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HealthEdge Horizons: Simplifying the Complexities of Healthcare Industry Regulations

From rapidly changing regulatory requirements and new competitive forces to changing payment models and rising consumer expectations, 2024 is shaping up to be another challenging year for health plans. In this 5-part blog series entitled HealthEdge Horizons, we dive deeper into the trends that are shaping our industry and explore how HealthEdge solutions are helping payers address their biggest challenges head-on. Be sure to check out the entire series:

The Complex World of Health Insurance Regulations

Healthcare in the United States is one of the most highly regulated industries, where healthcare providers and payers must stay on top of a myriad of ever-changing rules and regulations that can have a massive impact on their financial future. The constant evolution of these regulations demands adaptability and efficiency in administrative processes and technology systems.

For decades, health plans of all types and sizes have struggled to keep pace with ever-changing government regulations that occur at both the federal and state levels. While it may seem that federal changes would be easier to manage, the truth is that any regulatory shift is inherently difficult to administer mainly because these changes encompass a wide range of aspects, from timelines to benefit levels, and even provider contracts. Some regulatory changes are actually retroactive, forcing insurers to go back through claims and payments to make sure they remain compliant with government mandates.

Adding to the complexity, regulatory requirements can change over time as they are implemented. Payers are often given a three-year window to adapt to new programs, only to see mid-course alterations, sometimes for the better, but still demanding for payers to constantly respond and adjust course.

This constant state of flux has created a challenging environment that shows no signs of slowing down. In fact, it is expected to become even more frequent and command higher fines for non-compliance in the coming years. The pace at which CMS issues regulatory changes can be influenced by various factors:

  • Annual Changes: CMS typically releases an annual cycle of regulatory changes, which often coincide with the calendar year or fiscal year. These changes can encompass updates to payment rates, coding systems, quality measures, and program requirements. Health insurance payers can anticipate these annual updates and plan accordingly.
  • Legislative Mandates: Significant regulatory changes may be prompted by new healthcare-related legislation. When Congress passes laws related to healthcare, CMS is tasked with implementing and regulating these new requirements. The pace of change in this regard can vary depending on when new legislation is enacted.
  • Administrative Updates: CMS may issue administrative updates and clarifications as needed to address immediate concerns or ambiguities in existing regulations. These updates can occur throughout the year and may be issued more frequently when there are rapid shifts in healthcare policy.
  • Response to Public Input: CMS often seeks public input through the notice-and-comment rulemaking process. This involves publishing proposed regulations and allowing stakeholders to provide feedback. The time it takes to finalize regulations can vary depending on the complexity of the issues and the volume of public comments received.
  • Market and Healthcare Trends: Regulatory changes can also be influenced by emerging trends in healthcare, such as changes in technology, care delivery models, and public health priorities. CMS may adjust regulations to accommodate these evolving trends.
  • Political and Administrative Changes: The pace of regulatory changes can be affected by changes in presidential administrations and leadership at CMS. Different administrations may have different healthcare policy priorities, leading to shifts in the regulatory landscape.
  • Emergency Regulations: In response to public health emergencies or crises, CMS may issue emergency regulations to address immediate needs. These changes can be rapid and may not follow the typical rulemaking process.

In a recent Modern Healthcare article that summarizes the 2024 state legislative changes across 20 different states, “Health providers and insurers will have to navigate a bevy of state laws that took effect with the new year, covering key issues such as reproductive care, patient documentation, wages and reimbursement.”

For example, in Oregon, individual and fully insured group health insurance plans must cover three primary care visits per covered individual per year. Insurers also must cap the copay, waive the deductible for the visits and assign a primary care provider to the individual within 90 days of enrollment, if a member has not selected one within that period. In Pennsylvania, insurers are required to have an electronic communications network that allows prior authorization requests to be submitted and returned electronically. In Texas, payers are required to create and maintain a website where providers can verify if patients are covered by the issuer and see a patient’s potential deductible, copayment or coinsurance. Many of these state regulations mirror or complement federal regulations, such as the CMS Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule.

The Role of Modern, Flexible Systems

To help navigate this ever-evolving regulatory landscape, health insurance payers need flexible technology systems that can handle both federal and state-specific requirements with ease. While most systems can support compliance with federal requirements at a broad level, it is equally important for payers who participate in state-specific programs to have the ability to support the wide range of state-specific changes as well.

Very few systems can support a large portion of the state changes and care programs, leaving the rest of the rules to be implemented by already-scarce IT resources or vendor engagement. This is where flexibility in system configuration becomes critical.

Whether it’s adapting to changes in benefits, claim systems, fee schedules, or state-specific care programs, the ability to administer these changes in an automated fashion is key. The systems must be capable of adapting and accommodating these shifts without manual intervention. This applies to healthcare organizations of all sizes, from large health plans to smaller providers.

The Law of Large Numbers Gain

The regulatory burden is a “law of large numbers” gain, meaning that having more health plans on a single solution can everyone help tackle the problem more efficiently. Even if two health plans come together through a common platform, they can collectively handle the workload more effectively than two separate entities. Therefore, collaboration and synergy across the industry are essential to addressing regulatory challenges.

How HealthEdge is Making a Difference

At HealthEdge, we understand the importance of payers having access to highly flexible, configurable technology systems that can support an organization’s ability react to regulatory changes and CMS mandates to avoid sanctions, potential fines, and remain competitive. That’s one of the many reasons more than 130 health plans rely on our solutions today and why HealthEdge solutions consistently rank Best in KLAS for multiple years in a row.

Our technology solutions automate access to real-time data, ensuring regulatory compliance so health plans can save time, resources and streamline internal processes. HealthEdge solutions not only help payers meet regulatory changes, but also provide them with a competitive advantage in an increasingly complex industry. Here are a few practical examples of how HealthEdge solutions help payers address regulatory challenges.

HealthRules® Payer

    • Monitor federal and state level rules to identify rulemaking that impacts Payer Business Processes supported by HealthEdge
    • Develop business centric compliance requirements and use gap identification methods to develop a support strategy
    • Vet support strategy with the Steering Committee and collaborate with customers via monthly meetings
    • Communicate strategy and other compliance artifacts via a cloud-based repository, tracking over a year roadmap of compliance initiatives
    • Learn more about our core administrative processing system.

HealthEdge Source™ payment integrity platform

    • Research, Policy, and Data experts actively monitor government and industry resources to develop, deliver and maintain the most up-to-date content
    • Full-service delivery of payment policies & edits every two weeks ensures tightly linked payment processes
    • Third-party ecosystem readily extends payment integrity capabilities
    • Learn more about our payment integrity platform

GuidingCare® care management platform

    • Tracked changes and updates to state/federal program, reporting, and auditing requirements
    • OOB CMS-compliant Audit and Part C/D reports plus self-service custom reporting
    • Support for Regulatory audits/surveys, NCQA & URAC (utilization) review accreditation
    • NCQA Certified for HEDIS measures and Pre-Validated for Population Health Management since 2018
    • Learn more about our care management platform

Wellframe member experience platform

    • Secure, HIPAA-compliant messaging between care managers and members
    • Configurable, customizable programs and assessments aligned with state requirements
    • Direct member access to NCQA-aligned health and risk assessments
    • Real-time insights and alerts help care teams effectively identify gaps in care and improve HEDIS performance
    • Learn more about our member experience platform.

We encourage you to consider HealthEdge’s full suite of solutions can help your organization stay compliant with federal and state regulations while also growing margins. Visit