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Nearly 125 employees have participated in HealthEdge’s professional development program, now referred to as Emerging Leaders. Emerging Leaders is an experience designed for current and aspiring leaders to understand the personal and organizational behaviors required to be a strategic manager and leader within our organization.

Nominated by their managers, the program participants are strong cross-functional collaborators, strategic thinkers, and striving for a more significant manager or leadership role. When selecting the participants, we try to make sure the final group includes all functional areas and products to represent every part of HealthEdge in the program.

The program kicks off with a 360-review and a personality assessment called the Predictive Index, so participants can gain an understanding of where they are at, highlight their opportunities, and how they can get to where they would ideally like to be at the end of the year-long commitment.

In the first half of the year, the group meets once a month and participates in interactive training focused on topics including their own leadership styles, leading change, and communicating with impact. The trainings contain a mix of classroom sessions, interactive discussions, and group activities

Thanks to the feedback we received from past Emerging Leaders, we recently launched a formal mentorship aspect of the program. In the second half of the year, participants are paired with a leader to provide mentoring and direction as they drive towards their development goals. Mentors aren’t necessarily in the same functional area as the mentee. Matches are based on what skills the emerging leaders are looking to improve. Then, we find leaders at the company with strength in that area to help coach them and build on that area of focus.

Another benefit of emerging leaders is the ability to gain exposure with other leaders within the organization. We strive to create an open forum where participants can have open discussions, participate in breakout groups, and work with people they have never met before. There is a lot of collaboration, sharing experiences, and talking through approaching a similar situation or solving a common issue.

We strive to make sure the program is not generic for everyone but tailored to each person and helping them figure out where they need to grow and provide the tools to help them become effective leaders.

HealthEdge was recently named national Elite Winner in Employee Achievement and Recognition designation for the 2020 Medium-Size Best and Brightest Companies to Work For, Top 101 in the Nation®. We are also a proud winner of Boston’s 2020 Best & Brightest Companies to Work For® award, three years in a row, Boston Globe Top Places to Work, and Top Places to Work in the Nation in 2021.  Want to work with us? Check out our current job openings.

To remain competitive in today’s market, health plans must invest in critical areas such as member satisfaction, care coordination, and adding new lines of business. Still, many have limited resources and tight budgets. Transitioning manual processes—like processing claims, which can have a considerable cost impact for health plans—to electronic, can save plans and providers billions of dollars.

Headquartered in Brooklyn, New York, Elderplan is an established, not-for-profit health plan organization, serving 27,000 members and meeting the needs of Medicare, Medicaid, and Dual-Eligible individuals at every stage. For nearly 30 years, Elderplan has offered a wide range of innovative health plans.

In 2015, Elderplan’s Medicare auto adjudication rate was 47 percent, and the HomeFirst auto adjudication rate for Managed Long-Term Care was 77 percent.

More than half of the claims that came in were pending on the Medicare side, requiring significant time spent on manual adjudication of the claims and taking away from focusing on making continuous improvements and that attract and retain their members and drive success in their business.

Given these challenges, Elderplan needed to maximize operational efficiency, control administrative costs, and embrace evolving business models.

As Diane Pascot noted, “for health plans, operational efficiency could be the first step in their approach to innovation. While it may not be the most exciting aspect of the business, achieving operational efficiency will enable them to remain competitive in the long-term.”

Prioritizing operational efficiency would result in critical savings and enable Elderplan to redeploy resources typically spent on routine administrative tasks and shift to transformative projects. The health plan knew it needed a core administration system that breaks down product design barriers, increases efficiency, and delivers real-time transparency.

Continue reading this case study to learn how next generation technology enabled Elderplan to cut costs and maximize efficiency, while providing the flexibility to respond to unforeseen circumstances such as the COVID-19 pandemic quickly.

I recently participated in an AHIP webinar, “Growth and Innovation with a Consumer-First Future,” with HealthEdge customer Sal Gentile, CEO and Co-Founder of Friday Health Plans, along with UST HealthProof’s CEO Kevin Adams and Healthproof President Raj Sundar.

During the webinar, we polled the audience of health plan employees about what metrics matter most. “Member and provider satisfaction scores” ranked at the top, even over financial metrics. This represents an evolving point of view for health plans, who are increasingly recognizing that “members” are customers and consumers of their services.

Health plans can measure how well they are doing in a number of different ways. Take a government program, for example. Success depends on keeping costs low, staying compliant, STAR ratings, etc. While all of those factors translate to financial health, they’re built upon customer satisfaction.

For Sal Gentile, customer satisfaction is a key requirement for keeping their business growing, “Member satisfaction fuels our growth because the renewal rate is critical to our success. We can’t count on always winning in a market and taking somebody else’s members; we have to count on starting with renewing our own members first. And so, if we don’t satisfy the customer, we won’t last.”

Kevin Adams weighed in about what is required for customer satisfaction, “Customers can be members, providers, brokers, whatever the constituent is. And being able to surface the information and the needed response in real-time, it is the fundamental piece that outlines success in providing a better customer experience.”

Health plans need modern technology that offers transparency and provides access to real-time data and information across the entire enterprise. A customer service team cannot have a desk covered in sticky notes with exceptions and different rules outside the system. They need up-to-date information at their fingertips.

“Customers are satisfied a health plan can solve their problem on the first call,” said Sal. “The tools and the plans we’ve put in place have allowed us to achieve a first call resolution of 99%. And when you can satisfy members and brokers and providers on the first call 99% of the time, you’re going to have a really good outcome when the renewal process comes along, and with word of mouth for adding new members.”

With increased importance on customer satisfaction, health plans realize that they are part of a larger ecosystem. They are not working in a silo by themselves anymore. Health plans with the tools that enable real-time data and offer transparency to the members and providers that are part of that healthcare ecosystem will achieve higher levels of customer satisfaction and ultimately growth and success.

When I came into the industry, we worked on green screen mainframes, where each function was its own application compartmentalized into silos. For an operations person, claims, eligibility, billing, and benefits were all in separate systems.

Eventually, organizations realized that the older technology was costly to maintain and began to move to the modern core system that encompasses multiple health plan operation functions in one application. The core system was less expensive and easier to use—no longer did someone need to exit one system and enter another system to gather information.

Over the years, the siloed approach comes up occasionally. Sometimes it may be an ambitious startup, companies that want to be disruptors in the market. However, it can also be large organizations as well. Regardless, this viewpoint of searching for a utopian IT state with each function to be a separate solution is something that persists and continues to cycle and come up from time to time.

Developing a claims system is not easy. It takes five to ten years of solid development and battle-proven, customer-tested processing (accumulating millions of transactions and scenarios over time) to get to a semi-mature state of a claims adjudication engine.

So, when an organization feels they can build a claims engine with individual components, i.e., eligibility, capitation, pricing, claims, benefits, etc., they tend to underestimate how complex it is and neglect to consider its impact on the end-user.

Logistically, plans need to consider all the integration an organization would need to create to connect and those separate systems. Often the integration effort turns into a ball of spaghetti code that becomes increasingly complex and costly to implement and maintain.

In my industry experience, the sought-after solution these organizations are a mirage and do not exist successfully. As it is not just the TCO associated with implementing and maintaining all the different systems; however, it is the end-user who suffers the most because they need to navigate across the separate applications in their daily course of work. Additionally, from an operations perspective, if a health plan wants to introduce one change—whether it is regulatory or market-driven—they must coordinate the change now across many systems, which is incredibly difficult and leaves a significant risk of error.

While data replication for members and providers becomes increasingly common today, based on my experience, I would argue that a core system’s minimum viable product (MVP) provides benefit configuration and claims adjudication in the same container.  Additional required pieces of adjudication can be replicated with comprehensive APIs for the core system provided as a standard by today’s measures.  The reconciliation of transactions between systems and remediation of fallout are the bigger pain points that usually need to be addressed.

Nonetheless, on top of the MVP by adding flagship pricing (Burgess Source) and care management (GudingCare) capabilities complementing HealthRules Payer’s open integration, business empowered automation, configuration, and provider capabilities shape the unified vision of the HealthEdge solution into a best-in-class approach that provides the maximum value to our customers.

HealthEdge has hired over 100 people every year for the past three years. In 2020, we added 108 new full-time employees and 22 interns. When other companies in this space were forced to do hiring freezes and layoffs, we were fortunate enough to keep growing.

With COVID-19, we saw a change in the market and our candidate pool opened up tremendously. For recruiters that allows an even greater level of selectivity, so trying to stand out becomes key. For some roles we saw an explosion of applications. Instead of 30 people applying for a job, we would receive 150 applicants.

In such a competitive job market, how can a candidate stand out?

It’s all about first impressions. First, have an updated LinkedIn profile. Recruiters love to see a profile that’s current and showcases your work and personality beyond the resume. Follow different companies and thought leaders, share articles that interest you, and post your own content. For engineering roles, it’s great to see people that participate in open-source code sites like GitHub.

In a sea of applicants, referrals are also an excellent way for an individual to rise to the top. We trust our employees look at their network and connect us with people who were standout colleagues in the past. We received over 200 employee referrals last year. It’s our recruiting policy that every referral gets called. We give our employees credence for taking the time to refer someone, and we want to ensure those connections have a good experience.

The next step is the phone screen. The phone screen is not to test if you’re qualified for the role or have the right skills. At this stage, recruiters look for your interest level, communication skills, interpersonal skills, and how you would contribute to your team. It’s important to engage with the recruiter; being open and authentic is a big part of helping us make sure you’re the right fit for the company. Talk about your experience, what interests you about our organization, show us you’ve done your research. I love when applicants have followed HealthEdge and pay attention to what we’re posting about our culture and our business. Active, thoughtful conversations make a candidate shine, whether it’s for the current role or something in the future.

It’s not uncommon that we will have a call with a candidate, and it turns out they aren’t the best match for the position they applied for, but their personality and character are a great fit for HealthEdge. We will keep those people on our radar. We’ve stayed in touch with candidates for an entire year before a role opened up. If someone makes a good first impression, they open the door to endless opportunities.

HealthEdge was recently named national Elite Winner in Employee Achievement and Recognition designation for the 2020 Medium-Size Best and Brightest Companies to Work For, Top 101 in the Nation®. We are also a proud winner of Boston’s 2020 Best & Brightest Companies to Work For® award, three years in a row, Boston Globe Top Places to Work, and Top Places to Work in the Nation in 2021.  Want to work with us? One of our goals is to stand out as an employer of choice and if one of your goals is to work in an environment that challenges you and cares about you bringing your whole self to work, please check out our current job openings.

Interoperability remains front and center for compliance. HealthEdge continues to focus on the Patient Access API, which has an enforcement date of July 1, 2021. All of the data required for our clients’ compliance is in our data warehouse. Our HealthRules Payer customers can use the Common Payer Consumer Data Set (CPCDS) to move their data from our data warehouse to the HL7-FHIR-enabled solution. We are creating a patient access data mapping document to enable our customers to easily collect the data elements required by the CPCDS.

Also with a July 1, 2021 enforcement date is the Provider Directory API.  The data within HealthRules Payer can support this requirement, but it is likely plans will use the system of record they use today to produce their Directories.  HealthEdge will address following the Patient Access API.

Effective January 1, 2022, the Transparency in Coverage Final Rule will require all payers to post three machine-readable files (MRFs) to their public website every month, including in-network negotiated provider rates, in-network drug pricing, and out-of-network coverage rates. HealthEdge is working on the high-level requirement to map the data they need to create the in-network and out-of-network provider rate files every month.

Key provisions of the Consolidated Appropriations Act—which went into effect on December 27, 2020— impact payers.

The No Surprises Act includes federal protections against surprise medical bills from out-of-network providers for emergency services, including air ambulances. The Act also applies to out-of-network providers when the patient is at an in-network facility unless the patient agrees prior to the services.  Under this act, cost-sharing amounts are capped at those that apply to in-network services, providers cannot send bills for any higher amounts, and there is an arbitration process to resolve payment disputes between insurers and providers. The act borrows from the enforcement and state preemption frameworks from HIPAA and the ACA. There is also a clause for the Continuity of Care when a health care provider drops from an insurer or group health plan’s network.

This all becomes effective January 1, 2022, so we expect to see activity related to the No Surprises Act ramp up soon. The Tri Agencies must issue a new rule to implement these provisions, allow for at least 60 days for comments, and then have a six-month runway for implementation. They will also need to generate and authenticate data and reporting, particularly around these air ambulance providers and the insurer, and conduct studies on the effect on provider consolidation, health care costs, and access to care across the lines of business. The federal government will also need to issue several different reports, as defined in the Act.

The CAA also includes Transparency Rules requiring health plans to have a price comparison tool, available online and by phone, that will compare cost-sharing amounts for certain items or services at any provider. The intent is to improve disclosure of cost-sharing requirements by listing plan-specific deductibles and out-of-pocket maximums on insurance cards alongside a phone number and website where an individual can ask about network status.

There is also an “advanced” explanation of benefits. When a provider notifies the health plan that an enrollee is scheduled to receive health care services, the plan must send an advanced explanation of benefits that indicates if the provider is in- or out-of-network and includes estimated costs and disclaimers.

The CAA also includes protocols related to provider directory updates. Health plans must update provider directory information at least every 90 days and remove any providers with information that cannot be verified. They also must respond to enrollees about a provider’s network status within one business day of their request. If the provider directory is not up to date and the employer enrollees relied on inaccurate information, the health plan must treat the member as if they went to an in-network provider.

When it comes to the price comparison tool, advanced explanation of benefits, and provider directory, HealthEdge will continue to monitor the agencies for rulemaking and prepare to  support and enable compliance with these components.

The government is granting some funds for states to establish All-Payer Claims Database (APCD) which is a voluntary program to collect health care claims data from payers. Right now, 21 states have established or in the process of implementing APCDs, and 11 more states have indicated a very strong interest.

The states cannot require TPAs or self-funded group health plans to contribute data. The Secretary of Labor will provide guidance regarding the data collection process and standardized reporting formats because the APCD hits all lines of business.

Lastly, we have two proposed rules in the comment period. First, the comment period for the proposed modifications to the HIPAA Privacy Rule to support and remove barriers to coordinated care and individual engagement ends on March 22, 2021. The proposed changes align with the current interoperability and transparency rules aimed at becoming more member-centric in the release of information. We also have Medicare and Medicaid Programs, Contract Year 2021 and 2022 Policy and Technical Changes, which comes out every year for CMS programs. The comment period ends April 6, 2021.

HealthEdge works with our clients to help them achieve full compliance with the laws, rules, and standards when these regulations impact our products and services.