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In the dynamic California landscape of health care, capitation is gaining popularity as a reimbursement model. Capitation is the practice of paying care providers a fixed amount for each patient. California-based health plans are working to integrate capitation practices to meet regulatory demands—as well as provide a more efficient and member-centric experience.

Understanding the California Capitation Challenge

California-based health plans face unique and complex challenges amidst continuous regulatory changes. Capitation arrangements in the state have evolved, placing new emphasis on value-based care and risk adjustment. With the Patient Protection and Affordable Care Act (ACA) and other legislative milestones reshaping reimbursement rules, it’s clear that capitation isn’t merely an option—it’s on the brink of becoming the standard.

This increased use of capitation brings both opportunities and hurdles for payers. While it can encourage proactive, preventative care that contributes to better patient outcomes, capitation also requires robust data analytics and a strategic team that can manage risks and resources effectively.

To stay on top of capitation and ahead of competitors, adopting integrated digital solutions not only help reduce costs but also improve the overall patient experience. Compliance alone is not enough to future-proof your health plan—payers must become agile, adaptable, and innovative to thrive in this new ecosystem.

Adapting Core Administrative Platforms for Capitation Success in California 

The foundation of a successful transition to capitation lies in the modernization of Core Administrative Processing Systems (CAPS). A robust and responsive digital solution is essential to maintaining data accuracy.

Data Integration and Analytics

Accurate and comprehensive patient data is pivotal in any capitation model. By integrating data from a multitude of sources and employing advanced analytics, health plans can gain the insights necessary to effectively allocate resources, identify high-risk patients, and tailor care plans with precision.

Automated Payment Systems

Automated payment systems streamline the process of disbursing capitated funds to providers while offering transparency to both parties. These systems minimize errors, mitigate financial risks, and enhance trust and collaboration with care networks.

Member Engagement Platforms

Member engagement has been a major area of focus for health plans. Digital platforms that empower patients with health information, self-service options, and personalized outreach can significantly improve health outcomes, reduce unnecessary costs, and increase retention.

Digital Innovation for Capitation Readiness

A strategic approach to digital transformation equips health plans not only to comply with capitated arrangements but to excel in them. This includes adopting technologies like telehealth, remote monitoring, and AI-driven diagnostics that revolutionize the care delivery and management process.

Telehealth Integration

Telehealth services expand access to care while reducing the need for in-person visits, which is particularly beneficial for members managing chronic conditions. Integrating telehealth into capitated models can lead to increased patient satisfaction and lowered operational costs.

Remote Patient Monitoring (RPM)

Remote patient monitoring (RPM) keeps patients connected to providers, enabling real-time health data tracking and proactive intervention. For health plans, RPM can mean higher-quality care and lower overall care costs—as well as a strategic tool for managing capitated risks.

AI and Predictive Modeling

AI and predictive modeling can forecast patient needs and likely care pathways, empowering health plans with proactive decision-making capabilities. By leveraging these technologies, health plans can optimize their capitated efforts and ensure that resources are allocated where they’re most needed.

Cultivating a Digital-First Healthcare Culture

The success of any digital transformation effort in health plans is heavily dependent on the people behind the technology. Cultivating a digital-first culture that is open to innovation and change becomes imperative as health plans redesign their operations around capitation.

Training and Development

Investing in comprehensive training programs that build digital competencies among staff is an essential step toward a digitally mature organization. Regular upskilling sessions and continuous learning opportunities should be the norm, not the exception.

Change Management

Managing the transition to capitation and digital health care requires a concerted effort in change management. Clear communication, stakeholder involvement, and a phased implementation approach can ease the change process and promote buy-in from all levels of the organization.

Innovation Labs and Centers of Excellence

Establishing innovation labs and centers of excellence within health plans can serve as incubators for new ideas and best practices. They provide a structured environment to test and scale digital solutions before full-scale deployment, reducing risks and enhancing outcomes.

The Path to Becoming a Digital Payer

With technological advancements accelerating and consumer expectations evolving, California healthcare payers are evaluating how their CAPS systems can provide flexibility, transparency, and engagement, aligning perfectly with capitated models.

CAPS solutions like HealthRules® Payer enable forward-thinking payers to champion digital innovation and foster a culture of adaptability. By leveraging technology and adopting a digital-first approach, health plans can not only comply with California capitation requirements but also excel in this new reimbursement model.

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Are you looking for more information on how key technology features and authentic partnerships can help your health plan remain agile in an ever-changing industry? Watch our on-demand webinar, “Proactively Addressing Regulatory Complexities in California and Beyond.”

[Watch the Webinar]

Managing complex healthcare claims requires a flexible editing system that adapts to the unique needs of your health plan. Traditional claims editing tools often fall short, leaving you vulnerable to errors and inefficiencies. That’s why HealthEdge Source™ (Source) developed Advanced Custom Edits (ACE), a new feature that allows users to create and manage custom edits directly within the Source interface.

Our solution goes beyond pre-defined edits by analyzing the member’s claim history, allowing you to identify potential irregularities with a high level of accuracy. This opens doors to a whole new level of control and adaptability you can access in-house. With ACE, you can tailor editing rules to address specific scenarios and business needs with ease.

How do Advanced Custom Edits work?

Building on the foundation of our existing custom editing feature, Advanced Custom Edits empower your health plan to take editing a step further. You will have complete control over defining the edit itself, including name, ID, disposition, message, and provider type. In addition, it introduces a powerful new capability: evaluating data from historical member claims.

Think of it as adding a magnifying glass to your claims editing process. By incorporating claim history data (identified by beneficiary ID), ACE significantly expands the reach of your editing rules. This allows your team to analyze a broader range of claims data, resulting in more precise and comprehensive claim evaluation.

Advanced Custom Edits function through three key components:

1. Current Claim Conditions: Define the criteria that must be met on the current claim to trigger the edit.
2. History Claim Conditions (available with claim history license): Leverage historical member claim data to refine your edit’s focus and identify potential issues.
3. Relational Criterial (available with claim history license): Set up comparisons between current and historical data to pinpoint claims that meet your edit’s criteria.

When you activate an Advanced Custom Edit, these three components work together to identify claims that meet all the defined conditions and allow the edit parameters to determine whether to take action. This multi-layered approach empowers your health plan to achieve unmatched accuracy and control over your claim editing approach.

Plus, your team doesn’t have to worry about learning a new claims editing system. ACE seamlessly integrates with the familiar functionalities you already know and love. If your team needs to create a new edit quickly, they can copy and modify an existing edit. Your team can also leverage existing code collections within your edit conditions to ensure consistency and save you valuable time.

Have you already made changes and want to keep track of them? The Change Log keeps a record for easy reference. In addition, you can easily include your Advanced Custom Edits during configuration import and export for efficient workflow management.

4 Key benefits of using Advanced Custom Edits

With access to HealthEdge Source, your team can leverage tools like validation, payment integrity, and cost containment edits to improve control over your claims review process. But with Advanced Custom Edits, you can also:

• Reduce improper payments and ensure claims are paid correctly the first time by leveraging historical data for a more comprehensive evaluation.
• Streamline manual reviews and eliminate bottlenecks with more precise editing rules, freeing up valuable staff time.
• Boost your efficiency, accuracy, and flexibility with custom edits that leverage member claim history.
• Take control of your own edits without relying on external vendors.

What’s next in Advanced Custom Edits

Advanced Custom Edits is the ultimate solution for claim editing. It allows you to leverage the power of member claim history and customize your editing rules to meet your specific needs. Reduce errors, streamline workflows, and optimize your health plan’s operations.

HealthEdge Source is committed to continuous innovation. With Advanced Custom Edits, we are empowering health plans like yours to achieve a new level of control and efficiency in claim editing. Stay tuned for exciting upcoming features like edit exceptions, message mapping, and enhanced relational functionalities.

Are you looking for more information about how your health plan can take full advantage of retroactive claims configurations? Watch our on-demand webinar at your convenience: “Optimizing Retroactive Configuration Changes.”

 

 

Navigating the labyrinth of healthcare regulations is no small feat. This is especially true for health plans operating in California. The state has the largest population in the U.S., with varied healthcare needs. For healthcare payers, staying compliant with shifting regulations while optimizing operations and delivering quality care can feel like walking a tightrope. Luckily for health plans, the right Core Administrative Processing System (CAPS) vendor can be your partner in learning to navigate complex healthcare regulations and better serve your members. 

In a recent AHIP-sponsored webinar, three HealthEdge experts shared insights on how health plans are tackling regulatory complexities in California and beyond. This blog post dives deep into those discussions, providing you with practical strategies to stay ahead of the curve. 

The Challenge of Healthcare Regulatory Compliance 

Healthcare regulations are designed to protect patients and ensure high standards of care. However, they can also be a source of immense pressure for health plans. The rules are constantly evolving, and failing to comply can result in hefty fines, provider friction, and reputational damage. Understanding these regulations is crucial for any health plan looking to thrive in today’s competitive landscape. 

Regulatory Focus on Social Determinants of Health (SDOH) 

Social determinants of health refer to the non-medical factors that influence health outcomes. These include housing, nutrition, education, and transportation. SDOH can have significant impacts on member health—and can reduce an individual’s expected lifespan by 20 years. 

California has been a pioneer in integrating SDOH into healthcare models, pushing health plans to consider these factors in their care strategies. Among other requirements, health plans operating in California must collect data on patients’ living conditions, dietary habits, and more. This allows health plans to anticipate future needs and adapt to expectations. 

Implementing SDOH Strategies 

Successfully integrating SDOH into your healthcare model can improve patient outcomes and reduce healthcare costs. Many health plans across the U.S. are partnering with community organizations to gather relevant data on member populations, as well as connect their members with support services. This is vital to create personalized care plans that address both medical and social needs. 

Enhanced Data Privacy Protections 

With the rise of digital health data, privacy regulations have become stricter. Laws like the California Consumer Privacy Act (CCPA) and the Health Insurance Portability and Accountability Act (HIPAA) require robust data protection measures. CCPA grants California residents specific rights regarding their personal information, including the right to know what data is being collected and the right to opt-out of its sale. HIPAA, on the other hand, sets the standard for protecting sensitive patient information. 

To comply with these regulations, health plans must implement comprehensive data protection strategies. This includes encrypting data, conducting regular security audits, and training staff on privacy best practices. 

Regulatory Caps on Price Increases 

To make healthcare more affordable for more members, regulators are imposing caps on price increases for health plans and providers. While this aims to benefit consumers, it requires meticulous financial planning from health plans. 

Health plans must develop strong negotiation skills to manage these caps effectively. This involves working closely with providers to agree on fair pricing that aligns with regulatory limits. Integrated payment integrity systems that allow for real-time monitoring of pricing structures will empower your health plan to make necessary adjustments quickly and stay compliant with regulatory caps. 

The Role of Vendor Partners in Regulatory Compliance 

Successfully navigating regulatory changes often requires partnering with experienced vendors. These partners can provide the expertise and technology needed to anticipate future shifts and adapt accordingly. 

Selecting the Right Vendor 

Look for vendors with a proven track record in healthcare compliance. Evaluate their technology solutions to ensure they offer the flexibility and scalability required to meet your needs. It’s also important that your health plan cultivates long-term partnerships with your vendors. This collaborative approach supports continuous improvement and innovation in meeting regulatory requirements. 

The Need for Flexible and Configurable Systems 

Health plans must adopt flexible and configurable systems that allow for quick customization. This adaptability is essential for responding to regulatory changes without significant disruptions. 

Highly configurable systems enable health plans to adjust their operational processes easily, reducing the time and resources needed to implement new workflows and guidelines. Look for solutions that offer features like role-based access controls, real-time data processing, and automated compliance updates. 

The Importance of Data Management 

Effective data management is critical for compliance and operational efficiency. Organizing health plan data in a way that makes it accessible and secure is vital to ensuring compliance—as well as maintaining member trust. Implementing role-based access controls to ensure sensitive information can help minimize the risk of data breaches and ensures compliance with privacy regulations. 

The Value of Long-Term Vendor Partnerships 

Building long-term partnerships with vendors and stakeholders can foster a proactive approach to new regulations. This collaboration supports continuous improvement in meeting regulatory requirements.  

Engaging with vendors and stakeholders regularly to discuss upcoming regulatory changes makes it easier to proactively develop strategies to effectively address regulatory changes. In addition, focusing on continuous improvement by regularly reviewing and updating your compliance strategies can help ensure you remain ahead of regulatory changes and maintain operational efficiency. 

Utilize technology platforms like HealthRules® Payer to access the real-time updates and automated compliance features that streamline compliance processes and reduce the manual administrative burdens for your team. 

Navigating the complex landscape of healthcare regulations requires a strategic, proactive approach. By addressing social determinants of health, enhancing privacy protections, capping price increases, and partnering with experienced vendors, health plans can ensure compliance and optimize operations. 

Investing in flexible systems, integrating sensible data layers, and cultivating long-term partnerships are crucial for success. For additional insights on developing a proactive approach to regulatory compliance, watch our on-demand webinar, “Proactively Addressing Regulatory Complexities in California and Beyond.” 

[Watch now] 

In any organization, maintaining a culture of integrity and accountability is a top priority. At HealthEdge, one of the ways we uphold these values is by providing a hotline for employees, vendors, and customers to report issues and raise concerns. An effective whistleblower program empowers individuals to report unethical behavior, misconduct, or violations of company policies without fear of retaliation.

We’re highlighting five key reasons why offering Speak Up is crucial for employees, vendors, and customers:

1. Facilitates Transparency and Trust

Speak Up promotes transparency by encouraging employees, vendors, and customers to report unethical behavior, misconduct, or violations. This transparency helps build trust among stakeholders and fosters openness and honesty, which are essential for a thriving organizational culture.

2. Protects Whistleblowers and Builds Confidence

Individuals who report unethical behavior may fear reprisal. Speak Up provides a safe and confidential channel for reporting violations, ensuring whistleblowers are protected from retaliation. This protection builds confidence among employees, vendors, and customers, empowering them to speak up without fear of negative consequences.

3. Prevents Legal and Financial Risks

Organizations can mitigate the threat of legal and financial risks by recognizing inappropriate activity early. Speak Up provides an avenue for employees, vendors, and customers to report issues promptly, enabling HealthEdge to take corrective action before the situation escalates. This proactive approach helps prevent costly legal battles and protects the organization’s financial stability.

4. Promotes Accountability and Ethical Conduct

A robust whistleblower program holds individuals and the organization accountable for their actions. Knowing that unethical behavior at HealthEdge will be reported and addressed encourages responsible conduct among all stakeholders. This culture of accountability ensures that HealthEdge operates with the highest ethical standards, reinforcing our commitment to integrity.

5. Enhances Compliance & Drives Continuous Improvement 

Feedback received through the Speak Up program can identify compliance violations and areas for improvement. By addressing these issues, HealthEdge can refine internal processes and policies, leading to comprehensive improvements across the organization. This continuous improvement fosters a culture of excellence and ensures adherence to relevant laws, regulations, and industry standards.

Speak Up is an indispensable tool for fostering integrity and accountability within HealthEdge. It ensures transparency, protects whistleblowers, prevents legal and financial risks, promotes accountability, enhances compliance, drives continuous improvement, and strengthens corporate culture. Speak Up demonstrates our commitment to ethics, integrity, and responsibility. Prioritizing this program sets HealthEdge apart as an ethical leader in the healthcare industry, dedicated to creating a better future for all stakeholders.

When it comes to optimizing care management, it’s common to hear stories about care managers losing valuable time playing phone tag, and members feeling frustrated because they don’t know when or how to get in touch with providers when they need to. Digital care programs can give health plan members access to resources and interventions when it’s most convenient for them.

Wellframe’s whole-person digital care programs are designed to engage members by giving them the knowledge they need at the right time, empowering them to make informed health decisions. Leveraging digital care programs, care teams can build trusting member relationships that can improve outcomes and retention.

What Are Digital Care Programs?

Digital care programs leverage technology to streamline communication between care teams and health plan members. This approach helps streamline workflows and improve efficiency by cutting down on the time it takes for care teams to contact and get key health and wellness information from members. Consequently, care managers see a 2x increase in caseload size, and 6x increase in member interactions—without sacrificing quality.

The Wellframe solution currently offers more than 70 digital care management programs covering acute and chronic conditions, including diabetes management, weight management, hypertension, maternal health, and more.

Benefits of Digital Care Managemen

• Improved Care Outcomes: Members enrolled in the Diabetes care management program reduced their blood sugar readings by up to 25%. Members in the Hypertension care management program lowered their blood pressure by up to 9%.
• Complex Care Support: Members with multiple conditions who had access to Wellframe reported 33% fewer readmissions. Additionally, senior members using Wellframe reported 29% fewer Emergency Department (ED) visits.
• Cost Containment: Health plans using Wellframe digital care programs reported $641 in per member per month (PMPM) savings. Members using Wellframe also reported a 29% increase in utilization of preventive services, which can help lower long-term healthcare costs.

Designing for the Sweet Spot with Self-Directed Learning

The average lifespan in the U.S. is 79 years, but the average healthspan is only 63 years. This means many Americans spend about 20% of their lives unhealthy. Wellframe aims to bridge this gap by targeting high-risk and rising-risk members who would benefit from proactive and ongoing engagement.

For example, the Maternity digital care program encourages members to attend pre- and postpartum care visits and sends information relevant to where they are in their pregnancy. A Care Transitions program can provide extra support to members after a hospital discharge to reduce readmissions and complications.

Member-Centric Approach

Motivating members to actually use digital care programs involves a combination of educational content, a user-friendly interface, and interactive elements. Many members are open to self-directed care opportunities, and just need access to reliable information and guidance. Whole-person digital care programs provide trustworthy and relevant health information alongside care team communications, reducing the need to rely on potentially misleading online sources.

This approach not only makes health resources more accessible but also helps alleviate the cognitive burden on providers, extending their reach and effectiveness.

Creating Engaging & Interactive Content

Starting and sustaining healthy habits begins with removing obstacles to better choices. Our content is designed to make it easier for members to adopt healthier lifestyles by offering practical advice and actionable steps.

Visualization and Integrations

Visualization tools and integrations with health technologies help members set achievable goals and track their progress. Based on the care program they’re enrolled in, members are prompted to input information such as their weight, blood sugar, blood pressure, and step counts every day. The information is stored in the app and presented to users in easy-to-read graphs and other visuals.

Interactive Learning and Related Content

Wellframe digital care programs include [NB1] articles with multiple-choice questions to actively engage members. For instance, a blog about incorporating more vegetables into your diet might ask whether canned vegetables are a healthy food choice. The article may also be followed by an article on healthy recipes that are quick to prepare.

Linking Knowledge to Action

Whole-person digital care programs emphasize how members can make small improvements to their health and wellness by providing specific, supportive content. Some examples include:

• Substance Use Disorder: Promoting healthy habit formation and mindfulness while reducing feelings of shame and stigma.
• Perimenopause Support: Highlighting available care choices and agency in treatment.

For healthcare payers dedicated to making a meaningful impact on their members’ lives, Wellframe offers an innovative, engaging, and effective approach. Wellframe is not just a digital health management tool—it’s a visionary solution crafted to transform healthcare delivery and the member experience. By integrating advanced technology, evidence-based content, and empathetic interactions, we’re setting new standards in care management.

Experience the future of digital care management with Wellframe. Watch our on-demand webinar to learn effective health plan strategies for expanding staff reach and enabling them to meet members where they are to drive better member engagement, satisfaction, and clinical outcomes.

[Watch the webinar]

 

I think we’ve phased videos out of care programs for the most part [NB1]

In today’s competitive healthcare landscape, operational efficiency isn’t just a goal—it’s a necessity. Health plans are constantly seeking ways to streamline their processes, reduce overhead, and improve care delivery. Provider Data Management (PDM) for health plans is an often-overlooked solution that can improve efficiency and performance.

In a recent Becker’s Healthcare podcast, we explored how optimizing PDM can be a game-changer for health plans. With this blog, we dive deeper into addressing common challenges and highlighting how advanced PDM solutions, like those from HealthRules Payer, can revolutionize healthcare payer operations.

Benefits of leveraging Provider Data Management (PDM) For Health plans

Provider Data Management is the practice of collecting, validating, and maintaining accurate information about healthcare providers. This information can include demographics, specialties, locations, and network affiliations. Maintaining an accurate repository for provider data is crucial for several reasons:

• Improved Care Delivery: Offering updated provider data ensures that members can find the right care at the right time, leading to better health outcomes and greater trust.
• Operational Efficiency: Streamlined PDM processes reduce administrative burdens, allowing staff to focus on more strategic tasks.
• Compliance and Risk Management: Keeping provider data up-to-date helps in complying with regulatory requirements and mitigates risks associated with incorrect information.

Common Challenges in Provider Data Management

Health plans often face significant challenges in managing provider data. Outdated or inaccurate information can lead to claim denials, member dissatisfaction, and increased administrative costs. Common issues include:

• Internal Data Silos: Information is often stored in disparate systems, making it difficult to validate data and maintain a single source of truth.
• Reliance on Manual Processes: Many health plans still rely on manual data entry and updates, leading to errors and workflow inefficiencies.
• Lack of Real-Time Updates: Delays in updating provider information can result in outdated data being used for critical decisions.

5 Ways Health Plans Are Leveraging Advanced Provider Data Management Solutions

Advanced PDM solutions, like those offered by HealthEdge, can address these challenges head-on. These are five ways our current health plan customers are leveraging PDM at their organizations:

1. Ensuring Data Accuracy and Completeness

HealthEdge’s PDM system ensures no data loss by providing 100% coverage for provider demographics, customer-specific UDT, and benefit network data. It offers real-time provider API services for any missing, incomplete, or inaccurate provider cases. This ensures that health plans always have access to the most accurate and complete data.

2. Streamlining Processes to Increase Automation

The platform is configurable to align with the customer’s master data identification defined on HealthRules Payer. This streamlines data verification processes, increasing automation to reduce overheads and inefficiencies. By automating routine tasks like data verification, staff members can focus on more strategic activities and drive overall efficiency.

3. Enhancing Data Enrichment and Workflow

HealthEdge’s PDM solution provides data enrichment through validation checks and easy-to-use workflows. The platform leverages a centralized framework with more than 300 built-in quality checks and third-party validations (like NPPES) that address standardization and attestation. Its modern web application, with a native workflow module, allows customers to define, automate, and track changes—ensuring high data quality and consistency.

4. Facilitating Seamless Distribution and Integration

The PDM platform supports configurable data distribution and native Core Administrative Processing System (CAPS) integration. This includes a self-service module to set up, schedule, and deliver data extracts. Additionally, it supports real-time API, event-based distribution, and seamless integration with HealthRules Payer, allowing data to flow smoothly across systems.

5. Leveraging Modern SaaS Platform Features

HealthEdge’s PDM is a modern SaaS platform with web-based workflows. This cloud-native software offers high availability, unlimited scalability, seamless upgrades, and role-based access. It also features a customer-extendable data model, providing the flexibility to meet the unique needs of each health plan.

Key Differentiators of HealthEdge Provider Data Management for Health Plans

In a highly fragmented market, the HealthEdge PDM solution stands out in four key areas:

• Provider Master Identifier: Distinctly recognizes unique providers and organizations based on specific needs and business requirements.
• Data Mastering with Prebuilt Match and Merge Rules: Effectively handles and maintains data sourced from various channels, with users able to review and address conflicts.
• Low or No Code Framework: Generative AI-enabled framework allows users to easily set up and map source channels with minimal coding.
• Observability Dashboard: Provides insights into processing status, duration, and data quality from various source channels.

In an industry where efficiency and accuracy are paramount, optimizing Provider Data Management for health plans can be a significant driver of success. By leveraging advanced PDM solutions like those offered by HealthEdge, health plans can overcome common challenges, streamline operations, and ultimately deliver better care to their members.

Are you ready to transform your health plan’s workflows to improve efficiency and accuracy?

Read our case study, “HealthRules® Promote Empowers Medica Health Plan to Streamline Processes” to learn more.