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Regional health plans have generally flourished in the respective local markets that they have served. However, regional health plans only “extended” as far as the affiliated providers employed by the delivery system in a staff model or contracted in a group model.

Today, competitive pressures from larger plans offering statewide (or beyond) employer group networks that meet their overall needs have put regional plans at a disadvantage and forced them to look at new ways to grow their business to remain competitive.

How do regional plans respond? Regional plans should continue to leverage the collaborative payer/provider relationships that exist in the original service area. With these relationships they can maintain ongoing optimization of collaboratively developed value-based care, enhance use of integrated payer/provider data integration, and further develop complementary business processes that can help to improve the customer experience.

Regional health plans should also focus on transforming business practices and underlying technology that can easily configure to better position and police relationships beyond the original service area. Where strategic business objectives might be slightly or significantly different between payer and provider, functions that were historically collaborative in a shared regional market are potentially competitive in an expanded one.

Some of these functions include:

• Overall provider network management
• Enhanced provider reimbursement / contracting
• Customer-facing call center and self-help support to an increasingly disparate customer base
• More policing of care/utilization management capabilities

The transformation curve is significant. The time required for planning, general design, eventual investment, and execution requires buy-in from all stakeholders. The risks are high for not positioning for growth. The risks (and poor results) are exponentially higher for organizations that fail to fully account for the overall investment required from underlying/foundational core systems integrated with other value-added applications/utilities.

Health plans with legacy systems, disjointed workflows, and paper-based anything struggled to handle the sheer volume and veracity of new care and payment models, regulatory updates, and new entrants forcing rapid changes upon the industry this year.

Payers lacking the agility and flexibility to make adjustments quickly and update their administrative operations to support new care delivery provisions, evolving quality measures, and payment rules related to telehealth, telemedicine, and remote patient care fell behind.

As the Everest Group noted in its blog post, “The healthcare payer industry is plagued with notoriously old infrastructure. While healthcare payers are working to increase data transparency, offer member-centric solutions, and adopt a value-based care model, they’re obstructed by high reliance on dated, disconnected, and non-interoperable systems.”

Missing information, inaccurate coding, and variability of authorization rules amongst insurers add to the backlogs and costs associated with slow and inefficient claims systems. The COVID-19 requirements, exceptions, and payment-related complexities have only intensified payment integrity challenges. To add to the bureaucratic and information burdens, payer employees working remotely during COVID-19 cannot access their mainframes (typically hosted in a single location and requiring on-premise operation) and struggle to approve and process claims in a timely manner.

Unexpected Impacts on Billing and Payments

Consider the following real-life example of the unexpected impacts COVID-19  on billing and payment across providers, payers, and consumers. A 25-year-old student experiencing coronavirus symptoms went to her doctor’s office. Her doctor ordered a series of tests to rule out non-coronavirus respiratory disease before conducting a COVID-19 test, as these tests were in short supply and reserved for more serious cases.

Long story short, due to insufficient coding, confusion around what services the Families First Coronavirus Response Act covered, and whether the provider, payer, or patient was responsible for the charges, the student received a surprise bill for hundreds of dollars. Coincidently, this student had worked at a physician’s office and was familiar with manually working through billing and payment discrepancies between providers and payers and could reconcile the bill in the end.

This experience exposed what providers, payers, and consumers face daily: missing data, inaccurate coding, and confusion on guidelines that can slow down what should be fairly straightforward administrative processing across the spectrum of care delivery.

However, the pandemic did not create these administrative deficiencies – it merely magnified where outdated technologies present obstacles to providing responsive services and highlighted the limitations of current payer administrative systems and solutions.

To remain viable and competitive, Health plans must take advantage of the technologies that enable transparency, efficiency and agility.

Looking Ahead

As healthcare transitions to a more efficient, innovation-driven environment, so must our technology claims adjudication systems; systems that can offer interoperability and adaptability will enable payers to quickly customize policies and fee schedules and apply exceptions, adjustments and custom carve-outs.

According to the Everest Group, payers leave a lot of value on the table when managing medical and administrative costs separately. Administrative processes and IT management accounts for 15-20 percent of total payer costs, and a cloud-based prospective payment integrity platform can significantly help to reduce this number.

The industry could save $15.5 billion per year if payers processed claims correctly the first time. While almost all payers have some form of retrospective payment integrity scanning in place, few utilize emerging technology to proactively avoid paying claims improperly, even when the retrospective review of overpayments is 1.5x as costly as prevention.

In August 2020, HealthEdge completed its acquisition of The Burgess Group, LLC, an innovative payment integrity software company focused on improving healthcare payment operations through technology.

“Payment integrity is one of the principal tools to manage medical costs and, hence, is a key functionality that payers value in core-admin platforms. By adding The Burgess Group’s offerings to its own expertise, HealthEdge’s goal is to create an integrated claims processing, payment integrity, and adjudication platform that addresses both administrative and medical expenses,” the Everest Group reported in its blog.

Health plan customers will now benefit from claims cost savings via Burgess Source®, a cloud-based, prospective payment integrity platform with a once every two-week update cycle to enforce compliance and an interoperable ecosystem to deliver accurate results. The platform’s ability to identify and reduce the estimated $1 trillion wasteful spending in the U.S. healthcare system leads the way to on-time, accurate payments for millions of covered lives.

Changes to the health insurance industry have been traditionally very slow. However, the global pandemic has forced health plans to move forward with decisions and initiatives at full speed. There was no opportunity to analyze every aspect of a benefit plan and take months to implement it, changes needed to happen immediately.

The Need for Agile Healthcare in a Rapidly Changing Industry

At the beginning of COVID-19, it seemed that state and federal authorities introduced or changed regulations every day. It was challenging to sift through the noise and keep up. Everyone experienced hiccups along the way. Payers and providers alike had to fix errors, re-submit and reprocess claims, and course correct.

The pandemic has demonstrated the need for health plans to be agile, flexible, and methodical; it all comes down to configuration. Behind-the-scenes, successful configuration comes down to two things: sound business processes and consistency.

The HIPAA electronic data interchange introduced standards for the communications for payers. It forced the industry to standardize business processes to ensure that the correct data is required and used throughout the lifecycle. Sound business processes guarantee the data continues to maintain accuracy; consistency is key for clean data.

For example, as a result of the pandemic, specific benefits were rapidly mandated and changed “on the fly,” but the value of having consistent data requires that there are minimal variations or outliers to ensure accurate data analysis.  Certain information and fields must be uniform so health plans can easily look at claims experience, identify all of the claims that fall into specific buckets, and understand the historical data and what it means.

The Need for Agile Healthcare

The truth is, many claims processing systems are not as agile as they need to be. Now that payers have experienced the pressure and expedited timelines around COVID-19, no one wants to go through that again. That is why consistency, business processes, and agility are all very crucial for success.

Earlier in my career, I handled implementations for a software vendor and noticed a common occurrence among customers that is still prevalent today. The first few years with the software would be great; the company would send everyone to healthcare technology training classes to get all employees up-to-speed on the new technology. Then, by year three or four, that emphasis on training would lose momentum.

Staffing changes, people take on different roles, employees leave, and new hires come in. Ongoing training is crucial for companies to ensure employees have the proper skills and knowledge to use the systems effectively.

For example, I visited a client and saw that a woman processing a claim had stopped and opened an internet browser to determine whether the member had Medicare. Every time a claim would come in for a member over a certain age, she would do this manual process. I showed her where she could see if the member had other insurance in the system, make notes on the member record, and find it in the future. She had no idea this capability existed, and she developed her own workaround for it. This training took little time and completely streamlined the claims processing. This was just one person. Imagine if a company had 15 or 20 people working like this, and how much time and resources are wasted on these workarounds simply because the team does not have proper training?

Our technology provides so many capabilities; I hate to see organizations make a significant investment in these systems and not use them to their fullest.

Three Healthcare Technology Training Tips:

1. Start training early. Spend two full weeks of in-depth training on all the technical systems in the ecosystem before a new hire jumps into their role. Investing the time in training up-front will pay off in the long run.
2. Work with vendors. You don’t have to do this alone! Many vendors offer training options and have deep experience in training and education. Reach out to learn about their services or if they will help you build a training program that you can easily update and maintain.
3. Leverage exit interviews. If an employee leaves, take the opportunity to ask how the company can improve healthcare technology training. This first-person insight is incredibly valuable.

From my experience, the cost of healthcare technology training is always outweighed by the benefits, knowledge, and skills employees receive. When a workforce has adequate training, they will work more efficiently and help the organization achieve its goals.

The Patient Access API and the Provider Directory API will be enforceable on July 1, 2021. HealthEdge is confident that we will have our standardized data requirements to enable the plans to have full compliance.

Currently, plans are likely focused on the member portal technology, authentication, and authorization management. We have ensured that the data that we routinely move provides them everything they need for the FHIR-enabled data store.

The Payer-to-Payer Data Exchange is the heavier lift. While our current APIs will handle the data extraction, there is also an ingestion aspect of the data exchange. On January 1, 2022, health plans will likely just hold the data in a data warehouse. Beyond accepting an electronic file for a new member, the Rule does not yet outline how to ingest and use the information. There will be a translation process, but by building upon the x12 inbound transaction processing the path is already paved.

We expect to see some business cases for the use of historical data in 2021. HealthEdge is prepared to dig into those business cases as they develop looking for some synergy between what we do and what plans need.

ONC Final Rules on Information Blocking & HIT Certification

The ONC Information Blocking Final Rule was to become enforceable on November 2, 2020. However, due to COVID-19 and other current initiatives, ONC did not believe it was feasible to enforce the Rule and announced in late October that it would delay implementation.

ONC has released new dates and timeframes beginning on April 5, 2021.

Transparency in Coverage – Final Rule

The Transparency in Coverage Final Rule has been published and becomes effective on January 11, 2021.

On January 1, 2022, health plans must post and regularly update machine-readable files, to the plan’s public website, of in-network negotiated provider rates, in-network drug pricing, and out-of-network coverage rates.

On January 1, 2023, health insurance providers must offer an online shopping tool or similar platform that includes out-of-pocket cost estimates and negotiated prices for 500 of the “most shoppable” services (which are yet to be defined). We think there is potential to use trial claim functionality in HealthRules® Payor for this type of shopping tool. On January 1, 2024, the 500 cap is removed and online shopping must expand to all services.

In the tool, a user would log in to see their estimated cost-sharing, including what provider they want to go to, what service they need, and where that procedure might happen. There are still a lot of questions around this. At this point, the identification of the risk factors is up for debate. Most users will not have the CPT billing code or NDC – National Drug Code . They will not know whether there’s bundled services or not. There needs to be logic that explains how to display cost estimates for desired services.

Additionally, as health plans calculate their 2020 Medical Loss Ratio (MLR) reporting year, they can include any shared savings payment that the issuer has made to an enrollee due to the member choosing to obtain health care from a lower cost, higher value provider.

HIPAA Transactions and Code Sets (EDI)

The current version (5010) of the X12 HIPAA Transaction has been in use for about 10 years.  Looking back over the timeline of HIPAA EDI, spanning the past 17 years, we implemented the Rule using  V4010 and upgrade it to V5010 to support ICD-10.  The functionality of newer versions is needed and the National Committee on Vital and Health Statistics’ (NCVHS) and the Department of Health and Human Services have been in discussions for some time about adopting a newer version of the X12N HIPAA EDI Transactions.

X12 has been working on Version 7030 for several years as the next version to be adopted under HIPAA.

X12 works with the industry subject matter experts to develop implementation guides that meet the needs of the industry within the guidelines of HIPAA.

Recently, X12 announced that the completed V7030 implementation guides would form the basis of Version 8010, meaning we are a long way towards a completed Version 8010. It is expected that X12 will recommend to NCVHS that we skip 7030 and go directly to version 8010 as the next HIPAA transaction standard.

HealthEdge will continue monitoring this to determine the version and timeline for implementation.

Additional Policy and Regulatory Revisions in Response to the COVID– 19 Public Health Emergency

On November 6, 2020, the Tri-Agencies published an interim final rule (IFR) with request for comments about COVID-19 and the response. The effective date is January 1, 2021. HealthEdge has analyzed the IFR, and it does not appear that any significant details have changed regarding zero cost-sharing for testing and treatment, etc.

We are getting close to a COVID-19 vaccine, and CMS has provided guidelines about how to handle claims for the vaccine, minimizing delays that sometimes happen with the issues around release of new vaccines.

The American Medical Association (AMA) who is responsible for CPT-4 codes, issued the new vaccines specific codes to report the immunization for COVID-19. There are codes for the vaccine products as well as vaccine administration.

AMA worked very closely with CMS to create these new vaccine administration codes so that they are distinct to each vaccine and the specific dose. This specificity will allow them to track each vaccine dose, even if the vaccine product is not reported through a claim (i.e., if the vaccine was given to the patient for free.)

CY2022 – Advance Notices

We received advanced notices for the calendar year 2022 for your Medicare Advantage (MA) and prescription drug information Part C and Part D Payment Policies.

On September 14, 2020, we received part one. CMS is proposing to fully transition to the risk adjustment model adopted in the 2020 rate announcement. CMS will announce the MA capitation rates and final payment policies no later than Monday, April 5, 2021.

On October 30, 2020, we received Part Two, which includes preliminary estimates for the national per capita MA growth percentages and national Medicare fee-for-services growth percentages, which are key factors in determining the MA capitation rates. CMS also announced some changes in the Part C payment methodology, as well as annual adjustments to Part D prescription drug benefit parameters, Medicare Advantage PD star ratings, and economic information for the significant provisions.

Our team is drilling down on these notices and will provide more information on the calendar year 2022.

CMS – Annual Enrollment Period

The CMS Annual Enrollment period is happening right now and ends on December 7, 2020.

Next important deadline is coming up on December 4, 2020 MLR (Medical Loss Ratio) data for 2019 must be submitted to CMS via HPMS.