfaction can be a powerful marketing tool for attracting new members and retaining existing ones. Offering Wellframe as a solution positions health plans as modern partners in member engagement and satisfaction. Potential members will also compare health plan offerings during open enrollment to find the best fit. A member engagement solution with demonstrated results can drive interest and increase enrollment. 

It’s easier to engage members in their health by providing value upfront with easy-to-access resources and communication tools. This proactive approach significantly improves member experiences and satisfaction, leading to high rates of member retention as well as boosting healthcare market competitiveness. 

In an increasingly competitive healthcare market, member engagement and satisfaction are crucial for success. Wellframe’s digital health management platform offers a comprehensive, unified solution that enhances member satisfaction, reduces costs, and improves Star Ratings. By leveraging the Wellframe solution, health plans can differentiate their offerings, provide superior benefits to employer groups, and retain and attract members across lines of business. 

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To learn more about how the Wellframe solution can help your health plan drive member engagement and satisfaction, watch the webinar on-demand: “Using Digital Care Management to Meet Members & Care Managers Where They Are.” 

Hear about the strategies other health plans use to integrate digital engagement solutions into care management workflows and meet members across the risk pyramid. 

 In today’s rapidly evolving healthcare landscape, solutions such as GuidingCare are at the center of innovation in how health plans operate efficiently, adapt to regulatory changes, and improve internal collaboration to deliver exceptional care to members. As a core system in health plan operations, onboarding new staff efficiently and effectively to GuidingCare is crucial. Traditional training methods alone—such as live classes or reliance on dense technical documents—can result in knowledge gaps, reduced operational efficiency, and missed opportunities for new employees to become productive quickly.

On-Demand, Self-Paced Video Onboarding

GuidingCare University transforms the onboarding process by offering a flexible and streamlined solution tailored to the specific needs of health plans and care management teams. GuidingCare University provides on-demand, self-paced video modules that are easy to follow and designed to fit seamlessly into any schedule. New staff members can begin training immediately without relying on others, waiting for an in-person training session, or independently studying technical documents to learn about the GuidingCare solution suite.

Personalized Learning for Maximum Impact

One of GuidingCare University’s key features is its ability to create personalized learning paths for new staff. Each person can be assigned courses or curricula that align perfectly with their new roles and responsibilities. This targeted approach ensures that new staff receive the training they need without delay or the distraction of unnecessary information for their role.

Tracking Progress and Building Competence

GuidingCare University’s intuitive dashboard allows new staff to track their training progress in real time, ensuring they stay on track and complete their onboarding independently. This functionality can boost their confidence and give managers valuable insights into their team’s readiness. Furthermore, the platform includes knowledge assessments to verify understanding and assure health plans that their new staff members are equipped to perform at their best.

Empower Your Team with Seamless Onboarding and Training for Success

GuidingCare University enhances the onboarding process, making it more flexible, efficient, and tailored to the needs of each individual and their role. By leveraging this platform, health plans can ensure their new hires are well-prepared and fully integrated into their roles starting day one.

Learn more about how GuidingCare University can help your health plan maximize investments in new people and technologies in today’s fast-paced care environment.

Provider abrasion is an ongoing challenge for health plans, resulting in damaged trust, increased workloads, and unhappy providers. The problem usually arises from claim denials, payment delays, and cumbersome administrative processes. These obstacles not only lead to provider abrasion, but also significant financial losses, with improper payments accounting for $200 billion in waste spending in 2023 alone.

Health plans can reduce provider abrasion by adopting a payment integrity solution that uses modern technologies to improve payment accuracy and efficiency.

Factors That Lead to Provider Abrasion

In a recent Payer survey from HealthEdge®, “provider relations” followed closely behind “member satisfaction” in a list of health plan leaders’ top business concerns. These relationships are becoming increasingly important as payers and providers are expected to collaborate to achieve industry-wide goals such as reducing healthcare costs, improving clinical outcomes, and establishing effective value-based-care arrangements.

According to payers, inadequate access to real-time information and data sharing is the key contributor to provider abrasion. This is closely followed by inaccurate and delayed payments, and lack of transparency.

There are various reasons for these frustrations. When providers do not have access to updated information, they are unable to check the status of their claims or current reimbursement data. This lack of transparency can leave providers feeling confused or frustrated due to an unclear and complicated claims process. Additionally, payment delays or inaccuracies can leave providers facing potential financial stress, which can damage their reputation. Plus, the administrative burden of the time-consuming claim resubmissions and appeals process often leads to operational inefficiencies for both payers and providers.

So, how can your health plan ensure accurate, timely, and comprehensive claim payments to reduce provider abrasion?

3 Payment Integrity Features That Can Reduce Provider Abrasion

At HealthEdge Source™ (Source), our commitment to redefining payment integrity and reducing provider abrasion is apparent by the transparency and ease of use our platform offers. We have taken the bold step of rebuilding our original platform from scratch to become the first organization in the market to offer a cloud-based, interoperable payment integrity platform.

The Source solution combines cloud-based scaling capabilities, advanced automation, and an integrated ecosystem of solutions to deliver a robust and effective payment integrity platform.

1. Cloud-based Data Delivery

Our cloud-based data delivery solution streamlines claim processing, shortens payment turnaround times, and reduces provider abrasion. With all medical formats, standards, code sets, claim history, and updates accessible in real-time, Source can eliminate denials and improve claim accuracy. By ensuring your health plan has the most current and secure data available 24/7, you can decrease your reliance on outdated manual processes and fragmented solutions in favor of an effective modern solution.

And with data in the cloud, Source is laying the groundwork for integrated systems, automation, business intelligence, and other advancements in the payment integrity space and beyond.

2. Integrated Platform Ecosystem

Similar to your smartphone, HealthEdge Source’s integrated ecosystem of solutions effortlessly connects multiple claims systems to streamline key functions. Dealing with different vendors with diverse tech stacks, update cycles, and maintenance plans can be stressful. Working with disconnected systems often leads to complicated workflows and greater reliance on manual tasks, increasing operational costs and generating unpredictable outcomes. The single-instance Source solution unifies these elements, reducing administrative overhead, inaccuracies, and recovery costs.

Just as you can easily add apps to your phone, the extensibility of Source allows integration with various third-party solutions—without sacrificing quality. By streamlining these essential processes, Source can empower your health plan to foster smoother provider relationships. This approach enables your staff to focus on strategic initiatives and make more informed business decisions.

3. Advanced Automation And Intelligent Workflows

The integration of automation technologies like Robotic Process Automation (RPA) and Artificial Intelligence (AI) has caused disruptions across industries and contributed to continuous innovations. With Source, advanced automation minimizes user error during the claims process—saving time and money. Automated functions, such as eligibility and benefit verification, prior authorization, and claim management, can help simplify routine tasks, allowing your staff to concentrate on complex tasks that require human intervention.

Optimizing workflow efficiency can lead to substantial cost reductions. Health plans and providers could save nearly $25 billion annually by automating administrative transactions. Source’s innovative solutions not only enhance accuracy, but also transform the claims process, making it a game-changer for health plans and the providers they work with.

How A National Health Plan Reduced Provider Abrasion With HealthEdge Source™ 

HealthEdge Source partnered with a large national health plan to streamline their operations as they expanded their government lines of business and automated claims reimbursement. Their existing systems couldn’t handle the complexity of the new government programs, so they turned to Source to help them better manage payments and scale their operations across lines of business.

Today, more than a thousand of their employees use the solution for tasks ranging from claims operations to provider relations. The system can now handle over one million claims per month, even in complex situations. This has resulted in significant time and cost savings, with automations improving accuracy and saving millions of dollars annually. Over our 23-year partnership, the payer has significantly reduced operational overhead and improved first-pass payment accuracy, minimizing risk and strengthening their relationships with providers nationwide.

HealthEdge Source is an innovative payment integrity solution that can address the root causes of provider friction. Our platform gives health plans real-time data access, simplifies claim processing, and leverages advanced automation within an integrated ecosystem. By leveraging Source, your health plan can improve operational efficiency, build stronger partnerships with providers, and achieve significant cost savings. Here

Are you looking for more information on how your health plan can leverage content, technology, functionality, and analytics to achieve long-term organizational goals? Watch our on-demand webinar at your convenience: Avoiding Payment Integrity Pitfalls with HealthEdge Source™.

The healthcare industry, care management practices, and software that enables health plans to provide exceptional service to members are all undergoing significant changes. Market dynamics, disruptive technologies, innovations in data availability, regulatory pressures, and changing member expectations create new challenges for health plans. But they also promise a more efficient and member-centric healthcare system in the years ahead.  

 

Health plans’ adaptability and the technology that enables their transformations will remain at the forefront of strategic decision making in 2024 and beyond. Let’s explore the key trends that affect care management and raise the bar for software capabilities today. 

 

Trend 1: Rising Member Expectations 

 

According to the 2024 HealthEdge® Consumer Survey, member expectations are evolving rapidly. The survey findings indicate an increasing need for member experiences that are tailored to individual preferences, easy to access, and provide clear information about healthcare costs and coverage. Members’ expectations are increasing due, in part, to highly personalized retail experiences with commercial organizations. 

 

Health plans need to adapt to these changing expectations to stay competitive. Just as retail companies use algorithms to analyze behavior and provide personalized recommendations, health plans can utilize data to offer personalized care recommendations, wellness programs, and effective communication to improve members’ experiences. 

 

In contrast to many online retail experiences, human interaction is essential for success in healthcare. The 2024 HealthEdge Consumer Survey also shows higher satisfaction levels among those assigned a dedicated care manager, for example, but also a growing demand for high-touch care management. This highlights the importance of care managers’ access to member healthcare data, particularly social determinants of health data, to enhance personalized care. It is crucial for health plans to make people available to deliver customer service and, at the same time, to expand the self-service tools and resources that make interactions more efficient. 

 

Member expectations are also at the heart of numerous regulatory changes focusing on cost transparency and interoperability. From the Transparency in Coverage Act to the No Surprises Act, the Centers for Medicare & Medicaid Services (CMS) has stressed the significance of electronic data collection, retention, and utilization to enhance member experiences, improve health outcomes, and reduce inefficiencies in the long term. The pace of change is accelerating, pushing health plans to look further into the future, be more agile to meet member expectations, and update their requirements for a care management platform.  

 

Trend 2: Digital Member Engagement 

 

According to the 2024 HealthEdge Consumer Survey, there is a significant shift toward members looking for personalized healthcare experiences: 64% of respondents expressed comfort in using secure mobile apps to interact with their health plans. This trend is notably consistent across various age groups, underscoring the broad acceptance of digital tools for healthcare management. Today, omnichannel communications unify the member experience across websites, mobile apps, phone calls, and in-person visits, enabling seamless transitions and greater member engagement. This plays a critical role in enhancing member care management in two primary ways: 

 

• By integrating multiple channels, including mobile apps, care managers can customize interactions to individual member preferences, engage members more effectively, and focus on meaningful interventions for positive health outcomes. 

• Through streamlining processes and interactions via digital channels, health plans reduce member wait times for prescription refills, referrals, test results, etc., and empower staff to be more responsive through preferred contact methods. 

 

Adopting an omnichannel strategy, supported by modern care management software, empowers healthcare teams to provide personalized, efficient, and member-centric care—enhancing member satisfaction and improving outcomes. 

 

Trend 3: Increased Market Competition 

Historically, health plan members had limited options for coverage, and were often content to accept the narrow choices of employer-provided benefits, while seniors faced relatively straightforward decisions about Medicare. However, today’s landscape is vastly different, leading to increased competition between health plans: 

• Members now have a wide array of options. Seniors can choose from nearly 4,000 Medicare Advantage plans, offering an average of 43 options in their coverage areas. 

• CMS continues to emphasize the high weight of member satisfaction scores for the 2024 rating year, reinforcing that exceptional member experiences must be a top priority for health plans.  

• Participation in the Affordable Care Act’s health exchange marketplace, individual plans, and Medicaid has surged, leading to many new members comparing suitable health plan offerings. 

• Healthcare and government agencies focus on whole-person care that improves health outcomes and includes specialty areas such as behavioral health. Employers and health plans collaborate to create inclusive benefit plans, while integrating digital tools and virtual care options enable nontraditional care for various conditions. 

Health plans must prioritize personalized member experiences, innovative digital solutions, and cost transparency to attract members due to advancements in whole-person care, new regulations, and higher member expectations. This requires a care management platform that merges data, enables seamless care coordination, and allows effective communication with members on their terms.  

Trend 4: Social Determinants of Health and Person-Centered Care 

 

The Framework for Health Equity, from CMS, serves as a foundational roadmap to advance health equity, expand coverage, and improve health outcomes for over 170 million individuals. The framework addresses the following in pursuit of its mission:  

 

• CMS aims to enhance the gathering of individual-level demographic and social determinants of health data, including race, ethnicity, language, gender identity, sex, sexual orientation, and disability status, to ensure fair care and coverage for all.  

• CMS is dedicated to evaluating its programs and policies for unintended consequences and measuring their impact on health equity to develop sustainable solutions for closing healthcare access, quality, and outcomes gaps. 

• CMS supports healthcare organizations in reducing health and access disparities by empowering providers and organizations to address the root causes at the point of care. 

• The framework integrates health equity into existing and new efforts, driving structural change, eliminating barriers, and enhancing health outcomes through data-driven insights and personalized strategies. 

 

The focus on social determinants of health, person-centered care, and healthcare equity has increased. Modern care management systems play a key role in complying with these regulations, leveraging shared data, and coordinating care in an increasingly complex array of healthcare services. 

 

 

Trend 5: Artificial Intelligence (AI) in Healthcare 

 

The healthcare industry is investing in developing AI capabilities to streamline processes and improve the member experience, especially with the development of generative AI capabilities. Compared to other industries, healthcare has been slower in adopting these advancements, presenting a significant opportunity for improvement. Recent research suggests that increased use of AI could result in a 5-10% reduction in US healthcare spending, including member services.  

 

AI in member engagement shows promise in empowering care managers, assisting members with routine inquiries, and optimizing the care journey. Moreover, the increasing comfort with AI-powered tools reflects a growing demand for personalized and efficient healthcare experiences. About 65% of members prefer health plans that leverage AI for personalization. This technological shift enhances the member experience and enables health plans to provide more tailored and proactive care. For instance, natural language processing could be used in a chat-based interface to allow health plans to provide quick, accurate benefit details to members during live calls. This capability, combining robust data with AI-powered interfaces, will soon become a reality, streamlining benefit inquiries, improving service, and enhancing customer satisfaction.  

 

The march towards AI-powered healthcare is underway, and health plans must focus on the most impactful use cases, the right technology partnerships, how AI affects their roadmaps, and the governance required to use AI for its best purposes.  

 

Adapt to Modern Care Management with HealthEdge 

 

The HealthEdge® GuidingCare® care management software streamlines coordination across the care spectrum, automates care and service planning, and identifies high-risk populations to better enable whole-person, member-centric care. It centralizes health data to enhance care and uses advanced analytics to predict health issues for proactive intervention. The demands and opportunities of care management today lead to more health plans redefining their software requirements and seeking end-to-end solutions to grow membership and improve the care experience. 

 

To learn more about how GuidingCare can help accelerate your care management transformation, visit our infographic: “Secrets of a Successful Care Management Implementation.”