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:
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.
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.
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.
Imagine an expectant mother has high blood pressure and sees a specialist. After the visit, the provider submits the claim to her insurance plan, and from there it goes through a lengthy administration process. The insurance plan performs complex eligibility and benefits checks, provider contract checks, claims editing and pricing checks, and pushes the claim through several internal and external third-party solutions. Eventually, a reimbursement amount returns, but it moves to a medical records review, and is sent back for another trip through the process.
This case illustrates the complexities that often occur in the claims workflow. There are many time-consuming and redundant steps — sometimes more than 100 — to proper reimbursement. With this system, it’s evident why there is so much uncertainty about how much the expectant mother will have to pay.
But what if patients could pay the correct amount for the care they receive with full transparency of fees the moment a healthcare professional renders service? We can move closer to accurate point-of-service payments in healthcare, but we need advancements in technology to get there that include:
Just about every health plan that I have talked to in my career is currently experiencing, or has had experienced, problems keeping their provider population at a high level of satisfaction. Accurate provider data matching is a great example of a consistent pain point for health plans that contributes to lower provider satisfaction, no matter the health plans’ size or solution. If a health plan cannot match a provider accurately through integration for provider data management or claims processing, payment delays or incorrect payments occur.
What I have seen is, without the right integrated solution, something as simple as an accurate, reliable provider match can drain a payer’s time and resources. Incorrect payments lead to appeals, disgruntled providers, phone calls, the need to rework and reprocess claims, and ultimately negatively impact the bottom line driving up the precious PMPM that all health plans live and die by.
Worse yet, many other factors can impact the claims payment process, whether it is human or system error, unpredicted provider billing behaviors, or even outdated technology stacks. The myriad of issues like unprocessed authorizations, incorrect benefits, or pricing, missing electronic medical records, or lack of payment integrity and payment accountability are just some of the problems health plans experience daily. Customer service teams, provider appeals, and adjusted claims drive increased overhead and decreased provider satisfaction as a result.
With the right technology, health plans can use a provider-focused ecosystem leveraging advanced analytics to track provider satisfaction and work to understand different characteristics related to billing and claims administration. Actionable data can enable operations staff to put issues into context to adapt their business, introducing new pricing and reimbursement models accordingly. My colleague Diane Pascot recently published an excellent blog on the value of analytics, Leveraging Real-Time Data for a Meaningful Customer Experience.
Health plans have discovered one obvious key to provider satisfaction is having a solution that automates and accurately matches providers, which is also key to high auto adjudication rates (arguably the most valuable statistic, next to accuracy, for any given health plan). Additionally, they understand how accurate payments lead to lower administrative costs and overall increased satisfaction. For health plans, while it is critical to keep persistency in their membership, so is maintaining high levels of provider satisfaction. The most successful clients use a comprehensive, integrated ecosystem that can provide the best-of-breed in care management, pricing, clinical edits, and analytics that increases both provider payment accuracy and satisfaction.
According to Medpac, the country’s baby-boom generation (born between mid-1946 and 1964) began aging into Medicare in 2011 at a rate of about 10,000 people per day, a rate that will continue until 2030.
Over the next 15 years, Medicare’s enrollment is projected to increase by almost 50 percent— rising from 54 million beneficiaries today to more than 80 million beneficiaries in 2030!
Accordingly, the impacts of this enormous demographic shift will drive the evolution of market demand and the corresponding effective responses from providers and health plans alike.
Some of the key market driver questions include:
How will the incoming baby boomers affect the age structure of the Medicare population? Will the Medicare population be more racially and ethnically diverse, given the growing racial and ethnic diversity of the total U.S. population?
Given the improvements in life expectancies, will the next generation of Medicare beneficiaries live longer and healthier lives than previous generations? Or will the longer life expectancies increase the oldest age groups in Medicare, thereby increasing the rates of disease and chronic conditions?
Have baby boomers and especially the oldest baby boomers had time to recover from the 2007 to 2009 recession before entering retirement?
What is the outlook for the Medicare program’s financial health as the number of taxpaying workers per beneficiary declines?
What is the projected growth in the share of enrollment in private plans, and what do health plans do to be best positioned to address these unique needs?
With sufficient input from market demand, public policy, and the adoption of best practices in other industries, healthcare, and health insurance technology suppliers can offer scalable, data-driven solutions.
There are key areas of focus to address these business challenges, including value-based benefit plans and contract reimbursement development and administration. Customer service is also crucial, including enrollee navigation tools that help older members shop and choose the right health benefit for them and access to expert knowledge-based analysis and provider channeling. In addition, easy-to-use and highly-integrated “traditional” customer service support (e.g., call centers) and increasingly popular self-help tools (e.g., portals, “enhanced CRM,” handhelds). There is also increased use of customer-focused artificial intelligence (AI), particularly utilizing integrated payer/provider data that spans the full continuum of both “member” (health plan view) and “patient” (provider view).
While crystal balls are “foggy,” enrollment in Medicare Advantage and or Advantage-like plans is anticipated to increase at a healthy rate. In turn, the demand for seamless support will continue to evolve. Whether a health plan is regionally owned/provider affiliated or spans the country in a traditional insurance setting, the demand for integrating this population will require significant technical and organizational transformation investment. To do anything less risks missing the next frontier.
