Industry consolidation is one of the biggest trends in the payer space right now. National health plans might acquire other regional plans or enter a new line of business, resulting in multiple claims systems and different point solutions. The challenge is, how do they serve their core mission with technology that isn’t necessarily made to work together?
There are dozens of steps in the claims processing workflow, and they may all use different software solutions. Suppose a health plan uses a specific solution for pricing, another for grouping and another for editing. In that case, all those applications could update at various times and communicate results differently, putting strain on internal resources to manage the workflow. And if something goes wrong, it’s incredibly challenging to pinpoint where the error occurred.
Health plans want to improve operational efficiency, but they will not get the desired outcomes with different point solutions and applications from separate vendors.
Health plans need a single solution with real-time data and analytics that provides cloud-based delivery of regular updates to ensure they have all the correct information. Take Medicare and Medicaid, for example; at any given time, something is updating somewhere in the country. Health plans need to be aware of the changes and have those codes up to date across all of their solutions.
Without a cloud-based solution, health plans need to figure out all of these changes independently, manually make updates, and manage the software on their own.
Cloud-based solutions, however, have the ability to remotely deliver updates to payment policies as they occur, arming health plans with the most up-to-date information needed to process claims accurately and efficiently. With a single instance of a solution that includes all the business rules on top of it, the entire health plan will have the updated information, no matter where they are calling it from across the whole ecosystem.