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Security incidents that involve customer or member data are completely debilitating for a health plan’s business. On average, a data breach costs health plans $6.45 million. In addition to insurmountable fines and reputational damage, depending on the type of information disclosed in a breach, many organizations need to pay for credit reporting for the customers the breach impacts. For smaller plans with fewer resources and smaller budgets, all of these things combined or alone can drive a company out of business.

As technologies and companies continue to expand into the cloud as well as technology modernization in data centers, there continues to be technological advances in ways to protect systems and prevent unauthorized access to systems.And as the ways to defend networks and systems improve, so do the methods that hackers use to try to infiltrate the infrastructure of those systems and gain access to data that can be used in devious ways.

Today, sophisticated cybercriminals are not only working to infiltrate the systems, but also the backup system as well, so it is crucial to not just protect data, but also protect those backups and means to recover if security incidents occur. This is where having a strong health plan security strategy comes into play.

When it comes to disaster recovery, companies should look to their overall architecture and design to ensure they have high availability and redundancy in their systems; there must be backups and recovery means in place as well as disaster recovery plans. It is imperative to test those plans on a consistent basis as you must plan and prepare for the worst case.

Certifications like SOC2 Type2 and HITRUST prove that a health plan has achieved a high level of maturity that safeguards company and customer information. However, these certifications require significant time, executive commitment, and cost money and time. Onthe environment front, a health plan must ensure their systems and networks are secure and safe, and the policies and procedures in place are efficient and effective. Audits are time-consuming; it requires going through logs of information, validating that you’re following proper protocols and guardrails set up within each specific certification. It can take months of procedural validations to confirm you are aligned with controls of a certification.

Most leaders in healthcare are aware that it is vital to have security standards in place. But in my experience, it is the people or teams involved in day-to-day healthcare activity that must retain their focus on the importance of security. For payers of all sizes, but especially smaller organizations with limited resources and personnel, it is crucial that health plans have security training in place, so that all of the employees understand the importance of data privacy.  A solid security approach should also include Security newsletters and reminders to end users on safe guarding data and the correct security procedures.

Security around customer data is important to the business as well as the members. And without that in place, you’re putting your business at risk. Health plans are stewards of their members’ data and must do the right thing to maintain privacy and protection against that data.

Today, many health plans use homegrown or legacy systems that assume manual work as part of the process. With limited automation and integration, organizations spend valuable time and money on administrative tasks that could be simplified.

Claims processors often need to work on disparate systems. They can sometimes spend hours cutting and pasting information and keying or re-keying in data from one screen to another when they could be focusing on more productive tasks like handling increasingly complex claims or process improvement.

But the healthcare industry is dynamic, and health plans must evolve to meet the demands of the changing market. Technology plays a massive role in enabling us to embrace change. Next-generation technology solutions support centralized payment ecosystems that bring all aspects of claims payment processes together to deliver payment integrity prospectively before providers are paid.

Technology and innovation are key to remaining competitive in the healthcare industry today, and organizations should be evaluating their current payment ecosystem. Ask yourself these questions about your claims payment ecosystem. Can you:

• Connect to multiple claims systems and support all lines of business?
• Perform editing and pricing in a single pass?
• Allow for customization and configuration to match your business rules without creating workarounds?
• Provide complete information to support claims reviews, audits, and provider relations teams?
• Deliver advanced real-time analytics and claims modeling?

If no was the answer to any of the above questions, it might be time to explore new technology, discover its capabilities, and unlock endless possibilities.

In today’s world, health plans need a technology solution that can easily integrate with their core administrative processing system and make it work smarter. Payers should challenge the inefficient status quo in claims payment administration and invest in a technology that will enable innovation, accuracy, and operational efficiency.

Once a health plan finalizes a claim, they do not want to go back and fix it retroactively. Claims accuracy rates improve productivity, reduce errors, and are critical to a health plan’s success.

In order to improve claims accuracy rates, health plans need a technology that integrates easily with all of the systems in your IT ecosystem and infrastructure and allows data exchange in real-time. Real-time data enables a payer to match the members to the right benefit plan and the providers to the right contract provisions to ensure the correct payment is applied to every claim. Without the proper tools, data matching can drain a payer’s time and resources and adversely impact the bottom line.

I worked with a Mid-West health plan that had clear key performance indicators they were looking to improve. They needed technology that integrated with their entire ecosystem and shared data to track their success metrics. They specifically needed a technology that could integrate with trading partners for eligibility, medical claims editing, grouping and reimbursement, repricing entities, provider credentialing, and more. They also needed a way to enhance member and provider matching, standardize USPS requirements and format, and provide latitude/longitude coordinates, among other things.

Their existing legacy technology could not configure or integrate their systems to track the necessary data. Their only options were a mixed-bag of technology to cover basic functionality and custom code to resolve integration gaps. Maintaining the integration was cumbersome, and upgrades required custom remediation. Furthermore, extending benefit information to external systems required interpretation of legacy table data, increasing the chance for error.

The health plan needed a next-generation system that worked in harmony with all other solutions in their IT ecosystem to achieve their business goals.

With next-generation technology, health plans can be self-sufficient. This enables implementations and ongoing maintenance of your IT infrastructure to be lower cost and lower risk than with a legacy solution.

So many regulations are intertwined; health plans cannot ignore the ones that may seem insignificant. Every year these smaller regulation changes get bigger. However, there are also advantages of regulatory compliance that can benefit both the health plans and their members.

For example, the industry has been talking about provider directories since the mid-80s, but change was still very slow. The inhibitors to having up-to-date provider directories often moved initiatives for standardizing and updating the processes to the bottom of the priority list. CMS now has the ability to substantially penalize payers whose provider directories are out of date or otherwise inaccurate to the tune of $25,000 per member!

One of the key requirements in the Interoperability Final Rule is the Provider Directory API. This rule, enforceable in July 2021, highlights the importance of accurate and timely information about network providers for Medicare Advantage and Managed Medicaid. Health Plans operating in the CMS markets must take steps to ensure their data and processes to deliver the data are working properly, not just to be compliant but also to remain competitive.

Medicaid Managed Care, in particular, is evolving rapidly. A few years ago, most Medicaid recipients stayed with a fee-for-service Medicaid; they were not pushed toward managed care. Many states now prefer managed care over fee-for-service, as it is lower in cost and also preferred by an increasing number of members, as it provides more options and flexibility.

Medicaid is very fluid. A health plan with a Medicaid line of business must stay in-tune with what CMS is doing and how it interfaces with its state’s specific regulations. In particular, the business processes for Managed Medicaid enrollment can seem overwhelming. Daily full enrollment files are sent by the state, which must be translated into enrollment records that retain a historical view of all changes made throughout.

This deluge of information requires technology that can handle extensive slicing and dicing of the data. The enrollment record changes can impact everything from the available benefits for the member to their primary care provider assignment and even the amount payable for a specific service.

The enrollment data is required by core processing systems and must be viewable and usable by the health plans to properly address questions and other inquiries. Furthermore, these changes are typically time-sensitive, requiring that daily files are processed quickly and accurately and sequentially.

Many regulations are intertwined, some in conflict, some furthering a “cause” or process. The mission of all is to benefit the members, and in most cases, there are advantages of regulatory compliance to the health plans.

For example, health plans that focused on getting an updated provider directory in their claims system and also available to members create a win-win scenario! Members and potential members have the most up-to-date information, and health plans are processing claims without the worry of mass adjustments (or penalties!) down the road.

Everyone benefits!

If an organization is open to change, it will always result in a successful, smoother implementation of new technology.

For those who are reluctant to change, it’s an issue of comfort and routine. Some still want to do things the same way they have done them for the past twenty years because they are familiar with it. They’re in their comfort zone and want to maintain the way they’ve always operated.

I strive to help my customers understand that change is good; there’s a brand-new opportunity to enhance their process and improve how they interact with their system. If they embrace change now, they will be better off years down the road.

In addition, if there is hesitation, it’s often because the client may fully understand the benefit of changing their technology. Sure, the upper management understands, but getting that understanding to trickle down throughout the organization is a challenge. It’s a learning curve. I’ve found that the process goes much smoother if everyone at the organization has a clear understanding of why these changes are happening, what it means, and how it will improve their business.

In my role, I always strive to bridge this gap and help the people that I’m working with understand how our solutions operate and how it differs from their current system. When it comes to upgrades, I know the functionality coming in with newer versions and how it will impact a specific client; so a lot of my discussions show people what has changed between each version and how to use it. Setting up demos is also a great way to help customers identify opportunities and begin to understand the value and where they could see results.

Successful implementations are what I look forward to most. I deal with clients on a daily basis, and I love doing whatever I can to help them succeed. That’s what motivates me.

As health plans continue to compete for membership, I have seen a shift in the market toward a focus on member-centricity. Health plans competing to aggressively grow membership have begun to reinvent their companies by throwing away their old models and using a minimum viable product (MVP) approach that focuses entirely on creating a positive member experience.

This concept was introduced to me about five years ago by a client in the Midwest who had just purchased an existing health plan. They wanted to rebrand this newly acquired business using this approach. They recognized that their current business model was stagnant, but understood they also had a treasure trove of assets in terms of highly skilled resources and technology at their disposal to remake the future. As time elapsed, several other health plans across the country were asking how they could do this.

To increase speed-to-market, this concept centers on a fail fast/fix fast approach. This also aligns well with Agile methodology and helps clients that are challenged from shifting away from traditional waterfall-based delivery. The entire goal of getting into the system is to fail fast, and if the required result fails fast, the client needs to fix the failure through business user-enabled automation and keep the project moving forward— this overall thought is a key aspect of continuous optimization.

The strategy of the most successful efforts is to adopt automated-based testing that reduces the burden to the business. However, the true secret to this approach’s success is for health plans to recognize what is working within the current landscape and to persist forward into the future with a new, more successful version of the current enterprise.

Problems with this approach occurred with extremely adamant organizations that did not want to repurpose any part of the prior ecosystem, even if it worked well. With the “keep nothing” mindset, these projects often did not even get off the ground.

The plans that were successful with the MVP approach were willing to build their new business around a viable subset of the existing technology stack, identifying critical aspects like provider data sources and other key components of the ecosystem that provided a solid foundation to accelerate this effort. Looking back, this strategy enabled the health plans’ very aggressive timelines. This strategy also allowed them to focus on what was truly important, the member experience.

Health plans will always look for opportunities to break barriers into new markets both in the commercial and government areas. The MVP member-centric approach can serve as a way for health plans to reinvent themselves, differentiate their offerings, and break barriers into new markets to compete for the future.