Category: Uncategorized

With the new presidential administration coming this week, most experts are projecting significant shifts in the healthcare space, especially related to health insurance coverage.

Some changes may come faster than others, but one thing is clear – healthcare is the dominant issue for the Biden Administration. Proposed changes range from regulatory actions related to the Public Option, Medicare, prescription drug reforms, and rules related to the Affordable Care Act, short-term limited-duration plans, association health plans, and Medicaid programs.

According to the Health Research Institute at PricewaterhouseCoopers, “Broadly, healthcare executives can expect an administration with an expansionary agenda, looking to patch gaps in coverage for Americans, scrutinize proposed healthcare mergers and acquisitions more aggressively and use more of the government’s power to address the pandemic.”

If health plans are managing policy updates and fee schedules internally, the responsibilities are ever-increasing. With Medicare’s major quarterly updates being augmented by policy adjustments (such as COVID-19 vaccine administration policies and the Final Rule for 2021 Medicare Physician Fee Schedule, which includes new telehealth provisions) and retroactive changes, fee schedules require constant maintenance. The new administration’s focus on healthcare reform will only add to this workload.

To address the many changes on the horizon, health plans need to automate these processes and make it easier to handle the lift associated with regulatory updates. They need technology solutions backed by policy experts that take care of the research and manage and load in fee schedules automatically, with rates and payment policies modified, tested, and operational on or before the effective dates.

Cloud-based delivery of up-to-date Medicare and Medicaid policies and fee schedules loaded and configured in a way that meets their specific business needs, mitigates risk from a compliance standpoint while simultaneously giving health plans a competitive advantage.

With the right technology, health plans don’t need to worry about the new administration’s policy changes impacting their day-to-day business operations but can instead remain agile to new regulatory actions and a shifting marketplace. Which area do you want to focus on to bring the most value to your health plan?

Prioritizing Diversity, Equity, and Inclusion (DE&I) and is critical for an organization’s success and a company culture that creates a sense of belonging.

When I joined HealthEdge in June 2020, I knew the company valued DE&I, and I was excited to build on and formalize our existing efforts.

We started by looking at our organization’s makeup in terms of diversity and our representation across gender, ethnic, social, economic, religious, and personal backgrounds. As a company with a multigenerational, multicultural workforce, we know everyone has different experiences that may impact how we relate to one another. This summer, we launched the iBelong group to allow everyone to continue learning and growing by sharing their unique perspectives through regular conversations.

Every iBelong meeting is different; we have watched and discussed Ted Talks, reacted to articles, and invited internal or external guest speakers to present. The goal is to create a space where everyone can feel like they are a part of a bigger, broader community and included in the work we are doing.

In just six months, the iBelong group has grown across the organization to nearly 200 members, who all agree that DE&I is essential, and they want to be part of the path forward.

With the support of iBelong, we’ve made significant strides as an organization. We added Juneteenth as a company holiday and sponsored programs for LGBT awareness. We signed on to MassTLC Compact for Social Justice, making the commitment to improve our self-reporting of demographic data, increase racial diversity in talent pipeline development programs, and introduce educational programming, including a company-wide DE&I training series that launched in October. And, VentureFizz’s Lead(H)er series, which spotlights impressive women leaders in the Tech Industry, featured Laura Tomaino, HealthEdge’s VP of People and Culture.

Although I’m proud of what we’ve accomplished so far, the work is far from done. We actively ask for input and feedback from our employees to ensure we deliver relevant programming and opportunities that resonate with our workforce, as well as address any issues that may impact the employee experience.

The combined efforts, enthusiasm, and commitment to DE&I from colleagues at all levels across the organization ensured we could build on this momentum, be proactive, and work toward creating an environment and culture that allows our employees to feel comfortable and proudly bring their authentic selves to work.

The biggest issue facing payers today is that their business changes every year. The pressure to develop reimbursement methodologies with providers that account for the quality of care, access to care, and value-based payment models has increased. Regulatory updates, the worldwide pandemic, and ever-present competition impact payers on an ongoing basis. There are also growing requirements for payers to transact with their members, providers, and employer groups in a modern way. Take Amazon and other B2C businesses; as consumers, we have become accustomed to an easy online buying process and have come to expect this with all transactions.

These collective stakeholder demands have resulted in an industry required to act, behave, and structure its activities in a completely new way. At HealthEdge, it’s our goal to get out ahead of that and help our customers meet, and exceed, these expectations.

We believe that health plans deserve to have a highly automated, accurate, real-time computing infrastructure, and we know our core HealthRules® product, while serving as the heartbeat of key payer operations, can’t do it alone. That is why in 2020, we acquired Burgess Source® to add claims payment accuracy, pricing, and editing, complementing and enhancing our existing adjudication capabilities and most recently Altruista GuidingCare®, the most successful modern care management platform in the marketplace. Our customers can come to work with us for the first time through any of the three products, as they are available on a standalone basis today and in the future and can work with any technology infrastructure in the market.

The integration of Burgess Source and GuidingCare with the HealthRules core administrative claims processing system allows our customers to experience significant benefits from the combined capabilities.

We’re bringing together best-in-class solutions that drive the three most important value streams within a health plan. These value streams cut across the administrative costs of running the business, the medical expenses of paying claims, and the effort to help members with acute or chronic conditions comply with their treatments and obtain better care and better lifestyles.

These integrated solutions make possible a vision where claims processing is enhanced with software-driven payment integrity at the point of service that feeds data to an end-to-end care management solution.

With three, next-generation, cloud-based applications, this combined solution suite is the first-of-its-kind. While each product is viable and extraordinary on its own, we believe the unique value is how these applications work together, enabling automation and workflow efficiencies in a meaningful way. Other options in the marketplace can take years to connect to one another. HealthEdge already has health plans across the country successfully using a combination of these products.

Together, HealthEdge, Burgess, and Altruista empower customers to effectively compete and be resilient to changes in the healthcare marketplace. We will continue to build out from our core system and enable our customers to add next-generation technologies that lower administrative and healthcare costs while improving patient outcomes and quality and supporting regulatory compliance.

As we embark on the new year, I am most excited to accelerate our levels of collaboration and innovation so we can continue elevating health insurance and healthcare.

Many people have said that there has been more change now than ever before within the healthcare industry. However, if one reviews history, healthcare has been this way for decades. One thing we’ve counted on is that this is an industry of change. There are constant regulatory updates and new trends and advancements. Organizations must have the tools and resources to effectively manage the constantly evolving landscape from a technology perspective and a staffing perspective. Change is good and offers job security!

One of the most pressing healthcare security challenges that IT leaders face in this changing industry is how to keep information secure. In fact, in a recent survey of 245 healthcare IT executives, 43% of IT leaders say keeping information secure is their top challenge. There is a lot at stake for everyone across the company. Not only is there a risk of cybercriminals gaining access to sensitive information if there is a security breach, but an organization may also face hefty fines, and its board members could have personal liability. It takes ongoing training to help people at all levels of an organization understand the importance of remaining diligent.

The Importance of Addressing Healthcare Security Challenges

IT teams should always be looking for ways to continually improve security protocols and policies. Phishing attacks still account for a high volume of security incidents.

Regular phishing tests are a proven means of providing ongoing training to change behavior. Even poor results from phishing exercises provide awareness of where supplemental training may be necessary. Approaching training from the perspective of protecting not only company assets but also personal assets at home helps reinforce learning and change behavior, enabling employees to see a tangible personal benefit.

From a personnel perspective, there is significant competition for qualified candidates and employees, and security professionals are certainly in high demand. The loss of a key security expert can be devastating. Turnover can negatively affect a team, and recruitment and training each new hire can be costly. CIOs and other technology leaders must not lose sight of the importance of employee retention.

Even with the most sophisticated technology, no organization should bank on its security being impermeable. It is often stated – “it’s not a matter of if, it’s a matter of when.” There will be incidents, so it’s crucial to have the right protections in place and the ability to react, respond, and resolve quickly and effectively.

Successful health plans are focused on expanding membership, increasing revenues, and controlling administrative costs. However, administration costs attributable to outdated technology and manual processes result in one of the highest sunken costs in healthcare.

Outdated Technology in Healthcare

Health plan operations, especially at smaller plans with limited resources, are pulled in a million directions. They are continually searching for ways to innovate and improve operational efficiency while reducing costs. However, as administrative expenses increase, tighter budgets become, and less money is available to reinvest in crucial differentiators and forward-thinking initiatives. Outdated technology in healthcare and siloed systems can adversely impact operational efficiency, create significant processing challenges, drain productivity, and ultimately impact the bottom line.

For example, Michigan-based McLaren Health Plan’s outdated 30-year-old technology was resulting in a zero percent claims auto-adjudication rate. McLaren’s legacy solution was clunky, hard to configure, not user-friendly, and not scalable.

As Mike Comick described in a blog post, “At some point in time, the amount of road remaining for ‘investment modernization’ of existing organizational structure, use of data/business intelligence, and legacy technology is depleted. Ultimately the risk of minimal maintenance, or worse, doing nothing, is by far greater than ‘taking the big transformational jump.’”

McLaren agreed, as its Vice President of Business Information and Operations, Sara Mavredes, said, “We wouldn’t be in business if we didn’t make a change.”

McLaren decided that it needed to implement new technology that would allow the business to work more efficiently and intelligently, and that would provide it with the margin to implement new strategic initiatives like customer service, care coordination, new lines of business, and other innovations.

McLaren implemented next-generation technology and gained flexibility, transparency, and performance, critical for its success.

Continue reading this case study to learn how HealthRules Payer® enabled McLaren to respond to industry changes, reduce costs, increase efficiency, gain an edge over the competition, and more.

What are individuals called in a health plan? Members. What are people called when they meet with a provider? Patients. What is an individual person referred to in any other industry that uses end-to-end solutions? Customers.

The “unique” needs of a member vs. a patient in the B2C healthcare or health insurance setting aren’t really unique at all. At the end of the day, these needs are customer needs.

Not surprisingly, with the growth of government-based healthcare programs like Medicare, Medicaid, and Individual/Exchange lines of business, the migration from a dominant employer-based “customer” Business-to-Business (B2B) relationship has transformed and become more of a consumer-driven Business-to-Consumer (B2C) environment.  Health plans must find ways to treat members as customers and look at how to provide an end-to-end solution that best serves their needs.

How can different types of health plans cope with the consumer-driven B2C healthcare growth?

There are different paths to get there as plans can use their inherent strengths to meet this changing demand.

For larger plans, their respective budget capacity (and subsequent ability to invest in scalable solutions) have enabled them to heavily invest in front-end “consumer-experience” technology. While mid-sized (generally regional) type plans, the closer relationships between payer and provider and the willingness or, in some cases, equity structure (health plans that are owned or closely affiliated) provide a mechanism to more readily share data and collaborate on end-to-end processes, allowing members to enjoy a combined experience from a single entity.

Regardless of the means to “get more consumer-driven,” the common foundational technical requirement investment are back-office applications that are interoperable, data-integrity true, and secure. To move to the next generation of where healthcare is going, health plans must modernize their core system.