Category: Uncategorized

For claims and pricing teams, managing fee schedules can be a massive headache.

With Medicare undergoing major quarterly updates as well as policy adjustments and retroactive changes coming in regularly, fee schedules require constant maintenance. Add in Medicaid policies and rates, perhaps across different states, and the lift begins to grow exponentially. And when there are new codes and policies coming about rapidly, such as we saw this spring with changes around the handling of COVID-19 testing and treatment, it can be nearly impossible to keep the information up to date.

Researching these updates and then manually loading fee schedules into a system requires time that many payers could devote elsewhere. Furthermore, ensuring that all information is accurate, and current, is a time-consuming process that is vulnerable to human error and leaves plans at risk of non-compliance or delivering over- and underpayments to providers.

In the ever-evolving health care landscape, health plans need a way to automate these processes. They need technology solutions backed by a policy team that handles the heavy lifting, takes care of the research, and manages and loads in fee schedules automatically, with rates and policies modified, tested, and operational on or before the effective dates. With cloud-based delivery, health plans do not need to lift a finger. This lowers costs, increases operational efficiency, and mitigates risk from a compliance standpoint.

This is an important issue not just for claims pricing teams, but for multiple areas of health plans. In HealthEdge’s recent independent Voice of The Market Survey, a study of 245 IT executives at leading health plans, the top challenge these individuals cited with their organization’s core administrative processing system, was low claims accuracy and auto-adjudication rates.

But not all health plans are the same, and every insurer has different contracts and unique billing requirements. Payers need the flexibility to configure their system to meet their specific business needs. They need a technology that can easily apply certain policies updates that match their business structure. With fee schedules loaded in and configured in a way that matches their business, health plans no longer need to worry about policy changes impacting their day-to-day business operations.

With less maintenance on the system and additional flexibility to make real-time updates, resources can be re-directed to more productive and innovative tasks. Empowered by the right technology, health plans will have improved accuracy, reduced waste, and adaptability in a changing marketplace.

I know regulations can seem overwhelming, but if you look beyond checking the boxes to ensure compliance, there is so much opportunity. I always try to remind the health plans I work with that regulations result from constituents going to their legislator with a problem that needs to be fixed, eventually resulting in a mandate. Beyond compliance, addressing these mandates can have positive results for the health plans and its members.

Think of interoperability, for example. It may seem overwhelming, but the concept of serving tailored, customized information to an individual is not far-fetched. If someone turns on their TV or opens a streaming service, the consumer sees a menu of options and suggested programming or channels of interest based on previous activity. With interoperability, individuals can apply that same concept to healthcare.

Traditionally, members have had to collect data from various sources—member portals, lab results, claims statements, and more— and try to figure out what it all means, and what to do next! Interoperability will pull that information together and make recommendations based on that information.

The driver behind interoperability is that patients, or members, want to know more about their own health. Interoperability provides information and analytics that could help individuals connect the dots and take away guessing when it comes to their healthcare. Interoperability empowers individuals to address their concerns, ask questions, identify additional steps, and lifestyle changes they can take to improve their well-being and have the full picture of their health.

For members, interoperability is about getting access to the right information. For health plans, interoperability is about collecting and sharing that information.

To make interoperability successful in healthcare, health plans need the right technology and, almost more importantly, sound business processes, resulting in good data. Anyone can learn how to do FHIR-enabled APIs. But understanding how a claim should come in, how it should process in the system, and how it produces the information needed to be consumed by the APIs is very important. Payers should focus on the claims administration system and ensure they’re collecting the right data consistently so that they can provide the right message to the patient, other payers, and providers.

The alignment of business and technology, especially in this industry, is becoming increasingly important. To be successful, technology leaders, including CIOs in healthcare, must understand and become a part of the business they support. Effective partnerships outside of IT will strengthen the CIO’s influence.

The IT department is at the center of business decisions and initiatives. Once a need is identified, the IT department will work with the business to deliver a solution. Before delivery begins, technology leaders often must handle the contracting process and act as the liaison between solution provider, procurement, and legal departments.

Because technology leaders work with so many systems and vendors, CIOs can spend significant time on contract negotiations and tracking contract renewals and expirations. This can be time-consuming and reinforces the importance of fostering strong partnerships with departments and leaders throughout the organization. These relationships, or lack thereof, can make or break the implementation of technology to address a business issue.

When it comes to purchasing decisions, technology leaders are also often faced with obtaining support for technology investments from other executives or the Board of Directors. Strong relationships are essential for success in this area as well. There’s ROI that comes into play, too, beyond just keeping costs low. When making new technology investments, there is often an increase in cost before savings are eventually recognized. When a CIO needs to convince stakeholders, who may not be intimately involved with the projects, it’s important to always tie the purchase back to how it drives business value.

With technology implementations, there will be bumps in the road. Technology leaders must acknowledge this reality and share this with their business partners. The goal is to react and resolve quickly. It is essential to be transparent and set realistic expectations from the beginning. Being transparent minimizes surprise and gives the CIO credibility. Sincerity is key to forming successful partnerships with stakeholders. Once stakeholder trust and support are established, work becomes more enjoyable, and relationships thrive.

If a CIO in healthcare is solely focused on technology and does not appreciate the business perspective, it will make the job difficult and more stressful than necessary. Business and technology leaders must work together, share their insights, and form strong partnerships to achieve their organization’s goals.

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.