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Regulation: Innovation Springboard Rather Than Compliance Checkbox

The industry traditionally has addressed compliance requirements by solving for the Rule and waiting for specifics to come out of CMS, or other agencies, before taking any action. We need to stop solving compliance requirements for the moment and take a more holistic approach.

My personal mission is to change the mindset of health plans to use regulation as a springboard for innovation rather than a checkbox for compliance.

With any compliance mandate, there is a good intention behind it. Health plans should figure out the intent of the Rule, why are we doing it, and what is the best way to accomplish this that will benefit the entire healthcare ecosystem?

For example, take the CMS Interoperability Payer-to-Payer Exchange of Historical Data Rule, coming up in January 2022. The Rule allows for a member enrolling in a new plan to request that the plan from which they are disenrolling extract and send up to 5 years of historical data to the new plan; And the receiving plan must be able to accept that information. As a result, data will move with a member rather than being left behind.

The Rule just says what payers must do: send and receive the information, but the intent of the law is to use the data to improve care. The exchange of data is the “easy” part; the use of the data by the core administration systems to improve members’ overall health is the desired outcome of this and other compliance requirements.

At HealthEdge, we do not look at compliance simply as a check box. We are looking not only at how we support our customers’ ability to comply with the rules but also the why behind the Rule; Aligning the solution with the impacted business process in the best way to achieve the results we need in a highly regulated environment.

I want to help health plans go beyond achieving compliance.   I encourage you to look at compliance from the perspective of process re-engineering, considering the intent of the rulemaking, identifying the value it brings, and what benefits can be created as a by-product of the Rule.

In our digital world, this is where plans will distinguish themselves and create a reputation for partnering with members and providers to enable quality and affordable care that is member-centric.

About the Author

Maggie Brown has over 30 years of leadership experience in healthcare and insurance marketplace. Maggie transitioned from health plan management roles to implementing core business solutions for numerous health plans around the country. With the enactment of HIPAA, the Balanced Budget Act, and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 she focused on how to ensure a health plan could implement key technology solutions, meeting the needs of their members, while being compliant in a rapidly changing regulatory environment. Maggie has led implementations for government programs at both new and established managed care companies. Maggie holds a Doctor of Religious Arts degree with a major in Pastoral Psychology.