Health plans can reduce provider abrasion by adopting a payment integrity solution that uses modern technologies to improve payment accuracy and efficiency.

Factors That Lead to Provider Abrasion

In a recent Payer survey from HealthEdge®, “provider relations” followed closely behind “member satisfaction” in a list of health plan leaders’ top business concerns. These relationships are becoming increasingly important as payers and providers are expected to collaborate to achieve industry-wide goals such as reducing healthcare costs, improving clinical outcomes, and establishing effective value-based-care arrangements.

According to payers, inadequate access to real-time information and data sharing is the key contributor to provider abrasion. This is closely followed by inaccurate and delayed payments, and lack of transparency.

There are various reasons for these frustrations. When providers do not have access to updated information, they are unable to check the status of their claims or current reimbursement data. This lack of transparency can leave providers feeling confused or frustrated due to an unclear and complicated claims process. Additionally, payment delays or inaccuracies can leave providers facing potential financial stress, which can damage their reputation. Plus, the administrative burden of the time-consuming claim resubmissions and appeals process often leads to operational inefficiencies for both payers and providers.

So, how can your health plan ensure accurate, timely, and comprehensive claim payments to reduce provider abrasion?

3 Payment Integrity Features That Can Reduce Provider Abrasion

At HealthEdge Source (Source), our commitment to redefining payment integrity and reducing provider abrasion is apparent by the transparency and ease of use our platform offers. We have taken the bold step of rebuilding our original platform from scratch to become the first organization in the market to offer a cloud-based, interoperable payment integrity platform.

The Source solution combines cloud-based scaling capabilities, advanced automation, and an integrated ecosystem of solutions to deliver a robust and effective payment integrity platform.

1. Cloud-based Data Delivery

Our cloud-based data delivery solution streamlines claim processing, shortens payment turnaround times, and reduces provider abrasion. With all medical formats, standards, code sets, claim history, and updates accessible in real-time, Source can eliminate denials and improve claim accuracy. By ensuring your health plan has the most current and secure data available 24/7, you can decrease your reliance on outdated manual processes and fragmented solutions in favor of an effective modern solution.

And with data in the cloud, Source is laying the groundwork for integrated systems, automation, business intelligence, and other advancements in the payment integrity space and beyond.

2. Integrated Platform Ecosystem

Similar to your smartphone, HealthEdge Source’s integrated ecosystem of solutions effortlessly connects multiple claims systems to streamline key functions. Dealing with different vendors with diverse tech stacks, update cycles, and maintenance plans can be stressful. Working with disconnected systems often leads to complicated workflows and greater reliance on manual tasks, increasing operational costs and generating unpredictable outcomes. The single-instance Source solution unifies these elements, reducing administrative overhead, inaccuracies, and recovery costs.

Just as you can easily add apps to your phone, the extensibility of Source allows integration with various third-party solutions—without sacrificing quality. By streamlining these essential processes, Source can empower your health plan to foster smoother provider relationships. This approach enables your staff to focus on strategic initiatives and make more informed business decisions.

3. Advanced Automation And Intelligent Workflows

The integration of automation technologies like Robotic Process Automation (RPA) and Artificial Intelligence (AI) has caused disruptions across industries and contributed to continuous innovations. With Source, advanced automation minimizes user error during the claims process—saving time and money. Automated functions, such as eligibility and benefit verification, prior authorization, and claim management, can help simplify routine tasks, allowing your staff to concentrate on complex tasks that require human intervention.

Optimizing workflow efficiency can lead to substantial cost reductions. Health plans and providers could save nearly $25 billion annually by automating administrative transactions. Source’s innovative solutions not only enhance accuracy, but also transform the claims process, making it a game-changer for health plans and the providers they work with.

How A National Health Plan Reduced Provider Abrasion With HealthEdge Source 

HealthEdge Source partnered with a large national health plan to streamline their operations as they expanded their government lines of business and automated claims reimbursement. Their existing systems couldn’t handle the complexity of the new government programs, so they turned to Source to help them better manage payments and scale their operations across lines of business.

Today, more than a thousand of their employees use the solution for tasks ranging from claims operations to provider relations. The system can now handle over one million claims per month, even in complex situations. This has resulted in significant time and cost savings, with automations improving accuracy and saving millions of dollars annually. Over our 23-year partnership, the payer has significantly reduced operational overhead and improved first-pass payment accuracy, minimizing risk and strengthening their relationships with providers nationwide.

HealthEdge Source is an innovative payment integrity solution that can address the root causes of provider friction. Our platform gives health plans real-time data access, simplifies claim processing, and leverages advanced automation within an integrated ecosystem. By leveraging Source, your health plan can improve operational efficiency, build stronger partnerships with providers, and achieve significant cost savings. Here

Are you looking for more information on how your health plan can leverage content, technology, functionality, and analytics to achieve long-term organizational goals? Watch our on-demand webinar at your convenience: Avoiding Payment Integrity Pitfalls with HealthEdge Source.

Health plans’ adaptability and the technology that enables their transformations will remain at the forefront of strategic decision making in 2024 and beyond. Let’s explore the key trends that affect care management and raise the bar for software capabilities today. 

Trend 1: Rising Member Expectations 

According to the 2024 HealthEdge® Consumer Survey, member expectations are evolving rapidly. The survey findings indicate an increasing need for member experiences that are tailored to individual preferences, easy to access, and provide clear information about healthcare costs and coverage. Members’ expectations are increasing due, in part, to highly personalized retail experiences with commercial organizations. 

Health plans need to adapt to these changing expectations to stay competitive. Just as retail companies use algorithms to analyze behavior and provide personalized recommendations, health plans can utilize data to offer personalized care recommendations, wellness programs, and effective communication to improve members’ experiences. 

In contrast to many online retail experiences, human interaction is essential for success in healthcare. The 2024 HealthEdge Consumer Survey also shows higher satisfaction levels among those assigned a dedicated care manager, for example, but also a growing demand for high-touch care management. This highlights the importance of care managers’ access to member healthcare data, particularly social determinants of health data, to enhance personalized care. It is crucial for health plans to make people available to deliver customer service and, at the same time, to expand the self-service tools and resources that make interactions more efficient. 

Member expectations are also at the heart of numerous regulatory changes focusing on cost transparency and interoperability. From the Transparency in Coverage Act to the No Surprises Act, the Centers for Medicare & Medicaid Services (CMS) has stressed the significance of electronic data collection, retention, and utilization to enhance member experiences, improve health outcomes, and reduce inefficiencies in the long term. The pace of change is accelerating, pushing health plans to look further into the future, be more agile to meet member expectations, and update their requirements for a care management platform.  

Trend 2: Digital Member Engagement 

According to the 2024 HealthEdge Consumer Survey, there is a significant shift toward members looking for personalized healthcare experiences: 64% of respondents expressed comfort in using secure mobile apps to interact with their health plans. This trend is notably consistent across various age groups, underscoring the broad acceptance of digital tools for healthcare management. Today, omnichannel communications unify the member experience across websites, mobile apps, phone calls, and in-person visits, enabling seamless transitions and greater member engagement. This plays a critical role in enhancing member care management in two primary ways: 

• By integrating multiple channels, including mobile apps, care managers can customize interactions to individual member preferences, engage members more effectively, and focus on meaningful interventions for positive health outcomes. 

• Through streamlining processes and interactions via digital channels, health plans reduce member wait times for prescription refills, referrals, test results, etc., and empower staff to be more responsive through preferred contact methods. 

Adopting an omnichannel strategy, supported by modern care management software, empowers healthcare teams to provide personalized, efficient, and member-centric care—enhancing member satisfaction and improving outcomes. 

Trend 3: Increased Market Competition 

Historically, health plan members had limited options for coverage, and were often content to accept the narrow choices of employer-provided benefits, while seniors faced relatively straightforward decisions about Medicare. However, today’s landscape is vastly different, leading to increased competition between health plans: 

• Members now have a wide array of options. Seniors can choose from nearly 4,000 Medicare Advantage plans, offering an average of 43 options in their coverage areas. 

• CMS continues to emphasize the high weight of member satisfaction scores for the 2024 rating year, reinforcing that exceptional member experiences must be a top priority for health plans.  

• Participation in the Affordable Care Act’s health exchange marketplace, individual plans, and Medicaid has surged, leading to many new members comparing suitable health plan offerings. 

• Healthcare and government agencies focus on whole-person care that improves health outcomes and includes specialty areas such as behavioral health. Employers and health plans collaborate to create inclusive benefit plans, while integrating digital tools and virtual care options enable nontraditional care for various conditions. 

Health plans must prioritize personalized member experiences, innovative digital solutions, and cost transparency to attract members due to advancements in whole-person care, new regulations, and higher member expectations. This requires a care management platform that merges data, enables seamless care coordination, and allows effective communication with members on their terms.  

Trend 4: Social Determinants of Health and Person-Centered Care 

The Framework for Health Equity, from CMS, serves as a foundational roadmap to advance health equity, expand coverage, and improve health outcomes for over 170 million individuals. The framework addresses the following in pursuit of its mission:  

• CMS aims to enhance the gathering of individual-level demographic and social determinants of health data, including race, ethnicity, language, gender identity, sex, sexual orientation, and disability status, to ensure fair care and coverage for all.  

• CMS is dedicated to evaluating its programs and policies for unintended consequences and measuring their impact on health equity to develop sustainable solutions for closing healthcare access, quality, and outcomes gaps. 

• CMS supports healthcare organizations in reducing health and access disparities by empowering providers and organizations to address the root causes at the point of care. 

• The framework integrates health equity into existing and new efforts, driving structural change, eliminating barriers, and enhancing health outcomes through data-driven insights and personalized strategies. 

The focus on social determinants of health, person-centered care, and healthcare equity has increased. Modern care management systems play a key role in complying with these regulations, leveraging shared data, and coordinating care in an increasingly complex array of healthcare services. 

Trend 5: Artificial Intelligence (AI) in Healthcare 

The healthcare industry is investing in developing AI capabilities to streamline processes and improve the member experience, especially with the development of generative AI capabilities. Compared to other industries, healthcare has been slower in adopting these advancements, presenting a significant opportunity for improvement. Recent research suggests that increased use of AI could result in a 5-10% reduction in US healthcare spending, including member services.  

AI in member engagement shows promise in empowering care managers, assisting members with routine inquiries, and optimizing the care journey. Moreover, the increasing comfort with AI-powered tools reflects a growing demand for personalized and efficient healthcare experiences. About 65% of members prefer health plans that leverage AI for personalization. This technological shift enhances the member experience and enables health plans to provide more tailored and proactive care. For instance, natural language processing could be used in a chat-based interface to allow health plans to provide quick, accurate benefit details to members during live calls. This capability, combining robust data with AI-powered interfaces, will soon become a reality, streamlining benefit inquiries, improving service, and enhancing customer satisfaction.  

The march towards AI-powered healthcare is underway, and health plans must focus on the most impactful use cases, the right technology partnerships, how AI affects their roadmaps, and the governance required to use AI for its best purposes.  

Adapt to Modern Care Management with HealthEdge 

The HealthEdge® GuidingCare® care management software streamlines coordination across the care spectrum, automates care and service planning, and identifies high-risk populations to better enable whole-person, member-centric care. It centralizes health data to enhance care and uses advanced analytics to predict health issues for proactive intervention. The demands and opportunities of care management today lead to more health plans redefining their software requirements and seeking end-to-end solutions to grow membership and improve the care experience. 

To learn more about how GuidingCare can help accelerate your care management transformation, visit our infographic: “Secrets of a Successful Care Management Implementation.” 

The Rising Expectations of Healthcare Consumers 

Today’s healthcare consumers are not passive recipients of care services—they want to be active participants in their own health and wellness. Personalized and proactive outreach can build member trust and lead to stronger member relationships. According to the 2024 HealthEdge® Consumer Survey, members said personalization, transparency, and convenience mattered most in experiences with their health plans. 

To remain competitive, health plans must adapt to these evolving consumer needs. Digital health solutions enable care teams to reach more members in less time, improving clinical outcomes and reducing costs. The Wellframe digital care management platform is designed to provide personalized healthcare experiences through one convenient channel. 

Intuitive, Accessible Engagement with Digital Care Management 

Digital care management uses technology to extend the reach of care managers and streamline care delivery. Historically, health plans relied on telephonic outreach to conduct surveys and follow up after appointments. But phone calls can take a lot of time and aren’t always accessible for members. With digital care management, care teams can deliver personalized care and support to more members in less time via asynchronous communication, like HIPAA-compliant messaging. They can also send digital surveys for members to answer on their smartphones, which gives members more privacy to answer personal health questions without feeling rushed. 

With digital care management solutions like Wellframe, care teams and health plans can provide intuitive and accessible engagement opportunities as well as enhance personalization. Members can easily connect with their health plan and manage their health through a user-friendly mobile app. This accessibility is crucial in today’s digital age, where convenience and ease of use are paramount. Plus, members enrolled in digital care programs receive tailored content and proactive health reminders that ensure they feel supported throughout their health journey. 

Improve Retention and Quality Scores Through Member Satisfaction  

When members are happy with their health plans, they are less likely to switch insurance providers—reducing the costs associated with acquiring new members. Digital care management can help increase the effectiveness of healthcare interventions, empowering members and improving their experiences. Better experiences can lead to better satisfaction rates and higher quality scores, which can improve health plan ratings and make them more attractive to new members. 

When it comes to serving Medicare members, achieving high member satisfaction is critical for achieving high CAHPS scores, which contribute to a plan’s Star Rating. Improving Star Ratings has significant financial benefits, including federal bonus payments and increased member enrollment and retention. 

High rates of member satisfaction can also be leveraged for marketing purposes, helping to attract and retain member—and employer groups—across populations. According to the HealthEdge® 2024 Consumer Survey, one-third of respondents said they are “likely” or “very likely” to switch health plans in the next year. To avoid losing existing members, health plans must prioritize member engagement and satisfaction. 

Key Performance Metrics to Assess Member Satisfaction 

Wellframe’s digital care management platform delivers significant value to health plans looking to enhance the member experience. Here are a few ways the platform has demonstrated impressive results when it comes to improving member satisfaction and engagement.  

• App Store rating: The Wellframe app has a 4.7 of 5-star rating in the mobile app store, indicating that members are satisfied with the features and usability of the platform. 

• Onboarding rate: More than 50% of members who are invited to the app by their care managers fully complete the in-app onboarding process, which demonstrates the platforms effectiveness in engaging new members and the relevance of its content. 

• Increased touchpoints: On average, members enrolled in a digital care program on the Wellframe platform averaged 258 touchpoints per case—many of which were to access self-service resources. 

• Benefits utilization: Members in Wellframe’s Maternal Health digital care program reported significantly higher prenatal visits during the last trimester than those enrolled in traditional care management, along with a decrease in emergency department admissions. 

In an increasingly competitive healthcare landscape, member satisfaction is paramount. Wellframe’s digital care management platform offers health plans a way to differentiate themselves by providing a seamless digital experience and personalized interactions. By leveraging digital care management, health plans can improve member satisfaction, retention, and acquisition, ultimately leading to higher quality scores and financial gains. 

Ready to transform your member experience? Explore the benefits of Wellframe’s digital care management platform and start driving higher satisfaction and engagement. Read our blog, 4 Best Practices to Drive Member Engagement in Digital Care Programs. 

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There has been a lot of talk about digital member engagement and integrated care management in the market today. But for many payers, these phrases seem vague and lack the specificity that is needed to pinpoint what exactly is needed to pursue and achieve this heightened state of care management. Questions such as, “Where should we start our digital journey?” and “How will we measure return on investment?” and “How can I put even more work on my already overwhelmed care managers?” and even “Will my members embrace digital tools?” are often asked.  

HealthEdge® is helping payers answer those and many other questions about the pursuit of transforming their traditional care management strategies into high-performing integrated care management strategies that leverage modern, digital engagement capabilities. This fusion aims to enhance health outcomes and reduce costs through seamless digital care management integrations.

Integrating Traditional and Digital Care Management 

For HealthEdge, integrated care management means the integration of digital engagement technologies with traditional care management workflows to help members, care managers, and health plans deliver better health outcomes and lower costs. 

To help payers accelerate their digital care management journeys, HealthEdge made available an integrated solution that brings together GuidingCare® (the company’s traditional care management platform) and Wellframe (the company’s digital member engagement platform). The integrated solution enables payers to easily combine clinical data and real-time member insights to create one streamlined mechanism that empowers care managers to meet members where they are on their own terms. Extending the care manager’s reach to members with clinical use cases across the risk pyramid, Care-Wellframe enables health plans to effectively transform care management and drive tangible business impact. 

The Care-Wellframe solution also brings a wide range of capabilities and insights to care management team members. Care managers are empowered to more effectively reach and support members while reducing cognitive and administrative burdens.  

The solution enables the following integrated care management capabilities: 

• Omnichannel communications that help care teams meet members where they are, on their own terms 

• Prioritization of care manager outreach based on Alerts and Insights that indicate members who need urgent support 

• Access to clinical education resources, benefit plan information,
  and community SDOH resources 

• Seamless data sharing between the GuidingCare and Wellframe solutions, eliminating duplicate data entry and working in two disparate systems 

Building the Business Case for Integrated Care Management 

We sat down with one of our long-standing GuidingCare customers who recently chose to implement Wellframe and asked, “What benefits does your organization plan to see from leveraging both GuidingCare for traditional care management and Wellframe for digital member engagement?”  

Here are some highlights of what they expect to see once their integrated care management strategy is fully underway.  

Health Plans: 

• Mitigate costs and achieve higher industry performance ratings (i.e., Stars) to remain competitive 

• Improve effectiveness of health interventions and contain care costs 

• Increase member satisfaction, engagement, retention, and enrollment 

Care Managers:  

• Improve clinical outcomes for members with acute and chronic conditions 

• Quickly access up-to-date, actionable member information 

• Reduce “swivel chair” and administrative burden of switching between systems 

Members: 

• Easily navigate their care program and health plan resources 

• Obtain answers quickly to eliminate health barriers 

• Become active participants in their own healthcare journey 

Embracing Digital Trends in Healthcare

In HealthEdge’s recently published Annual Member Expectations and Satisfaction Report, we see that today’s healthcare consumers are becoming more and more comfortable with modern, digital technology when interacting with their health insurance provider.  

• 64% of members say they are comfortable using mobile applications to access their health information.  

• 65% of respondents said they would likely be interested in health insurers who provided AI-powered tools to deliver more personalized services. 

As today’s consumers become more tech-savvy in their everyday lives, they expect to have similar digital capabilities available when interacting with their health insurance providers. This trend underlines the importance of adopting digital care management integrations to meet the evolving expectations of consumers. Embracing digital technologies, like Wellframe, that can support bi-directional, asynchronous communications between members and care managers is becoming more critical to success. These integrated care management solutions help care managers more effectively and efficiently engage with members and help members become more active in their care plans and achieve better health outcomes

To learn more about how integrated care management solutions like Care-Wellframe can help your organization accelerate its digital transformation journey, visit our eBook on Integrated Digital Care Management. 

However, when engaging members with multiple chronic and complex healthcare conditions— such as many members on Medicaid, Dual Eligible Special Needs Plans (DSNP), or pediatric populations under the Comprehensive Family Life (CFL) program—the challenges become even more formidable.

Challenges to Member Engagement for Complex Populations and Chronic Conditions

The clinical needs of Medicaid populations with chronic illnesses are diverse and often require coordination across multiple specialties. For pediatric populations, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screenings are required for early identification of health issues. Care managers must fulfill the needs of providers, staff, families, and regulations while also overcoming operational hurdles that create inefficiencies and high administrative loads. To deliver compassionate and comprehensive care, care managers require more advanced systems to manage larger caseloads more effectively, reduce frustration, and streamline their vital role in enhancing care quality.

Member communication

Effective communication is crucial for engaging members in their care plans regardless of their situation. Yet, ensuring a smooth experience across multiple channels—from in-person visits to digital platforms—can take time and effort, particularly with high-risk populations. Integrating communication channels, accounting for member preferences, and making the care experience easier to navigate requires a thorough understanding of member resources, behaviors, and preferences, as well as advanced technology.

Social Determinants of Health

Social Determinants of Health (SDOH) significantly impact members living with multiple chronic illnesses. Effective member engagement for complex populations goes beyond traditional clinical interventions and requires partnerships with community organizations and a robust data-sharing infrastructure to address SDOH like housing instability, food insecurity, and education.

Regulatory Reporting

Government programs have strict regulatory reporting requirements that care managers must follow. These regulations continuously change, and updates come at an increasing frequency while the penalties for non-compliance get steeper. As federal and state agencies push for greater transparency and interoperability, care managers must adapt to these administrative changes. This can distract from their focus on care, especially when dealing with legacy systems.

Disparate Technology Systems

Many member engagement solutions operate in silos, making it difficult to access a unified view of members to coordinate care, communicate effectively, and tackle administrative tasks. Interoperability between systems is critical to providing coordinated care and a personalized and effective member experience.

The complexity of care, integration of social support, and the barriers to communication for the populations in greatest need require a nuanced approach to service delivery and the technology that supports it.

Digital Care Management Goes Beyond Just Communication

Digital care management is an innovative approach to healthcare that transcends traditional communication methods, offering more engaging, informative, and proactive interactions that are crucial to member engagement of complex populations. At its core, digital care management solutions offer services including:

• Health education articles tailored to the individual’s clinical needs and based on specific care programs to help members understand and manage their health conditions.
• Interactive assessments that enable real-time data sharing about a member’s health status, keeping care managers informed and allowing them to be proactive in their care strategies.
• Encouragements and motivational messages that help members become advocates for their health and foster improvement through ongoing discussions.
• Automated reminders that help care managers and members stay on track with critical activities and milestones, ensuring that important care management tasks are not overlooked.
• Omnichannel features such as chat and secure text messaging that facilitate real-time, bidirectional communication, making it easier for members to connect with their care teams and vice versa.
• A dashboard view of each member that allows a care manager to have a unified view of their situation, interactions, and health journey.

Digital care management, as delivered by the HealthEdge® Wellframe® member experience platform, represents a shift from episodic, intermittent support to a continuous, holistic care model. It leverages technology to extend the reach of care teams, enabling them to engage more fully with high-risk members and significantly impact engagement:

• With the Wellframe platform, members average 258 touchpoints per month with their care teams.
• Wellframe drives significant increases in Medicaid member engagement without increasing staff. A HealthEdge analysis of one health plan showed a rise from 3 touchpoints per case to nearly 200, resulting in 14 days engaged per month.
• With Medicare members, another analysis showed that care managers increased total touchpoints from 3 to nearly 500, resulting in 15 days engaged per month for six months.

With digital care management, members are empowered to take an active role in their health journey, supported by the tools and resources necessary for effective self-management and improved outcomes.

Care-Wellframe: Integrating Engagement and Care

Care-Wellframe is an integrated solution that combines HealthEdge’s premier care management platform, GuidingCare®, with Wellframe. The solution transforms how health plans approach digital care management, removing barriers for the most complex use cases with one solution rather than trying to solve care and experience with separate solutions.

This packaged integration makes the following possible:

• Seamless data sharing between GuidingCare and Wellframe that eliminates redundant data entry and the inefficiency of using separate systems.
• Instant access for both care managers and members to clinical education materials, benefit plan details, and community resources related to Social Determinants of Health (SDOH) in one system for quick, relevant referrals.
• Prioritization, through alerts and insights, of members who most urgently require outreach, streamlining the care management process and personalizing content to their needs.
• Tracking care plan adherence directly from the member’s profile, and an online chat feature accessible through the interface.
• Omnichannel communication which allows care teams to reach members through their preferred channels.

With Care-Wellframe, members benefit from personalized interactions and are supported by trusted care managers who empower them to make informed health decisions. Digital care management enables care managers to improve clinical outcomes, engage meaningfully with members, and reduce administrative tasks—especially when dealing with high-risk populations such as pediatrics or those covered by Medicaid or DSNP.

Next-Generation HealthCare Member Engagement

To effectively manage member experience for populations with complex healthcare needs and enrolled in government programs, it is essential to have a comprehensive approach that combines integrated, next-generation technologies with compassionate, person-centered care.

Health plans must efficiently scale care management teams to support more complex use cases. Streamlined member engagement integrated with care management leads to better health outcomes, membership growth, higher member satisfaction, and better Star ratings. With Care-Wellframe, health plans can meet these vulnerable groups’ clinical, social, and regulatory needs while fostering continuous engagement and support.

Learn more about how your organization can improve member engagement and care management with key insights from our 2024 Consumer Survey.

Empowering Care Teams with Digital Solutions

Care teams today face unprecedented pressures from multiple angles. They are tasked with managing complex patient needs while grappling with administrative responsibilities and high workload volumes. Wellframe’s digital care management solution offers a lifeline by delivering real-time member insights and enabling care teams to reach multiple members at once.

Using the Wellframe platform, health plans can reach and engage rising-risk members before they become high-risk.

Member Empowerment

Empowering members to take control of their own health and wellness is at the heart of Wellframe’s approach. With over 70 care programs that enhance traditional care management models, members are equipped to manage their health proactively.

The platform offers a self-service resource center that features clinically reviewed articles relevant to members’ health and wellness needs. They also have access to benefits information written in plain language to help improve understanding and utilization. These tools promote self-advocacy and health literacy for health plan members, enabling them to become more independent and confident in navigating the healthcare system.

Workflow Efficiency

The Wellframe solution helps significantly reduce the cognitive load on care teams through several features that streamline their workflows while enabling them to increase care management capacity.

1. Dynamic Decision Support:

Intelligent alerts and insights recommend high-impact interventions, helping care teams prioritize and act swiftly on critical issues.

2. AI Summarizing Capabilities:

Streamlined summaries facilitate quick, informed decision-making, allowing care managers to focus on member-centered care rather than administrative tasks.

3. Digital Assessments:

Digital surveys and assessments remove the administrative burden associated with telephonic health risk evaluations, making the process more efficient and less time-consuming. Members can respond at their convenience, with fewer concerns about information privacy.

4. Many-to-One and Group Action Options:

These tools enable care teams to reach multiple members with the same message templates, ensuring that more members receive timely and necessary healthcare communications.

Expanding the Reach of Care Management

Traditional care management methods, such as telephonic outreach, often fall short of effectively engaging members. Long phone calls not only frustrate members but also hinder care managers from practicing at the top of their license. One large Blue Cross Blue Shield plan encountered these challenges head-on.

The health plan’s existing care management processes made it difficult to scale resources and engage with more members, necessitating a modern solution. Using Wellframe, care managers were able to leverage digital channels to increase member touchpoints and establish trusted relationships with members, leading to improved engagement and better health outcomes:

• 91% Increase in Successful Calls: Digital interactions established trust, making members more likely to answer phone calls from care managers and increasing preparedness for those calls.
• 2x Increase in Active Caseload Size: Care managers using Wellframe supported significantly more members than with traditional care management alone.
• 6x Increase in Member Interactions: Digital adoption led to more frequent and meaningful engagements with members.

Measuring Value and ROI of Digital Care Management

The value of digital care management goes beyond immediate savings on care costs. Using digital care management, health plans achieved measurable outcomes in the following areas.

1. Medical Cost Savings

Engaging more members through care management leads to better health outcomes and reduced medical costs for larger populations. By preventing complications and ensuring timely interventions, health plans can save substantially on medical expenses. In one study, health plans were able to save $1,923 per member over a three-month period.

2. HR Cost Avoidance

Expanding care team capacity through digital tools means that care managers can support more members without increasing headcount. This leads to significant HR cost avoidance and better resource allocation.

3. Higher HEDIS/Star Scores

Improving health plan quality scores translates to federal bonus payments (in the case of Medicare) and increased member enrollment across all lines of business. Higher quality scores also enhance the plan’s reputation and competitiveness.

Digital care management is not just a technological advancement; it’s a strategic imperative for modern healthcare organizations. By empowering care teams, enhancing workflow efficiency, and expanding the reach of care managers, solutions like Wellframe enable healthcare organizations to deliver better care at scale.

For healthcare leaders looking to innovate and drive efficiency, integrating digital care management into their operations is a crucial step. It offers a pathway to improved health outcomes, better resource utilization, and a more competitive market position.

Ready to transform your care management approach and achieve better health outcomes for your members? Discover how Wellframe’s digital care management solutions can enhance efficiency, reduce administrative burdens, and improve member satisfaction.

Watch our on-demand webinar, “Activate Today’s Medicare Member: Effective Engagement Strategies” at any time on our website.

• The role of care managers continues to expand as multiple business and payment models emerge.
• Healthcare consumers’ expectations for personalized digital engagement continue to rise.
• Regulatory requirements become more complex and burdensome to follow, while clinician burnout reaches an all-time high.

By transforming traditional care management teams into digital care management teams, payers hope to bring benefits to all stakeholders: members, care managers, and the health plan itself.

However, it’s important for payers to understand that this transformation is not just about implementing modern technology solutions, like HealthEdge GuidingCare® and HealthEdge Wellframe. It must include a comprehensive approach to organizational change management that ensures the full business objectives are met.

Understanding the Need for Change

The journey toward digital care management begins with recognizing the necessity of change. Health plans must understand why the change is important and align it with the organization’s vision and mission. Without aligning on change management goals, efforts may falter from the outset. Organizations must foster a pervasive culture of change across all levels, involving not only clinical leadership but also IT, data, and community-based partners. Change must be embraced by the entire organization, supported by multilevel activation and champions to push the strategies forward.

Leveraging HealthEdge for Digital Transformation

HealthEdge GuidingCare is a comprehensive care management platform designed to help health plans better support some of their most complex populations. Health plans have found that partnering closely with HealthEdge facilitates seamless integrations and implementations. This partnership can also enable health plans to successfully transition new member populations onto their GuidingCare system and integrate with newly acquired health plans.

For health plans looking to embrace digital care management capabilities, Wellframe offers a comprehensive digital member engagement solution. Health plans that adopt Wellframe experience transformed care delivery, providing nurses with a powerful tool to engage members more effectively. This transition is not without its challenges, as nurses must adapt from traditional telephonic methods to a new digital interface. However, the benefits soon become evident: streamlined processes, increased member engagement, and improved clinical outcomes.

Wellframe’s app enables care managers to provide tailored, member-centric support, including medication reminders and educational content. The efficiency gains are substantial, with care managers able to deliver interventions and follow-ups much faster than through traditional methods. The app also allows for asynchronous communication, giving members the flexibility to engage with their care at their convenience.

The integration of GuidingCare and Wellframe (Care-Wellframe) creates a comprehensive digital care management ecosystem. This care management interoperability ensures that all functions work seamlessly together—without having to swivel between disparate systems. Health plans can leverage this integration to achieve scale without having to expand their care management teams. Automation and digital tools become force multipliers, enabling health plans to provide consistent and high-quality care to their members.

Best Practices for Change Management

Transforming care management involves more than just implementing new technology; it requires a cultural shift within the organization. Health plans must foster a culture that embraces change and transformation while maintaining regulatory compliance and performance measures. This begins with understanding the organization’s capabilities and identifying opportunities for improvement based on data insights.

For example, health plans can leverage data to track clinical quality, resource use, and customer service measures, setting strategic priorities that align with member outcomes. This alignment ensures that everyone in the organization, from customer care to pharmacy teams, understands their impact on these measures. Training and education play critical roles in empowering staff to contribute to the organization’s goals.

Successful change management involves several best practices:

• Communicate the Why: Over-communicate the reasons for change to ensure all stakeholders understand and buy into the vision.
• Empower Early Adopters: Engage early adopters with input from the team to drive transformation.
• Simplify Architecture: Streamline systems to reduce unnecessary touchpoints and ensure seamless interoperability.
• Foster Collaboration: Encourage collaboration across departments and with external partners to solve problems collectively.
• Embrace Continuous Improvement: View change as an ongoing process of improvement rather than a one-time event.

Measuring Care Management Success

Success in care management transformation can be measured in various ways. For executive leaders, it’s about return on investment (ROI). For case managers, success means effective member interactions and efficient workflows. For administrative teams, it’s about minimizing errors and ensuring regulatory compliance. Health plans must be willing to measure success in different ways than traditional care management metrics, acknowledging both wins and failures as opportunities for growth.

For example, health plans can hold stakeholders accountable to timelines, encouraging collaboration, and giving permission to fail. By creating an environment where staff can raise their hands and seek help, organizations can foster a culture of continuous improvement and innovation.

The Future of Care Management

Automation and digital solutions are today’s key to the future of care management. Care management teams must adapt to the changing healthcare landscape by doing more with fewer resources. Automation and digital care management enable care managers to scale and reach more members, which improves both care manager and member satisfaction.

Integrating digital with traditional care management is a complex but necessary journey for health plans. HealthEdge GuidingCare and Wellframe are at the forefront of this transformation, providing health plans with both the technology and the change management support services necessary to navigate the complexities of today’s healthcare environment. As a result, every stakeholder wins:

• Members: Engage with care managers on their own terms via preferred communication channels, experience more personalized customer service, and experience better health outcomes.
• Care managers: Access real-time clinical and social data to effectively meet members where they are, with the right care and support.
• Health plans: Find new ways to scale care management teams to reach more members, contain costs, improve performance measures (Star ratings), and remain competitive.

To learn more about how HealthEdge can help transform your care management team from traditional care management to digital care management, read our case study, “Next Generation Care Management at Denver Health Medical Plan”.

Wellframe’s digital care management solution is designed to improve the effectiveness of healthcare interventions by equipping care management staff with the insights needed to close gaps in care and improve clinical outcomes in less time. One study even demonstrated $1,923 in cost savings per member over a three-month period. 

How Wellframe digital care management enables cost savings 

Increasing member engagement with care management resources  

Engaging members in their own care management is critical to achieving long-lasting improvements in clinical outcomes. Wellframe transforms traditional member engagement using a comprehensive digital platform, which is designed to meet members where they are. 

By offering a library of accessible self-service resources, Wellframe empowers members to manage their health proactively. Members can read articles relevant to their health conditions and benefits coverage at any time using the app and follow up with their care teams later. Instead of enduring the inefficiencies of phone tag or trying to find reliable information online, members gain a trustworthy, streamlined channel to connect with their care teams, improve their health literacy, and manage their health effectively. 

Enabling Rfeal-time Health Interventions 

Wellframe enhances the ability of care managers to deliver timely and effective interventions. The platform also triages members based on risk level, ensuring care teams stay informed of urgent member needs. As members complete digital surveys and assessments, chat with their care teams, and submit biometric data, Wellframe notifies care teams of critical insights that necessitate immediate follow-up. 

This proactive approach ensures that potential issues are addressed promptly, thereby improving overall care outcomes and increasing trust between members and their care teams. Improving the effectiveness of healthcare interventions can also positively impact quality scores such as HEDIS and Star ratings through improved clinical outcomes and care gap closures. 

Enhancing Member Outcomes with Advanced Digital Care Management 

Lowering Blood Sugar Levels  

Nearly 1 in 10 Americans have diabetes, and about 1 in 5 don’t know they have it. Properly managing diabetes is crucial to preventing life-threatening complications like chronic kidney disease, nerve damage, and liver disease. Diabetic members using Wellframe’s digital care management programs have shown significant results: 

Prediabetes: Up to a 10.9% reduction in blood sugar. 

Diabetes: Up to a 25% reduction in blood sugar. 

These improvements are achieved through Wellframe’s comprehensive Diabetes and Prediabetes Support programs, which include educational resources, biometric tracking, and secure messaging with care teams.  

Managing Hypertension 

Managing hypertension effectively can prevent severe health complications and readmissions. Members using Wellframe’s app demonstrated impressive results: 

Stage 1 Hypertension: 7% reduction in blood pressure. 

Stage 2 Hypertension: More than 9% reduction in blood pressure. 

Wellframe’s digital care programs, including Adult Biometrics, provide integrated tools for logging and tracking health data such as blood pressure, blood sugar, step tracking, medication reminders, and more. 

Measuring impact and ROI 

Effective care management interventions can significantly reduce healthcare costs in the long run. With Wellframe, healthcare providers can achieve notable savings by reducing unnecessary emergency department visits and readmissions. In one study, members who used the Wellframe app after being discharged from a hospital stay reported a 33% reduction in subsequent readmissions and a 25% reduction in ER usage over the following 30 days. 

Higher HEDIS and Star ratings not only improve a health plan’s competitiveness in the market, but also lead to increased member enrollment and federal bonus payments. In a recent study of members enrolled in Wellframe’s maternal health program, health plans reported an 8% increase in HEDIS PPC outcomes, higher prenatal visit rates, and decreased third-trimester ER utilization. These metrics are essential for health plans aiming to optimize their financial performance and member satisfaction. 

Are you looking for more information on how to successfully implement and leverage digital care management at your health plan?

Visit our eBook, “Integrated digital care management: Meeting members and care managers where they are” to learn about successful strategies for adopting digital care management solutions. 

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.

[CTA]

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]

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.”

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] 

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.

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 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.

The 2024 HealthEdge® Consumer Survey provides valuable insights into these shifting dynamics in health. With over 3,500 healthcare members participating, the consumer survey sheds light on the member expectations and satisfaction levels. This comprehensive analysis not only underscores opportunities in a changing landscape but also highlights how HealthEdge solutions can empower health plans to address these changes and ultimately enhance member satisfaction.

Member Voices: Health Plans Get High Marks with Room for Growth

The consumer survey revealed some interesting findings regarding member satisfaction and expectations:

• High Satisfaction Rates: A significant 69% to 86% of members reported being “very satisfied” or “satisfied” with their health plans, particularly those in Dual-eligible and Medicare Advantage programs.
• Early Intervention: Members want a more proactive and preventative approach from their health plans. This includes a focus on preventative care, cost transparency, and improved care coordination.
• Digital Tool Adoption: A substantial 65% of members are comfortable using digital tools such as mobile apps and AI-powered solutions to interact with their health plans.
• Potential for Churn: About one-third of the surveyed members indicated a likelihood of switching their health plans within the next year, especially those with individual or employer-sponsored coverage.

These findings show a clear trend: consumers are actively seeking more engaged, transparent, and personalized healthcare experiences. Health plans that prioritize these areas will be well-positioned to not only maintain satisfaction but also build stronger member relationships.

A Demand for More Personalized and Proactive Healthcare

Today’s healthcare consumers are no longer passive recipients of medical coverage. They demand a service that is personalized, proactive, transparent, and convenient. The main factors driving these expectations include:

• Expanded Selection: The expansion of options through the ACA Marketplace and Medicare Advantage empowers consumers to shop around for plans that best meet their needs.
• Digital Fluency: As everyday activities shift online, consumers expect their health plans to offer similar digital conveniences.
• Cost Awareness: With rising healthcare costs, consumers emphasize the importance of financial transparency and affordability in their health plans.
• Regulatory Shifts: Recent regulations have enhanced patients’ access to their medical records, encouraging deeper engagement in their health decisions.

The full research report dives deeper into the satisfaction levels of different member populations, the likelihood of members switching health insurance plans in the coming year, and the expectations that consumers have for their health plans. It also describes what “personalized healthcare experience” means to most consumers, which includes:

• 60% – Focus on preventative care and early intervention
• 49% – Proactive approach to health management
• 46% – Streamlined communication and easy access to information

A dedicated section of the report examines how care management teams can enhance member satisfaction, noting that only 36% of those assigned a care manager were fully satisfied with their care management. Despite care managers’ extensive responsibilities, which include care coordination, medication management, and care plan development, members want more individualized care that meets their unique needs.

Modern solutions, like those offered by HealthEdge®, are essential in meeting the rising demand for more personalized experiences and engagement between members and their health plans.

How HealthEdge® Supports Payers in Elevating Member Experience

At HealthEdge, our mission is to innovate a world where healthcare can focus on people. That’s why we offer integrated software solutions designed specifically for modern healthcare consumers. These solutions enable us to work together with members and care managers to create personalized care plans, ultimately fostering a more people-centric healthcare experience.

• Empowering with Technology: HealthEdge’s platforms, such as the GuidingCare® care management suite and the Wellframe digital engagement platform, integrate seamlessly to empower members, care managers, and payers with more personalized care. Features like one-click referrals, real-time data access, and personalized content delivery significantly enhance the member experience while reducing the administrative burdens on care managers.
• Improving Transparency and Convenience: HealthEdge solutions support the Transparency in Coverage Act requirements, providing members with real-time cost-sharing estimates and comprehensive access to their health plan information through user-friendly portals and mobile applications.
• Supporting Personalized Care: The solutions support personalized care management, enabling health plans to effectively and proactively address and fulfill individual member needs. This tailored approach is crucial for boosting member satisfaction and fostering loyalty.

Moving Forward: Health Plans as Partners in Care

The survey’s insights reveal a crucial shift in the healthcare sector: members no longer see health plans merely as payers but as partners in their health journey. They expect proactive guidance and personalized support from their health plans.

To stay relevant and competitive, health plans must adopt advanced solutions like those offered by HealthEdge to meet these expectations. These modern solutions facilitate proactive, personalized engagement, allowing plans to offer the kind of service that consumers now demand. Furthermore, the integration of care management and member engagement solutions optimizes operational processes and enhances member satisfaction through improved services. This translates to a win-win for both health plans and members.

As the healthcare landscape continues to evolve, so do consumer expectations. The 2024 HealthEdge® Consumer Survey highlights a critical trend in healthcare: the need for health plans to adopt a more personalized, informed, and technology-driven approach to member engagement and satisfaction.

Don’t let your health plan get left behind! HealthEdge is at the forefront of this transformation. We offer the modern solutions you need to meet and exceed these evolving demands. Uncover the data behind the member voices. Download the full 2024 Consumer Survey report today.

Below are 5 key ways the Wellframe solution can improve ROI for healthcare payers.

1. Improving Chronic Condition Management

Every year, the U.S. spends about $4.5 trillion in health care expenditures. 90% of this goes toward treating members with chronic and mental health conditions. For members living with one or more chronic conditions, staying on top of health and wellness can be a challenge.

Wellframe addresses these issues by providing a robust digital solution. Diabetic members utilizing the Wellframe app have experienced a remarkable 25% reduction in their blood sugar readings, while members with hypertension have seen their blood pressure drop by up to 9%. These impressive statistics underscore the platform’s ability to facilitate effective chronic condition management, leading to better health outcomes and reduced healthcare costs.

For more on this topic, explore our Member Impact Report.

2. Supporting High-Risk Members Throughout Their Journeys

High-risk members require comprehensive, high-touch support to navigate their complex healthcare needs. Wellframe ensures these members are not left behind. The app offers personalized tasks on daily checklists tailored to individual clinical requirements, including medication reminders, biometrics tracking, and educational content. Moreover, members can securely communicate with their care teams via the app, providing a seamless and effective way to manage their health.

Learn more about supporting high-risk members in our Medicaid Maternal Health Resource.

3. Streamlining Staff Workflows and Increasing Capacity

Traditional care management methods often involve time-consuming tasks such as making phone calls, leaving messages, and conducting questionnaires over the phone. Wellframe revolutionizes this process by enabling care managers to reach more members efficiently. Through the app, care managers can send secure messages to multiple members simultaneously, allowing members to respond at their convenience—leading to a 6x increase in member interactions. Digital surveys and assessments can also be sent directly to members’ smartphones, saving time, ensuring greater security compared to traditional phone calls. By leveraging Wellframe’s digital tools, care managers can double their caseload size, and increase successful phone calls by up to 91%.

Read more about streamlining staff workflows in our Staff Efficiency Case Study.

4. Proactively Identifying and Addressing Health Barriers

Members often feel hesitant to discuss sensitive personal information over the phone. Wellframe mitigates this issue by providing a secure messaging feature where members can comfortably share their concerns and ask questions. Additionally, the platform allows care managers to uncover social determinants of health through digital surveys. With real-time notifications when members complete assessments and automated flagging of high-risk members, care managers can prioritize their outreach effectively, addressing health barriers proactively.

Discover effective strategies for identifying and addressing health barriers in our guide.

5. Increasing CMS Star Ratings and Member Satisfaction

Achieving higher CMS Star Ratings is crucial for health plans aiming to enhance their reputation and secure more rebates—and increasing member satisfaction is a major contributor. The Wellframe solution plays a pivotal role in these endeavors by supporting health plans in delivering timely and effective care, reducing preventable readmissions, and improving the patient experience. Members benefit from a single digital health management platform that provides them with the relevant information and support they need, precisely when they need it. The Wellframe member app boasts a 4.7 of 5 star rating on the App Store, demonstrating its use to members. Proactively focusing on member satisfaction can help health plans increase their CMS Star Ratings, ultimately resulting in greater financial incentives.

Explore our Star Ratings Guide to learn more about improving your scores.

Wellframe stands as a transformative force in the realm of health plan management, offering a comprehensive digital solution that addresses the multifaceted needs of members and care teams alike. By improving chronic condition management, supporting high-risk members, streamlining staff workflows, proactively identifying health barriers, and enhancing CMS Star Ratings, Wellframe delivers exceptional value to health plans. Embrace the future of healthcare with Wellframe and witness firsthand the profound impact it can have on your organization’s efficiency and member satisfaction.

Ready to take the next step? Connect with us today to discover how Wellframe can revolutionize your health plan management.

How are industry shifts impacting the requirements of effective training for care management staff?

Sontz-Morrison: There are several factors influencing the demand for more and accessible staff training opportunities in functional areas like care management. The first is, without a doubt, workforce shortages and high turnover rates. The World Health Organization (WHO) predicts a shortage of 10 million health workers by 2030. This ongoing workforce shortage across allied and behavioral health, long-term services, nursing, primary care, and women’s health is placing an immense pressure on clinicians and support staff to “do more with less.” Despite these constraints, maintaining quality care remains paramount.

Second, the regulatory environment in healthcare is constantly changing. Health plans must remain updated on Medicare and Medicaid regulations while also focusing on improving pricing transparency and healthcare access. Though it can put more administrative burden on care teams, staying up-to-date on new guidelines is essential to ensuring compliance and remaining competitive.

Lastly, the consumer demand for personalization is shaping how we need to develop our training. Modern consumers have come to expect personalized experiences in most aspects of their lives—including their healthcare. These expectations are pushing healthcare payers to adopt new technologies that are transformational. Training for any of these technologies, which can require staff behavioral changes and high adoption rates to be effective, must be fool proof.

The integration of new technologies, evolving regulations, and current workforce dynamics significantly impacts the requirements for technology onboarding and training at health plans. Health plan staff must enhance their knowledge and stay current with regulations to streamline their processes without adding extra layers or underutilizing talent. Without proper education, new tools can become cumbersome for users, causing issues like technology underutilization, administrative errors, missed regulatory deadlines, or missed opportunities to improve member outcomes.

What is GuidingCare University, and how can it support health plan staff?

GuidingCare® University (GCU) is a self-service learning and development solution designed to empower customers and end-users by giving them control over their success. GuidingCare® users even receive alerts before new training modules go live to improve visibility. With GCU, staff have access to comprehensive training on GuidingCare content, technology, optimization, and best practices.

GuidingCare University was designed to serve staff working in a variety of roles, including utilization management, nurses, medical directors, appeals and grievance staff, and population health professionals. By targeting all staff that utilize GuidingCare software, GCU ensures comprehensive training and knowledge sharing across teams. This leads to optimized solution usage, breakdown of internal siloes, and streamlined daily operations.

What are some of the benefits to leveraging GuidingCare University training?

• Continuous Learning: New courses are added quarterly and as needed based on product feature enhancements, ensuring that there are no delays due to a lack of instructors or updated information.
• Real-Time Updates: Training modules go live at the same time as product updates, providing insights and best practices whose value can be passed on to members.
• Increased Efficiency: Employees can access and revisit trainings at any time, reducing time spent searching for answers and getting stalled by not knowing who to ask.
• Improved Accessibility: Training modules are broken into “bite-sized” 5-20-minute segments, making them easy to watch and understand even with a busy schedule. This is particularly beneficial for care managers who balance training with patient care.
• Self-Empowerment: On-demand training modules ensure employees never have to feel like they don’t have enough training to perform their roles effectively. Trainings can also be used alongside organizational onboarding to give new users a comprehensive resource.

Which metrics do health plans use to measure the impact of on-demand training from GuidingCare University?

Key performance indicators (KPIs) play a crucial role in evaluating the effectiveness of training tools like GCU. In addition to tracking metrics like messaging and touchpoint volume, health plans can assess training effectiveness in other ways. Increasingly, organizations are using badge programs and certifications to demonstrate employee skills and understanding of a digital solution.

To help healthcare payers understand how their employees are using the modules and absorbing important information, GCU will be incorporating three new tools into the platform:

• Knowledge checks that pop up throughout training videos.
• Pre- and post-training quizzes to gauge understanding and identify areas for improvement.
• Reporting that tracks video engagement, including watch duration, completion rates, and most rewatched content.

Recently, a customer interview revealed that employees found GCU training streamlined their comfort with the GuidingCare solution. New employees also reported the GCU training modules enhanced their overall onboarding process and helped them feel empowered to fulfill their roles successfully.

The Bottom Line

Today’s healthcare environment demands a responsive and adaptive approach to staff training, especially when it comes to using new technologies. Effective training solutions are not just an option for health plans, but a necessity. By providing continuous learning opportunities and real-time updates, GuidingCare University ensures that staff are well-equipped to meet the dynamic demands of the healthcare industry—leading to better performance, improved member outcomes, and more efficient operations.

Read our brochure, “Empowering Health Plans to Advance Care Management with GuidingCare”

Unlocking the Potential of Digital Care Programs

Digital care programs offer immense potential to improve clinical outcomes and member engagement. By implementing best practices such as omnichannel support, consistent communication, personalized information, and accessible language, health plans can enhance the member experience and increase care program completion rates.

The Wellframe solution makes it easier for members to take control of their health by providing information and support through a convenient digital app. Here, we’re sharing best practices to drive member engagement for digital care programs.

Omnichannel Support: Meeting Members Where They Are

Today’s healthcare consumers expect convenience. They need to be able to reach out to their health plans and care teams on their own time, using the channels they prefer. For many members, this goes beyond answering sporadic phone calls or waiting on hold.

Making care programs available to members via smartphone makes it easier for them to engage at their convenience. They can also engage in multiple ways, depending on their needs and preferences. Wellframe’s omnichannel support ensures that members can interact with their care programs via smartphone or tablet at any time of day, providing flexibility and accessibility.

Key Features:

• 1:1 HIPAA-Compliant Messaging: Members can send secure in-app communications to their care teams. Participants can also send attachments (like photos) and links to helpful information.
• Digital Assessments & Surveys: Instead of calling members and asking them dozens of questions over the phone, send a digital survey or assessment. Members can answer them discreetly, and care managers are alerted when they’ve been completed.
• On-Demand Educational Content: Clinically reviewed articles are written at or below a 4th-grade reading level. This information helps empower members with information they need when they need it.

By offering multiple ways for members to interact, Wellframe makes it easier for individuals to stay engaged and committed to their health and wellness goals.

Consistent Communication: Building Daily Habits

Consistency is key to forming healthy habits, and Wellframe leverages this by providing members with a personalized daily checklist of health-related tasks. Members can check in with the app daily to check messages from their care managers, track biometric data, complete medication reminders, and take other health actions. This consistent communication helps members integrate care activities into their daily routines, making it more manageable and sustainable.

Key Features:

• Personalized Checklists: Tailored tasks and recommended articles based on care program enrollment, medications, and health goals.
• Medication & Appointment Reminders: Keep members on track with the option to create in-app prompts for medications and doctors’ appointments.
• Biometrics Tracking: Encourage members to log biometrics such as weight, blood glucose, blood pressure, and step counts regularly to foster a sense of accomplishment.

By maintaining a steady flow of communication, Wellframe keeps members engaged and motivated to complete their care programs.

Personalized, Relevant Information: Enhancing Member Experience

One size does not fit all in healthcare. Wellframe ensures that each member receives personalized and relevant information tailored to their specific needs and health conditions. This personalization enhances the member experience by making educational content more applicable and engaging.

Key Features:

• Digital Care Programs: Clinicians enroll members in digital care programs based on diagnosis, condition, or health goals. Currently, Wellframe offers more than 70 care programs.
• Targeted Content: Members receive links to suggested articles on their daily checklists. Articles are related to the member’s current care program.

Providing personalized articles and information keeps members engaged and helps them feel understood and supported.

Steer Clear of Healthcare Jargon: Bridging the Health Literacy Gap

With only 12 percent of Americans having proficient health literacy skills, it is crucial to use accessible language in digital care programs. All Wellframe content is written at or below a 4th-grade reading level to ensure it is accessible to as many members as possible. But accessible language should go beyond educational health content—nearly 1 in 4 members said they are “often” or “always” confused by health plan communications.

Key Features:

• Simplified Language: Avoid healthcare industry jargon and use clear, straightforward vocabulary. Member communications should be written at or below a 4th grade reading level.
• Educational Resources: Healthcare information should be easy to understand and act upon.

By simplifying the language used in member-facing communications and articles, Wellframe makes healthcare more approachable and reduces barriers to engagement.

Leveraging Wellframe Solutions: A Comprehensive Approach

Wellframe offers robust solutions designed to enhance member engagement and improve clinical outcomes. Wellframe’s Digital Care Management and Clinical Advocacy services provide comprehensive support across the healthcare continuum.

Key Solutions:

• Digital Care Management: Streamlining care processes and improving member experience.
• Clinical Advocacy: Offering personalized support and guidance to members.

By leveraging Wellframe’s solutions, health plans can create a more connected, efficient, and effective care ecosystem.

These shifting regulations give health plans a huge opportunity to reach more members more effectively. In 2023 alone, 5.2 million individuals enrolled in a Medicare Advantage plan designed for dual-eligible individuals—a 13% increase from 2022. How is your organization preparing for these changes? And how can your vendors work with you to ease this transition?

What are the requirements of Dual Eligible Special Needs Plan (D-SNP) offerings?

D-SNPs are specialized Medicare Advantage plans designed to provide tailored health coverage for individuals eligible for both Medicare and Medicaid. Those who qualify for D-SNP plan coverage are among the most vulnerable member populations. Often, D-SNP members live in rural areas, are older than age 65, or have cognitive impairments.

As the administrative complexities surrounding D-SNPs increase, healthcare organizations must adapt to meet new requirements and ensure optimal care for this vulnerable population.

Use CalAIM Strategies to Inform D-SNP Offerings

Not sure where to start when it comes to competitive D-SNP offerings? For an example of effective strategies that support high-risk member populations, look at what payers are currently doing to support Medi-Cal members under CalAIM.

CalAIM initiatives fall into four categories: Shifting to Population Health Management, Standardized Managed Care Benefits, Mandatory Medi-Cal Managed Care Plan Enrollment for Dual-Eligibles, and Behavioral Health System Transformation. Understanding each of these areas can help your health plan get started on creating competitive D-SNP offerings that are effective and support members’ whole health.

A few strategies your health plan can leverage include:

• Targeted interventions that are timely and relevant to members’ health needs
• Use a multichannel communication approach that enables your plan to reach members where it’s most convenient them
• Focus on improving the member experience by making healthcare and information more accessible

As new requirements emerge, payers will have to stay flexible so they can adapt to new demands and shifting member needs.

Streamline D-SNP Care Management with GuidingCare®

Health plans that serve D-SNP members need an integrated solution for care management and population health. Holistic platforms like GuidingCare can streamline care delivery, improve clinical outcomes, and reduce costs—while ensuring state and federal regulatory compliance.

GuidingCare can also help improve member satisfaction and outcomes by providing coordinated care and ongoing encouragement from their care teams. Care managers can also uncover and leverage social determinants of health (SDOH) information to address barriers to healthcare access and other needs.

1. Enhanced Care Coordination

Effective care coordination is crucial for managing D-SNPs. GuidingCare facilitates seamless communication between healthcare providers, payers, and patients to advance care management. This integrated approach ensures that all stakeholders are on the same page, enhancing the overall quality of care and reducing the risk of errors or omissions.

2. Compliance Management

Navigating the regulatory landscape can be daunting. GuidingCare offers robust compliance management features and a regulatory support team with clinical expertise that help organizations stay ahead of new requirements and maintain compliance. The platform continuously updates to reflect the latest regulations, ensuring that healthcare payers and executives can focus on patient care instead of administrative tasks.

3. Data-Driven Insights

In an industry where data drives decisions, GuidingCare provides actionable insights through advanced analytics and business intelligence. These insights enable healthcare organizations to identify trends, track performance, and make informed decisions that enhance patient outcomes and operational efficiency.

4. Population Health

The GuidingCare solution features a stratification rule that helps health plans identify members with specific health conditions as well as provide risk scoring and offer patient management suggestions. In addition, GuidingCare users have access to advanced gaps-in-care analytics that flag high-risk members, making it easier for care teams to prioritize clinical interventions.

Comprehensive Reporting and Dashboards Deliver Key Clinical Insights

In addition to surfacing SDOH insights, GuidingCare offers near-real-time reporting and integrated dashboards with business intelligence capabilities that empower care teams to make more informed decisions, faster.

Access multi-layered analytics capabilities, including:

• Interactive dashboards with custom views
• Download and export capabilities
• Access to more than 20 CMS reports covering ODAG, CDAG, and Part C/D needs
• Audit and annual reporting support
• Front end/database/source documentation

GuidingCare also offers ongoing training to make sure health plans are making the best use of the platform and taking full advantage of the tools available.

Preparing for the D-SNP transition: Strategic Steps

To effectively leverage GuidingCare® for managing D-SNP offerings under CalAIM, healthcare payers and executives should consider the following strategic steps:

1. Evaluate Current Systems: Assess the existing care management systems and identify gaps that can be addressed by GuidingCare® solution suite.
2. Training and Development: Invest in dynamic, self-paced training to ensure that staff understand GuidingCare benefits and are proficient in using available tools.
3. Integration Planning: Develop a detailed integration plan that outlines how GuidingCare® will be incorporated into existing workflows and systems.
4. Continuous Improvement: Establish a feedback loop to continuously monitor the platform’s performance and identify areas for improvement.

The transition from MMPs to D-SNPs under the Medi-Cal program is a significant step towards achieving a more integrated and coordinated healthcare system in California. By leveraging GuidingCare®, healthcare payers and executives can navigate this transition smoothly, ensuring compliance with new requirements while enhancing care quality and patient satisfaction. Embracing this change is not just about meeting regulatory demands; it’s about pioneering a future where healthcare is more inclusive, efficient, and patient-centered.

Is your health plan ready to build innovative and competitive D-SNP offerings for your dual-eligible members?

To learn more about how health plans are using GuidingCare to drive engagement and improve clinical outcomes, watch our on-demand ACAP webinar: Leveraging Clinical Expertise and Compliance Support to Serve Your Most Vulnerable Members.

HealthEdge conducts an annual nationwide study to help health plans understand their members’ needs and expectations for healthcare services. This year, we surveyed more than 3,500 healthcare consumer—and almost one-third are considering switching health insurers next year.

The findings highlight an immediate need for health plans to prioritize member satisfaction. To remain competitive amid a rapidly shifting healthcare industry, health plans must innovate to attract and retain membership.

“Rising healthcare costs and more choices for consumers puts health plan members in the driver’s seat.”
-Alan Stein, Chief Product and Strategy Officer at HealthEdge

The Age of Choice and Churn

Consumers now have more health insurance choices than ever before. For example, the Affordable Care Act (ACA) Marketplace is currently providing private health insurance to 21.3 million consumers, with 92% of them having the option to choose from, on average, three different insurance plans. Additionally, this year, Medicare beneficiaries had an average of 43 Medicare Advantage plan choices available to them.

The age of consumer choice in health insurance is here, making it crucial for health plans to put member satisfaction at the forefront of their digital transformation strategies.

According to Alan Stein, Chief Product and Strategy Officer at HealthEdge, “At HealthEdge, we are working with health plans to address critical challenges across the landscape. Those challenges range from rising healthcare costs and more choices for consumers which puts health plan members in the driver’s seat. Now more than ever, members are expecting more from their insurers. This latest survey highlights the importance of investment in personalized plans that meet members where they are.”

Which Members are More Likely to Change Health Insurance Carriers?

Members with individual and employer-sponsored coverage are the most likely to switch, highlighting the urgency for health plans to prioritize member satisfaction initiatives.

It’s not surprising that individual consumers might want to change health insurance carriers, especially with ACA Marketplace enrollment reaching record highs and generating significant activity in this sector. Medicare Advantage members are another group known for frequent health plan changes, with 23% indicating they are “very likely” or “likely” to switch health plans next year.

Age also affects the healthcare consumers’ willingness to switch health insurance plans. Health plan members aged 26–45 are the most likely to change health insurance carriers. This may be attributed to their life stage, which often involves more frequent job transitions, the onset of health issues, and a growing awareness of the financial responsibilities tied to healthcare utilization.

The Opportunity for Health Plans: Catching Members that Change Health Insurance Carriers

There are an increasing number of options members can choose from and a growing demand for more personalized care. Modern health plans that have empowered their teams with the right digital tools have an opportunity to attract more than their fair share of these moving populations

We asked consumers what would impact their decision to switch health plans. The most popular responses centered around cost-related factors, network coverage, and customer service/access to self-service tools.

How can Health Plans Mitigate the Risk of High Member Churn Rates?  

Beyond lower monthly premiums and out-of-pocket costs, members want to ensure they have access to a wide range of in-network doctors and hospitals. Health plans with strong networks have the opportunity to ensure members receive timely, quality care from the right providers, thus improving their experiences and streamlining care coordination for improve health outcomes.

The survey revealed that health insurance coverage plays a significant role in healthcare decisions for many consumers:

1. 57% reported that their coverage often or always influences their decisions on when to seek care.
2. 46% indicated that their coverage impacts their choices regarding where to receive care.
3. 32% have considered changing care providers due to their in-network coverage.

Members also want clarity and accessibility when it comes to their health insurance information. This includes understanding the cost of medical services. In fact, only 25% of respondents were fully satisfied with their health plan’s ability to provide this clarity.

Modern care management platforms allow health plans to meet regulatory requirements while empowering members with the insights and estimates they need to make informed healthcare decisions. These solutions provide members with self-service tools, such as portals and mobile applications, granting them enhanced control and access to their individual health plan information.

Insights on Health Plan Member Technology Adoption

The survey indicates a strong acceptance of technology among members, with 64% saying they are comfortable using secure mobile apps for health plan interactions and record tracking. This comfort spans across age demographics, led by the middle-aged group (ages 36-55) at 73%. A notable 50% of older adults (ages 56+) also embracing mobile app usage. This trend is consistent across plan types as well, with Medicaid plan members showing the highest comfort at 69%, followed closely by those with employer-sponsored (70%) and individually purchased plans (74%).

Digital care management solutions are transforming health plans by streamlining operations, fostering collaborative relationships with provider networks, and enhancing member and care manager engagement. These solutions provide critical information that supports personalized care and promotes transparency—empowering your health plan to retain members and capture new members looking to chance health insurance carriers.

To learn more about these consumer trends, download the full report: 2024 Consumer Survey: Key Trends in Healthcare Member Expectations and Satisfaction.

In our five-part blog series, HealthEdge Source Horizons, we demonstrate how our payment integrity solution empowers health plans to achieve compliance, expand market reach, and manage value-based care. In this blog, we will dive into how health plans can enhance payment accuracy and transparency, the cornerstones of member trust and engagement.

Read the entire series at the links below:

• Ensure Regulatory Compliance and Cost Transparency
• Improve Payment Accuracy and Efficiency with Advanced Automation
• How Payment Integrity Innovation Helps Expand New Business Opportunities
• Simplifying Value-Based Care Contracts & Reimbursements
• Increase Member Engagement & Build Trust with Cost Transparency

Why member engagement matters

Member engagement goes beyond profit; it directly impacts health outcomes. Engaged members take a more active role in their healthcare, leading to better health outcomes and lower long-term costs for your plan.  However, factors such as inaccurate payments, lack of transparency, and delays can erode trust and disengage members.

Our recent webinar, “Empowering Modern Health Care Consumers,” highlights the importance of member satisfaction. We emphasize the critical role of payment accuracy and transparency in building member engagement. By offering clear explanations of benefits, coverage details, and out-of-pocket expenses, you enable members to make well-informed healthcare decisions. This not only reduces anxiety about surprise bills but also fosters collaboration, leading to a stronger partnership and better health outcomes.

Increase health plan efficiency to improve member relationships and engagement

Reduce clinician burnout from administrative overload

Clinicians are drowning in administrative tasks, leading to burnout and less time spent with patients. Every minute spent on paperwork steals valuable time from direct patient care, hindering the ability to deliver personalized and attentive care.

HealthEdge Source alleviates this burden for clinicians, creating a ripple effect of positive outcomes. Our solution automates essential claims and payment processes, freeing up time for clinical decision-making. By streamlining routine tasks and simplifying complex processes, we eliminate the need for time-consuming manual reviews. This allows clinicians to refocus their energy on what matters most—delivering high-quality patient care.

With more time dedicated to patients, improved communication and a more positive patient experience naturally follow. And reduced clinician burnout leads to lower turnover rates, saving on costly recruitment and training expenses.

Offer pricing transparency and easy access to information for members

Transparency in healthcare costs and coverage is a top priority for both your members and regulatory agencies including the Centers for Medicare and Medicaid Services. Empowering your members with clear, accurate information is key to building trust and driving engagement.

Here’s how we help health plans achieve transparency:

• Eliminate Surprise Billing: Our cloud-based system ensures accurate estimates upfront, preventing surprise bills and fostering trust from the beginning.
• Real-Time Information Access: With 24/7 data access, your plan or any providers can proactively communicate coverage details and potential cost-saving options directly to members.

Cloud-based data delivery ensures that your plan has the most up-to-date and accurate content and regulatory updates, eliminating confusion and errors. Furthermore, cloud-based processing reduces wait times by streamlining claims and inquiries. Most importantly, the cloud provides a secure and scalable environment to protect member data and ensure smooth system performance even during peak demand.

Happy providers = Happy members

Building strong provider relationships is crucial for a health plan’s success. Happy providers lead to happy members, yielding better health outcomes and reducing long-term costs. Designed for true Payment Accountability, HealthEdge Source not only streamlines internal operations but also allows you to nurture these crucial relationships.

Traditional claim processing frustrates providers with errors and inconsistencies. Our Platform Access technology solves this issue by streamlining internal operations, ensuring accuracy, transparency, and comprehensive claims payments upstream in the adjudication process. Now you can transform your business, organize your data in a single place, address root cause issues, and pay claims right the first time.

With key features including:

• Editing Library with History: Access historical data, parameters, and exceptions for edits, allowing for informed decision-making.
• Custom Edit Builder: Tailor specific edits to meet your unique payment arrangements and cost-saving goals.
• Real-Time Analytics: Gain valuable insights into performance metrics and the impact of edits on your claims process.
• Monitor Mode: Test the impact of edits on your system before implementation, minimizing disruptions.
• Comprehensive Audit Trail: Track and view claim-level edit details for complete transparency.

Our platform seamlessly integrates with your existing systems, eliminating the need for disruptive rip-and-replace solutions. Regular updates ensure your system stays current, while the scalable design allows you to adapt to future needs.

By providing a single, streamlined platform for accurate and efficient claims processing, we can help you to build stronger relationships with your providers. This translates to a win-win for everyone: happier providers delivering better care, a more satisfied member base, and a healthier bottom line for your health plan.

Ready to learn more?

Explore our blog series, “HealthEdge Source Horizons,” to discover how our solution can help you achieve compliance, expand market reach, and manage value-based care.

Want to learn more about how your health plan can access valuable analytics while increasing payment accuracy and transparency? Read our blog, “The Shift to Payment Accountability®: An Enterprise Approach to Healthcare Payment Integrity.”

Leveraging Retroactive Change Management to Improve Payment Accuracy

Retroactive change management refers to the process of adjusting previously completed healthcare claims transactions to correct errors or reflect new information. For healthcare payers, this is essential for maintaining accuracy and compliance. HealthEdge Source solution incorporates retroactive change capabilities, helping healthcare payers to manage discrepancies and avoid financial losses.

The Costs of Making Retroactive Payment Changes

Throughout 2024 alone, experts anticipate over 600 changes to fee schedules, edits, and pricing logic. Updates to guidelines and regulations come from various sources, including:

• Regulatory bodies (e.g., Center for Medicare and Medicaid Services (CMS) updates, Medicaid rate changes)
• Network contracts (e.g., modifications to provider agreements or payment policies)
• Internal configurations (e.g., changes in fee schedules or other system configurations)

Retroactive changes can impact a health plan’s bottom line in a few ways. Delays in enacting these changes may result in overpayments to providers, leading to financial losses. Conversely, underpayments can strain relationships with providers and pose administrative burdens for your team. Both overpayments and underpayments can damage your health plan’s reputation and expose you to potential regulatory penalties.

Implementing a solution with retroactive change management capabilities can help payers improve:

1. Accuracy: Ensures all payment adjustments are accurate and compliant.
2. Efficiency: Streamlines the process of managing retroactive changes.
3. Compliance: Keeps up with regulatory requirements by applying necessary changes retroactively.

Shift from a Reactive to Proactive Strategy

Manually managing retroactive changes is a time-consuming and error-prone process that diverts valuable resources away from other important tasks. The volume and complexity of retroactive changes can be overwhelming for staff. But health plans can mitigate manual roadblocks with a proactive approach to reimbursement management.

Here at HealthEdge, we understand the financial burden retroactive changes create. Our solution aims to reduce overpayments and underpayments and ensure claims are paid correctly—the first time. With our Retroactive Change Manager (RCM) tool, your team can spend less time finding, chasing, and collecting what’s already gone out the door.

HealthEdge Source Retroactive Change Manager

Last year, HealthEdge Source launched the first phase of the Retroactive Change Manager. The tool helps healthcare payers automate core tasks, such as flagging claims that will be automatically eligible for reconciliation upon delivery. Scheduled reviews save valuable time that would have been spent on manual searching.

Additionally, RCM users receive regular variance reports that detail all the claims impacted by retroactive changes, along with the exact adjustments needed. This comprehensive approach gives health plans a clear picture of financial exposure and eliminates guesswork. This initial rollout laid the foundation for a more proactive approach to managing reimbursements, saving time and money, and avoiding potential payment issues.

Latest Enhancements to the Retroactive Change Manager

The latest enhancements to the Retroactive Change Manager go beyond regulatory updates. They empower health plans with a range of features designed to streamline workflows and maximize financial security.

With new targeted analyses and streamlined operations, healthcare payers can:

• View configuration updates within specific timeframes to focus analysis on impacted claims related to provider types or edits.
• Receive timely email notifications and enhanced claim summary reports for a clear understanding of adjustments needed.
• Enhance the user experience with increased performance and stability for smoother operations.

Leveraging the RCM directly translates to a healthier financial bottom line for health plans in three primary ways. First, it automatically recovers overpayments that might have been missed before. Second, faster and more accurate payments to providers lead to stronger relationships and fewer disputes—which can save time and administrative costs. Finally, the RCM keeps claims data organized and readily available, ensuring health plans are always audit-ready. This peace of mind allows payers to focus on strategic initiatives that drive organizational growth.

By shifting from a reactive to a proactive claims management approach, health plans can leverage a single system to identify and address retroactive changes. Imagine complete data sets analyzed automatically, underpayments identified and addressed proactively, and overpayments recovered internally. This not only saves time and money, but also fosters stronger provider relationships and ensures compliance. With fully incorporated industry changes and provider configurations healthcare payers can finally move from reactive adjustments to proactive control.

For more information about how your health plan can leverage retroactive change management, watch our on-demand webinar, “Optimizing Retroactive Configuration Changes”.

Gain a Competitive Edge by Consolidating Your In-Network and Out-of-Network Pricing Management

Specifically designed to extend to third-party best-of-breed content solutions, HealthEdge Source uniquely addresses these challenges. With this integration, payers can seamlessly incorporate FAIR Health data into their workflow to streamline in-network and out-of-network pricing for Medicare parts A and B, or any line of business that utilizes FAIR Health. 

FAIR Health is a renowned third-party vendor that collects data for pricing management. It uses pricing benchmarks based on the region and zip code, as well as national averages, providing just the kind of data needed to streamline your operations and cut out wasteful processes.  

The Value of Integrating FAIR Health’s Data with HealthEdge Source

Utilizing FAIR Health’s robust data offerings and bringing them to Source is a significant step in providing our clients with more value. It enables Source members to deliver unique insights and analytics that could transform your claims operations – making them more efficient and cost-effective. 

The FAIR Health integration will not only resolve common issues you face but also potentially introduce UI changes based on client requests. This can include data reference views and new pricers connected to the FAIR Health fee schedule. The latter is similar to wrapper pricers and other third-party pricers presently in Source.  

Moreover, users can expect potential enhancements in configurations, unlocking even greater capacity for your operations. Our development teams are working behind the scenes on utilizing a data pipeline for file transformation to ensure this integration provides maximum advantages for your health plan operations. 

The End Goal: Smoother Workflow and Seamless Integration

Ultimately, the end goal is to facilitate a smoother workflow and a more seamless integration between multiple claims or data systems. The integration of FAIR Health content into HealthEdge Source opens up a myriad of opportunities for healthcare payer claims operations teams to streamline their processes and work more efficiently. 

Our five-part blog series, HealthEdge Source Horizons, highlights how our payment integrity solution helps healthcare payers adapt and scale to meet their organizational goals.

Read the entire series at the links below:

• Ensure Regulatory Compliance and Cost Transparency
• Improve Payment Accuracy and Efficiency with Advanced Automation
• How Payment Integrity Innovation Helps Expand New Business Opportunities
• Simplifying Value-Based Care Contracts & Reimbursements
• Member Engagement

The shift to value-based care (VBC) raises the bar for care standards, establishing a healthcare system where quality and value take precedence. This approach aims to improve patient experiences, health outcomes, and cost efficiency while promoting preventive care.

However, navigating the complexities of a value-based care delivery system presents challenges for health plans.

Simplifying Value-Based Care with Payment Integrity Solutions

Modern payment integrity solutions offer the tools health plans need to thrive in the VBC environment. These solutions go beyond error prevention to ensure accurate reimbursements, optimize resource allocation, and strengthen relationships with providers.

These solutions enable health plans to extend their existing resources and analyze key historical data and coding patterns to identify wasteful practices, such as avoidable readmissions. Early detection enables payers to implement proactive interventions and collaborate with providers to reduce costs and improve patient outcomes through high-quality care delivery.

HealthEdge Source: An Innovative Approach to Simplifying Value-Based Care

The intricacies of value-based care contracts can be challenging for healthcare payers to understand and abide by. HealthEdge Source offers key features that reduce payment complexity for your plan:

• Always Accurate Pricing: Bi-weekly updates provide up-to-date data for complex contracts, eliminating costly overpayments and underpayments.
• Streamlined Workflow: A single platform for claims pricing, editing, and configuration simplifies customization and saves time.
• Seamless Integration: Third-party content synchronizes to the platform, reducing administrative burdens and automating your operations.

In addition, the Source solution offers the flexibility to operate alongside traditional fee-for-service contracts. With customizable terms, a single configuration layer, and shared business rules, Source makes it easier for health plans to manage multiple scenarios.

Supporting All Payment Models: Prospective and Retrospective

No matter how your health plan approaches value-based care, Source has you covered. The solution handles both prospective and retrospective payment models, ensuring accuracy and efficiency in aligning payments with outcomes.

For prospective payment bundles, Source encourages efficiency by ensuring accurate payments for bundled care episodes, incentivizing quality improvement. When it comes to retrospective payment bundles, health plans can reconcile payments based on actual outcomes achieved, motivating providers to deliver high-quality care while controlling costs. This flexibility fosters collaboration and accountability, leading to better patient outcomes. 

Empowering Informed Decision-Making

Health plans must have access to updated intelligence and performance insights to remain flexible and compliant with regulations. HealthEdge Source empowers payers to make more informed strategic decisions with advanced tools like embedded analytics and predictive modeling.

With embedded analytics, centralized data lets you benchmark performance and model different VBC strategies. The modeling tool makes it easy to create multi-dimensional reports and “what-if” scenarios to compare provider claims against various contract terms. Payers gain real-time insights into the potential impact of edits, allowing for proactive decision-making. This data-driven approach ensures you’re making the best choices for your VBC initiatives.

Building Trust and Reducing Provider Abrasion

At the heart of HealthEdge Source lies a commitment to reducing provider abrasion, a common challenge in value-based care adoption. We demonstrate this commitment through:

• Single Point of Management: Manage contracts, configurations, and payments in one place—eliminating the need to juggle multiple systems and simplifying communication with providers.
• Transparency Breeds Trust: Real-time data access and clear reporting foster trust between you and your providers. This transparency promotes accountability, drives improvements in care delivery, and ultimately, leads to better patient outcomes.

With HealthEdge Source, you can build strong provider relationships that are key to thriving in the value-based ecosystem.

Holistically Addressing Value-Based Care Requirements

HealthEdge Source delivers a holistic solution that empowers payers to address obstacles throughout the value-based care journey. When using the Source payment integrity platform, health plans can expect access to:

• Fair & Fast Payments: Eliminate errors and ensure providers receive accurate compensation on time, reducing frustration and fostering collaboration.
• Smoother Operations: Consolidate multiple sources of payment integrity editing into one platform, minimizing internal resources and simplifying workflows for cost savings.
• Enhanced Decision-Making: Gain full insights across all payment functions, empowering you to make informed business decisions.
• Simplified Adjudication: Leverage a single platform for pricing and editing, leading to faster claim processing.
• Beyond Basic Integrity: Access to a suite of additional solutions like modeling and analytics can root out the causes of key inefficiencies.

Don’t just survive the transition – thrive with a solution that simplifies complexity, ensures accurate reimbursements, and fosters collaboration for a future of quality, patient-centered care.

Our five-part blog series, HealthEdge Source Horizons, highlights how our payment integrity solution helps healthcare payers achieve their organizational goals.

Read the entire series at the links below: 

• Ensure Regulatory Compliance and Cost Transparency
• Improve Payment Accuracy and Efficiency with Advanced Automation
• How Payment Integrity Innovation Helps Expand New Business Opportunities
• Value-Based Care
• Member Engagement

Stay Ahead of Industry Changes with a Flexible Payment Solution

The healthcare landscape is in constant flux, with new regulations, shifting reimbursement models, and technological breakthroughs. To stay competitive, health plans need to be adaptable. A flexible payment solution can help you adapt to new regulations, seamlessly integrate systems, and scale into new markets —all while providing valuable data for continuous improvement.

HealthEdge Source offers a platform that gives your organization control of claims payment workflows to reduce dependency on third-party vendors. The solution also delivers unified data that allows for real-time business decisions, enhancing efficiency and improving transparency. This integrated digital solution helps prevent inaccurate payments and resource wastage by ensuring claims are paid correctly the first time.

Support All Claims Systems and Provider Types with a Single API

Payer IT ecosystems can be a patchwork of different systems and providers. This kind of internal fragmentation can make it challenging for payers to properly scale their solutions and expand into new markets. HealthEdge Source simplifies this process with a single application programming interface (API) that can connect with any claims systems and support all provider types:

• Unified Access: One gateway for pricing, editing, and analytics. No more interface juggling – it’s all here.
• Cloud-Based Efficiency: Our solution was built to support cloud-based delivery—unlike many of our competitors—keeping you up-to-date on compliance and improving accuracy.
• Seamless Integration: Connect to your claims systems through a single instance, streamlining your workflow and eliminating integration headaches.
• Automated Third-Party Connections: Gain access to the latest industry edits through automated connections.

Easily Create and Customize Contract Configurations with Rules Management Synchronization

Complex contract configurations are often bottlenecks to health plan growth. Different lines of business (LOBs) often have unique contract needs, resulting in numerous configurations that demand time and resources. HealthEdge Source cuts through the clutter with a user-friendly solution that simplifies and streamlines configuration management to facilitate your market expansion journey.

Effortless Configuration, Exceptional Results:

• Easy Setup: Remove redundancy with one configuration layer for edits and pricing, freeing you to focus on growth.
• Consistent Results: Shared business rules ensure consistency and compliance, with customization options for specific needs.
• User-Friendly Customization: Create and adjust contract settings easily with an accessible interface.
• Pre-Production Powerhouse: Model new contracts in a test environment before launch, guaranteeing a smooth transition.

HealthEdge Source goes beyond basic configuration. It’s a comprehensive solution that optimizes your claims processes through an emphasis on payment integrity innovation.

Scale Your Organization’s Growth, Agility, and Transformation

HealthEdge Source isn’t just built for today’s needs—it anticipates tomorrow’s challenges. Whether your organization is focusing on the commercial sector, government programs, or niche markets, the payment integrity solution can adapt to support your growth.

• Simplified Workflow: One solution handles pricing, editing, and contract configuration to help your health plan quickly resolve payment integrity issues.
• Reduced Maintenance, Increased Efficiency: Bi-weekly updates ensure minimal maintenance when contract terms evolve.
• Enhanced Analytics: Get valuable insights from a unified source. Model and analyze data to conduct “what-if” scenarios on contract changes to negotiate better contracts and confidently enter new markets.
• Compliance Confidence: Transparency and a single workflow lead to improved compliance through enhanced detection and resolution of issues. Focus on delivering exceptional care, knowing your payment integrity is in good hands.

Your organization doesn’t have to turn to disruptive “rip-and-replace” solutions. HealthEdge Source offers a platform access approach that seamlessly integrates with your existing workflow, empowering you with a smooth onboarding process and the ability to scale up as your needs evolve. Our approach ensures your solution grows with you, meeting your needs today and well into the future. With HealthEdge Source, you can embrace a future-proof solution that empowers your confident growth in any market.

Access Comprehensive Support for Medicaid Reimbursement 

Medicaid is a significant segment of the healthcare landscape, and HealthEdge Source can support your reimbursement needs across 19 states (and counting). We go beyond typical inpatient and outpatient Medicaid pricing and payment policies to deliver content that is automatically updated on time to ensure adherence and accuracy.

Investing in HealthEdge Source for Medicaid unlocks several benefits for your health plan:

• Boost Efficiency: No more manual tasks like research and vendor management. HealthEdge Source streamlines your processes so you can focus on what matters.
• Ensure Accuracy: Our thorough Medicaid edits and contract configurations mean fewer mistakes.
• Speedy Payments: 12% of claims are stuck in accounts receivable for longer than 120 days. With Source real-time editing and pricing, claims get processed faster, keeping your members and providers happy.
• Audit Confidence: Stay audit-ready with frequent updates and a robust audit trail. With HealthEdge Source, you’re prepared for anything.

Your Launchpad for Growth in Healthcare

HealthEdge Source empowers you to conquer new markets, seamlessly configure for diverse needs, and navigate change with agility. Our dedication to payment integrity innovation empowers health plans like yours to streamline workflows, optimize efficiency, and reduce administrative burdens – all while delivering exceptional care.

HealthEdge Source isn’t just a payment integrity solution; we’re your trusted partner in driving digital transformation, streamlining automation, and delivering real-time insights. Let’s unlock the potential of your organization – together.

Want to learn more about how your health plan can access valuable analytics and increase transparency? Read our blog, “The Shift to Payment Accountability®: An Enterprise Approach to Healthcare Payment Integrity.”

Read the entire series at the links below:

• Ensure Regulatory Compliance & Cost Transparency
• Improve Payment Accuracy and Efficiency with Advanced Automation
• New Market Expansion — coming soon
• Value-Based Care — coming soon
• Member Engagement — coming soon

As we move through 2024, the healthcare landscape is undergoing a significant transformation. Regulations such as the Transparency in Coverage (TiC) mandate and the No Surprises Act (NSA) are reshaping how payers interact with members and providers.

The Transparency Imperative

The Transparency in Coverage mandate represents a major shift in communication between payers and members. It demands unprecedented levels of clarity regarding cost and coverage, empowering consumers to make informed decisions–with the goal of fostering a more competitive and cost-effective healthcare market.

Protecting Patients from Surprise Bills

The No Surprises Act protects patients from unexpected bills for out-of-network services. Additionally, it establishes a new process for resolving billing disputes and eliminates “gag clauses” that prevent providers from discussing costs with patients.

While each regulation brings its own set of challenges, the underlying goal is clear: to promote transparency, efficiency, and patient empowerment within the healthcare system. For your health plan, navigating compliance with these regulations presents an opportunity to redefine your role and positively impact the healthcare continuum.

How HealthEdge Source Enables Payers to Remain Compliant

At HealthEdge Source, we understand the challenges and opportunities arising from the TiC mandate and NSA. We’re committed to empowering health plans and their members through data and pricing transparency.

Simplifying Transparency in Coverage

Maintaining compliance with the TiC mandate can be an ongoing challenge. This regulation necessitates that health plans make healthcare price information readily available to members before they receive services or incur any charges. The initial phase requires this data to be shared in a Machine-Readable File (MRF).

HealthEdge Source solution adheres to Centers for Medicare & Medicaid Services (CMS) mandates while accommodating your specific needs and system capabilities. With this platform, your health plan can:

• Generate MRFs containing specific rates based on your configurations within the HealthEdge Source system.
• Conveniently schedule and produce MRFs through a user-friendly interface (UI).
• Offer both monthly (as required) and on-demand scheduling choices.
• Calculate rates based on specific services and modifiers, going beyond configuration-based data.
• Incorporate data dictionary updates alongside MRFs to ensure clear data comprehension.

No More Surprises

Price transparency is at the core of our commitment to empowering both you and your members. Our Price Comparison Tool, seamlessly integrated with HealthRules® Payer, allows you to provide members with personalized cost estimates for various services and treatments. This promotes informed decision-making and compliance with both the NSA and TiC regulations.

Furthermore, we simplify compliance with the NSA through the Trial Claims functionality within HealthRules Payer. This feature enables you to deliver required pricing information to members through various channels, guaranteeing transparency and meeting all regulatory requirements.

Introducing the Retroactive Change Manager

As you navigate the evolving healthcare landscape shaped by regulations like the TiC mandate and NSA, ensuring accurate claims processing and compliance remains a top priority. At HealthEdge Source, we tackle these challenges head-on with our groundbreaking tool, the Retroactive Change Manager.

This revolutionary tool streamlines claims processing by automating critical tasks like monitoring, reconciliation, and repricing. This eliminates the risk of missed adjustments and guarantees accurate payments to providers. Additionally, the tool proactively identifies and corrects underpayments and overpayments, minimizing your audit risk.

With a user-friendly single API for managing all aspects of claim pricing, editing, configuration, and policy updates, the Retroactive Change Manager eliminates the need to toggle between multiple systems. This streamlines workflows and minimizes human errors.

By automating critical tasks and ensuring compliance with ever-changing regulations, the Retroactive Change Manager empowers you to focus on what truly matters – delivering exceptional healthcare experiences for both providers and members.

Embracing transparency, efficiency, and automation can make it easier for your health plan to navigate the changing healthcare landscape with confidence. HealthEdge Source is here to partner with you every step of the way. By leveraging our solutions, you can build trust with your members, foster informed decision-making, and achieve compliance with evolving regulations.

Read the entire series at the links below:

• Ensure Regulatory Compliance & Cost Transparency
• Improve Payment Accuracy and Efficiency with Advanced Automation
• New Market Expansion
• Value-Based Care
• Member Engagement

The healthcare industry loses billions of dollars annually due to payment errors, fraud, and overpayments. According to Gartner, 3-7% of all U.S. medical claims are paid incorrectly, with an estimated $100 billion lost to improper Medicare and Medicaid spending in 2023 alone.

With the increasing demands on healthcare resources and increasing costs, payment accuracy and efficiency are the next area of focus for payers. Health plan leaders are adopting modern digital solutions to address payment integrity and continue providing high-quality care to members.

Navigating Challenges in Healthcare Payments

Healthcare payers face numerous challenges that impede the efficiency and integrity of payment processes—negatively impacting their ability to deliver value to members, clinicians, and other stakeholders.

Integrated payment integrity solutions can help streamline claims processes and reduce losses by:

• Automating manual processes to expedite operations and reduce risk of errors
• Updating payment guidelines and regulations to prevent incorrect billing
• Using advanced fraud detection to prevent financial losses
• Breaking down internal siloes with an integrated data system

Achieving payment accountability requires a proactive and collaborative effort to standardize practices, share data, and make the most of digital solutions.

Leverage Integrated End-to-end Automation

Recognizing the inefficiencies in your claims and payment processes is a great start—but your health plan must also take action to stay competitive in an ever-changing healthcare industry. The HealthEdge Source solution is designed to streamline operational workflows and enable payers to accurately, quickly, and comprehensively pay claims the first time.

Source is an interoperable, cloud-based platform that delivers scalability and flexibility. The solution provides users with access to comprehensive content libraries for pricing and editing. It also leverages integrated end-to-end automation, transforming claims management for payers. This translates to a single, unified platform for managing edits, adjudicating claims, and running powerful analytics—all within the Source ecosystem.

Regular Intelligence Updates

Within the Source platform, editing and pricing tools are assessed simultaneously during claim adjudication, driving accurate and prompt decisions. Automatic bi-weekly product updates guarantee your edits and pricing data are always up to date and give your team access to the latest content. Regular updates also ensure decision-making processes are based on the most current data, increasing transparency and first-pass accuracy.

Seamless Integration and Data Interoperability

Source empowers health plans with a single source of truth. All data sources are fully integrated and interoperable within the platform, eliminating the need for juggling multiple systems. With all your data in one place, your plan able to:

• View daily metrics dashboards to analyze utilization and financial impacts on payment policies
• Assess the impacts of claims or contract edits before they go into effect
• Avoid unnecessary overpayments
• Improve provider relations
• Reduce need for manual management and review
• Proactively adapt to policy and rate changes to remain in compliance with shifting regulations

The Source platform is built to seamlessly integrate with your health plan’s existing technology infrastructure. By leveraging open Application Programming Interfaces (APIs), Source bridges the communication gap between electronic health record (EHR) systems, claims management platforms, and other healthcare IT systems.

In addition, the solution can effectively aggregate and reconcile information from disparate sources, including claims, clinical, and administrative. Data interoperability is essential for advanced analytics and predictive modeling—empowering your team to drive payment accuracy and efficiency.

Operational Efficiency and Adaptability

By increasing claims auto-adjudication, Source reduces the need for manual payments and reviews—eliminating bottlenecks and inaccurate payments. As the volume and complexity of claims transactions continue to increase, the solution can scale to meet new demands and help future-proof your operations.

Read the entire series at the links below:

• Automating regulatory compliance and accuracy
• Enabling automation with integration
• Expanding new business opportunities
• Optimizing value-based care & reimbursement 
• Delivering superior customer service 

Leverage a single solution to improve the member experience

The healthcare industry is shifting toward a value-based care approach, pivoting away from traditional fee-for-service models to focus on improving healthcare outcomes and patient experiences. This transformation is powered by cutting-edge technology and innovative platforms—including HealthRules Payer. Our CAPS solution leverages the latest in AI enablement and cloud-based agility, simplifying the transition to VBC for health plans and elevating member engagement.

1. Provide superior customer service with first-call resolution

Nobody has time to be bogged down by playing phone tag or sitting on a call with slow customer service—especially members trying to navigate their healthcare options. HealthRules Payer recognizes this critical need for speed and efficiency. The platform boasts a Contact Center with a first-call resolution rate of more than 90%. This not only reduces member frustration but also boosts confidence in their health plan. By leveraging HealthRules Payer, health plan leaders can ensure their members are not just satisfied but genuinely pleased with the level of service they receive.

2. Make decisions at the point of care with real-time data

Healthcare decisions are too important to be delayed or based on outdated information. HealthRules Payer empowers health plans to make informed decisions at the point of care by providing real-time member data. This ensures that care providers can access the most up-to-date member information, enabling them to make the best possible decisions for patient care. Access to the most current member information streamlines the process and significantly improves clinical outcomes.

3. Enable self-sufficiency for members seeking cost transparency

One of the most significant barriers to satisfaction and improving member engagement in healthcare is the lack of cost transparency. Members often feel left in the dark about potential costs, leading to frustration and a decrease in trust. HealthRules® Payer addresses this issue head-on by enabling self-sufficiency for members looking for accurate cost information. Through the use of intuitive tools and features within the platform, members can easily compare prices and understand their cost-sharing responsibilities prior to receiving health services. This empowerment leads to a more engaged, informed, and satisfied member base.

4. Improve member satisfaction with faster and more accurate claims payments

The timely and accurate processing of claims is a backbone of member satisfaction. Delays or errors can lead to considerable dissatisfaction and can lead to dissatisfied members. By leveraging HealthRules Payer, health plans can drastically improve both the speed and accuracy of claims payments. The platform’s cutting-edge technology reduces manual processing demands, ensuring that claims are handled efficiently and correctly the first time around. This not only improves the operational efficiency of the health plan but also greatly enhances member satisfaction.

As the healthcare landscape continues to evolve toward a more member-focused, value-based care model, the need for innovative solutions like HealthRules Payer has never been more critical. By providing superior customer service, real-time data for point-of-care decisions, enabling member self-sufficiency, and ensuring faster, more accurate claims payments, HealthRules Payer is transforming the member experience. Health plan leaders looking to stay ahead in this dynamic environment will find HealthRules Payer an indispensable ally in their mission to improve member engagement and satisfaction.

Read the entire series at the links below:

• Automating regulatory compliance and accuracy
• Enabling automation with integration
• Expanding new business opportunities
• Optimizing value-based care & reimbursement
• Delivering superior customer service – coming soon

Streamline configurations and improve member satisfaction

The pivot to value-based care is not just a trend; it’s a significant shift necessitated by the urgent need to improve healthcare outcomes and patient experiences. The HealthRules® Payer solution suite can help simplify and streamline the transition.

1. Future-proof your plan with AI-enabled, cloud-based software

The move towards AI-enabled and cloud-based solutions represents a bold step away from traditional legacy systems that don’t always have the flexibility payers need to adjust to the healthcare market. This technological evolution enables health plans to adapt quickly to industry changes and regulatory requirements while also offering a scalable and reliable platform. HealthRules® Payer, with its intuitive design and cloud infrastructure, ensures health plans remain future-proof and ready to tackle challenges head-on.

2. Improve user understanding with the HealthRules Language

One of the most daunting aspects of integrating new technologies into your healthcare operations is the learning curve associated with adoption. The HealthRules Language, with its patented, English-like healthcare-specific vocabulary, addresses this challenge head-on. It democratizes the use of the application, making it accessible not just to IT professionals but also to business analysts, claims examiners, and customer service representatives. This universal understanding ensures seamless communication and operation across all departments, a critical component in delivering cohesive value-based care.

3. Quickly configure new benefit plans and contract arrangements

In the realm of value-based care, flexibility and speed are crucial. Health plans need to rapidly configure new benefit plans and adjust contract arrangements to stay competitive and responsive to market needs. The HealthRules Payer’s core administrative processing system and care management workflow solutions empower organizations to do just that. They enable the quick rollout of new products and benefits without the need for custom code or duplication of effort. This strength lies in the HealthRules Language’s ability to transparently define and manage complex configurations with ease.

4. Share actionable data with stakeholders

Value-based reimbursement models thrive on actionable data. The ability to share this data with stakeholders — from providers to members — ensures that everyone involved in the care continuum is informed and engaged. HealthRules Payer, through prospective payment integrity and enhanced member experience features, delivers precise and timely data. Consequently, health plans can make informed decisions, track performance against key performance metrics, and identify areas for improvement with unprecedented precision.

5. Realize value-based reimbursement & improved customer satisfaction

Ultimately, the goal of transitioning to value-based care reimbursement models is twofold: to enhance patient care and to achieve financial sustainability. With HealthRules Payer, health plans are witnessing real, measurable success in these areas. The platform boasts up to 96% billing accuracy even for claims incorporating complex value-based agreements. This accuracy not only mitigates financial risk but also improves customer satisfaction by delivering clear, understandable billing and benefits information.

The constant shifts in the healthcare industry demand innovative solutions, and HealthRules Payer is facilitating a smooth transition to value-based care reimbursement. Its unique blend of AI-enabled efficiency, the HealthRules Language, and configuration capabilities makes it an indispensable tool for health plan leaders aiming to excel in the healthcare market. By adopting HealthRules Payer, payers can ensure better outcomes for their members and set new standards in healthcare delivery.

Do you want to know more about how your health plan can drive quality performance and hit key benchmarks?

Read our brochure, “Health Plans With Home & Host Capabilities Are Market Leaders” to learn more about HealthRules Payer supports health plans with capabilities like support compliance, claims automation, and rapid implementation.

Read the entire series at the links below:

• Automating regulatory compliance and accuracy
• Enabling automation with integration
• Expanding new business opportunities
• Optimizing value-based care & reimbursement – coming soon
• Delivering superior customer service – coming soon

Adapt to shifting healthcare industry demands with HealthRules® Payer

You know the healthcare market, but you need to compete differently than you have before. Smaller competitors are differentiating their offerings through rapid innovation and adaptability. What they may lack in funding, smaller plans make up for in their ability to test offerings on smaller populations and pivot accordingly. They’re also able to take on more manual work due to lower overall claims volumes.

While being responsible for more lives may mean longer implementation times for new initiatives, larger payers often have the resources to invest in comprehensive solutions and strategies that can help expand their business opportunities. HealthRules Payer, gives your health plan the tools to compete more effectively and grow your market share.

1. Establish new contracts faster

In an industry where timeliness is key, HealthRules Payer shines by reducing the set-up time for new contracts to as little as 10 minutes. This efficiency frees up valuable time, allowing health plans to focus more on fostering relationships with new partners rather than being bogged down by backend administration.

Using HealthRules® Promote, regional non-profit health plan expanded lines of business, and grew from operating in four to 12 states in six years. This achievement underscores the platform’s capacity to not just streamline processes but to amplify growth.

2. Configure (and reconfigure) benefit plans in less time

Create virtually any benefit plan or provider contract and start serving new members sooner. The adaptability to swiftly respond to changing market demands and regulatory landscapes is another critical advantage that HealthRules Payer brings to health plan customers. Or platform enables users to create and adjust benefit plans or provider contracts in mere hours or days, significantly reducing turnaround times.

In 2020, a metropolitan non-profit health plan was able to configure and re-configure benefit plans impacted by the COVID-19 pandemic in about two weeks by harnessing the HealthRules® Language. This feature allowed the payer to meet new regulatory requirements and remain focused on members’ well-being.

3. Personalized strategy support

HealthRules Payer is designed to reflect your plan’s unique needs and ecosystem, offering personalized strategy support that aligns with specific organizational objectives and market realities. The HealthRules® Answers feature empowers your team to better leverage real-time data to identify new opportunities as well as reduce costs, assess new offerings, and support modern digital workflows. Our in-house

This tailor-made approach ensures that solutions are not just effective but perfectly suited to each health plan’s individual context.

4. Easily scale to keep up with membership fluctuations

With HealthRules Payer, scalability becomes an operational advantage, enabling health plans to effectively manage membership fluctuations and achieve enrollment accuracy of up to 97%. This level of precision not only enhances operational efficiency but also supports sustained growth and market competitiveness. The combination of technology, strategic partnership, and experienced configuration teams help ensure health plans like yours can achieve their goals in the most timely and cost-effective way.

Do you want to learn more about how HealthRules Payer can empower your health plan to optimize system configurations and optimize business performance?

Read our Case Study “Configuration as a Service Expedites Time-to-Value for Health Plans” to see how our solution empowers customers to reduce delivery risk, increase quality, and maximize cost-efficiency.

The forum focused on the role of integrated digital health management solutions in driving efficiency, clinical outcomes, and organizational goals by making the most of the resources payers already have. Speakers also discussed the need to embrace the constant change and modernization of the healthcare industry. Health plans across the U.S. are being asked to improve experiences and outcomes without raising costs—and the right digital health solutions can help. In this article, we delve deeper into the discoveries and experiences shared during our exclusive event.

“We need to think about how technology will change our processes to add more value to businesses and customer experiences, and then we have to organize ourselves to change those processes.”

-Steve Krupa, CEO, HealthEdge®

Key Takeaways: We’re being offered the opportunity to change everything we do

The pace of healthcare industry innovation continues to accelerate. Members expect a convenient and personalized experience, regulatory requirements keep shifting, and high-needs populations are growing. Three customer panels stood out for their emphasis on engaging members to improve health outcomes and the member experience.

Address Health Equity Using Digital Care Management

One of the forum’s highlights was a panel led by Dr. Sandhya Gardner, Chief Medical Officer at HealthEdge. Dr. Gardner facilitated a discussion between clinicians from three large regional health plans, who shared how they address health equity among their member populations using digital solutions.

This discussion underscored the benefits of offering digital health management tools to members and care managers. For care managers, integrated digital health tools help improve staff efficiency and make it easier for care managers to identify health equity challenges and social determinants of health. The insights care teams get from digital health solutions enables them to deliver more timely and relevant care that meets members where they are. Digital health tools can also improve the accessibility of healthcare services by giving members a single point of access where they can reach out to care teams, read relevant health and benefits information, and keep track of their health goals.

“What we’re really concerned about are the folks who are working but unavailable to us. They may be shift workers, they may be working overnight, or beyond the hours our regular care managers work. They may have a burner cell phone. All those things lead to disparities. So figuring out ways to reach people through other channels, whatever they may be, is critical to reducing disparities.”

-Vice President of Clinical Operations, Regional Health Plan

Combat Industry Pressure with Integrated Care Management

Healthcare payers are under a lot of pressure—trying to combat rising costs, satisfy regulatory requirements, and increase member satisfaction while trying to stay competitive. In a session with two statewide health plan executives, panelists discussed the role of integrated care management in empowering key member, care team, and health plan stakeholders to achieve their goals. The fusion of digital member engagement and hands-on care management empowers members to take control of their health and make more informed decisions.

Attendees were given an exclusive look into the ways connected care ecosystems enhance operational capacities and forge a more empathetic, responsive culture. A digitally enabled care management approach is particularly beneficial for high-risk populations, like maternity and Medicaid. Plus, demonstrations of the Care-Wellframe solution provided concrete examples of how this technology can be seamlessly integrated into existing workflows, offering a glimpse into a future where healthcare is both high-tech and high-touch.

“Instead of asking our staff to take on the additional cognitive burden of choosing which members to call, we can clearly identify exactly who the members are who have emerging risks. It also gives our members access to a repository of information that they can access 24/7, 365.”

-Chief Medical Officer, Regional Health Plan

Championing Change Management: Best Practices

In a rapidly evolving healthcare landscape, adaptability is key. In one session, leaders from three regional and national payers shared best practices based on their experience with change management throughout the digital implementation process. Earning buy-in from stakeholders and future users can be a challenge. One way to improve adoption and reduce pushback is to build trust with your internal team through transparent communication and early involvement.

Panelists also emphasized the importance of cultivating a company culture that not only adapts to digital innovations but thrives because of them. From workflow optimization to team engagement, the health plan leaders provided a comprehensive toolkit to support successful digital transitions. Most notably, this included the importance of transparency throughout the implementation process. When stakeholders and employees know the “why” behind a change, they’re more likely to feel involved in the solution.

“Once you have team members that understand the value of ‘why,’ and over-communicating the value of ‘why’ so it’s not just sitting with the clinical team, that’s how you gain some traction.” 

-Chief Medical Officer, National Health Plan 

Leveraging AI for Care Management

Discussions about the applications of AI are everywhere. But where can it have the greatest impact on health plan operations? Many AI solutions need more training before they can fully replace manual documentation. But digital health management platforms like GuidingCare® and Wellframe leverage AI algorithms to improve clinical decision-making and member outcomes.

An AI assistant helps improve staff productivity by suggesting message templates, flagging high-risk members, making engagement recommendations, and suggesting next best actions. HealthEdge views AI as a key component of helping our customers become digital payers through transformational consumer experiences and business agility enablement.

“What are you actually trying to use this technology to solve for? Are you trying to save people time, generate insights, proactively take something that took a lot of manual effort and uplevel their skills to work top-of-license? Those are all areas we think are core-value oriented.”

-SVP of Product Management, HealthEdge®

Looking Forward

The 2024 Clinical Leadership Forum was a testament to the power of collective insight and a shared commitment across the healthcare sector to drive positive change. The discussions and solution demonstrations highlighted not only the current capabilities of digital care management, but the possibilities for future innovations.

For health plan executives and healthcare leaders, the forum served as both a call to action and a way to build relationships with leaders at similar organizations. The Clinical Leadership Forum was a powerful reminder that the future we aspire to is not just a possibility but an inevitability if we continue to innovate, collaborate, and lead with empathy and vision.

Learn more about HealthEdge® digital health management and member engagement solutions, visit the GuidingCare® and Wellframe pages on our website.

Read the entire series at the links below:

• Automating regulatory compliance and accuracy 
• Enabling automation with integration 
• Expanding new business opportunities
• Optimizing value-based care & reimbursement
• Delivering superior customer service

Take advantage of end-to-end automation with HealthRules® Payer

In today’s healthcare landscape, the pressure to reduce costs and simultaneously enhance operational efficiency is more intense than ever for health plan leaders. Amidst this complex industry, automation emerges not just as a solution but as a strategic imperative for health plans seeking to invest in. HealthRules Payer is a platform uniquely designed to leverage the power of end-to-end automation to streamline operations and improve efficiency.

By harnessing the automation capabilities of HealthRules Payer, health plans can dramatically reduce administrative burden, streamline redundant processes, and optimize resource utilization. Equally critical is maintaining regulatory compliance in a strict and shifting environment. Through regular, automated updates, HealthRules Payer ensures that health plans remain compliant—significantly mitigating the risk of costly resubmissions.

Leveraging advanced automation will also let your plan reallocate manual resources toward higher-value work.

For health plan executives, the message is clear: leveraging end-to-end automation with HealthRules Payer not only addresses the immediate challenge of cost pressures but also unlocks the potential for strategic growth and sustainability.

1. Improve operational efficiency  

Streamline workflows and create efficiencies by automating the claims adjudication process and saving manual reviews for what matters most. With HealthRules Payer, our health plan partners regularly achieve auto-adjudication rates over 90%, and claims accuracy of 99%.

For one metropolitan non-profit health plan, leveraging HealthRules Payer led to:

• 96% increase in auto-adjudication rate for Medicare claims processing
• 95% decrease in pending claims
• 0 claims aged over 15 days on a monthly basis

2. Increase productivity and transparency

By automating more of the claims review process, your health plan can reduce complexities and administrative burdens associated with manual reviews. Plus, the HealthRules Payer platform is regularly updated with the latest payment regulations to reduce repayments and adjustments—saving time and money. For one customer, automating key processes led to savings of more than $1.6M.

3. Leverage auto reprocessing capabilities

The HealthRules Manager feature within HealthRules Payer allows your health plan to make adjustments based on your specific criteria to reduce reprocessing times. HealthRules Manager also allows users to manage membership, providers, billing and commissions, pricing, cost estimators, pricing transparency, and integrations with care and utilization management tools.

4. Support remote operations with hyper-automation

Accelerate payment accuracy and advanced configurations with integrated end-to-end system automation—what we call hyper-automation. By bringing disparate systems together and controlling information processing this way, your health plan can adapt more easily to industry demands and shifting payment guidelines. HealthRules Payer can integrate with your existing technology suite, as well as HealthEdge Source for payment integrity, GuidingCare® for care management, and Wellframe for member engagement.

Do you want to learn more about how HealthRules Payer can lower production time, reduce errors, and easily build audits across claims environments? 

Read our Case Study, “HealthRules® Promote Empowers Medica Health Plan to Streamline Processes” to see how our solution empowers customers to drive efficiency and quality.”

This blog serves as a summary of the webinar. To listen to the full webinar, visit the HealthEdge Resources section on the HealthEdge website.

A Regulatory Refresher

The Transparency in Coverage and No Surprises Acts have both passed, but the final ruling on how health plans must implement these Acts and how they will be enforced are still evolving. New rulings, such as the Mental Health Parity Act and Advancing Interoperability & Improving Prior Authorization Acts, have emerged, and CMS recently released FAQs to help clarify how health plans must provide personalized cost sharing information for ALL items and services.

The rapidly evolving regulations can feel like a complex puzzle for many health plan leaders. But when you step back and look at the evolution of healthcare policy as a whole, it starts to make a bit more sense. The big picture is all about seeking transparency in healthcare processes and pricing, consumer protection, digital access to information and care, and the different regulations tend to build upon each other.

While these regulations tend to build upon each other, everything is constantly evolving so health plans can no longer respond to individual rules just in time. They must understand where the policies are going and be prepared with the right technology and partners who can help them implement strategies that will support compliance long term.

What We Know: Regulatory Evolution

As regulations continue to be finalized, they seem overwhelming, but they are designed to build on one another, giving payers opportunity to leverage a stepped approach. If we approach them as building upon each other, leaving room for unexpected regulations, it optimizes the ability to successfully prepare, taking one step at a time.

4 Concrete Steps Plans Can Take Today to Ensure Readiness 

Concrete Step #1: Make sure you have the right technology, especially the right core administrative processing system (CAPS) in place and are focused on the right functions for existing and future rulings and implementation guidelines.

Your CAPS technology needs to have the structure that can pull together the right pieces of administrative data and the flexibility to support compliance as guidelines evolve. For example, with the new interoperability regulations, health plans will eventually have to show how many times each patient uses an access API in a year.

To achieve compliance with this reporting requirement, you need to start with a CAPS and a technology partner that can help you thoughtfully set up the access and structure to gather the meaningful data about individual and aggregated patient access. This must be done in a way that can be configured for any required audience or requirement.

1. Benefits administration and member management

1. Ensuringmembers are associated with the right benefits package
2. Properly tracking member accumulators so cost-sharing information is accurate and up-to-date

2. Provider network configuration and management

• Seeking negotiated rates with all providers
• Establishing processes for out-of-network providers so members aren’t surprised
• Maintaining up to date provider directories with complete and accurate information

3. Billing and Data

• Automated billing practices to ensure that members are held harmless under NSA criteria
• Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) application programming interfaces (APIs) to improve the electronic exchange of health care data and streamline prior authorization processes
• Cost-sharing data for all items and services available online

4. Claims Processing

• Processes to avoid, and handle provider disputes
• Processes that build on existing claims workflows, but can generate claims information for AEOBs for members – without triggering a bill or a payment

Compliance can get a bad reputation, because the regulations and changes can lead to burdensome manualized processes. In fact, many CAPS systems require payers to pend claims. But, when you leverage flexibility and configurability within the right structures, you can retain automated processes, minimize pending, pay your providers on time, and remain compliant. Well thought out reporting and analytics can be used to monitor trends, identify trends, reduce access to care issues and ultimately improve outcomes.

Concrete Plan #2: Web-based Price Comparison Tool

According to the No Surprises Act that builds on the Transparency in Coverage Act, health plans must provide web-based and personalized cost information, allowing members to compare prices for different providers and find out what their cost-sharing responsibility will be with respect to current accumulators.

Your CAPS system should have some kind of flexible claims functionality. With HealthRules® Payer, for example, plans can call for current accurate data into basically a ‘practice’ claim without triggering an adjudication.

This is a big deal, because in most claims processes, going through the process of pulling provider and member data together would automatically trigger a payment process. And, if plans try to work-around NOT using the claims system, they can’t get the same level of up-to-date accuracy. This is important because not only does provider pricing change, but member accumulators change every time they contribute to their deductible or out of pocket max.

While the regulations relating to this requirement were passed quite a while ago, just last month, in February, more detail was released.

This is another example of how plans can take a phased approach for evolving regulations by establishing and auditing this type of a tool also gives a good opportunity to see if there are any billing/benefits changes needed for your plan to meet parity guidelines, i.e., mental health co-pays are equivalent to physical health.

Similarly, interoperability and the prior authorization enhancements will rely not only on accurate data, but the ability to assemble the data into a meaningful story.

Price Transparency Snapshot

Challenge: Provide a web-based service for members to compare pricing for specific providers with respect to their current plan and accumulators

Solution: A CAPS system with flexible claims functionality will help health plans produce accurate claim adjudication details that include member responsibilities regarding:

1. Provider-specific payment/contract terms and fee schedules
2. Member benefit plan data
3. Member cost sharing based on accumulators at the time of trial claim adjudication

With the right technology, health plans can aggregate member-specific, provider, and service details according to accurate (not estimated) claims data. There is also CAPS technology available to connect this data to web-based member tools (e.g., member portals) so members can access cost information at any time and platforms through which customer service representatives can provide member-specific price comparisons to support member price comparison questions via phone.

Concrete Step #3: Advanced Explanations of Benefits (AEOB)

The Advanced Explanations of Benefits (AEOB), a key requirement introduced by the Consolidate Appropriations Act of 2021, is still pending. Guidelines are in development, with an RFI concluding last year. The AEOB will be triggered when a provider notifies the health plan that services have been scheduled, using a good faith estimate. Health plans must be able to respond with cost sharing based on that good faith estimate, which will include estimates from all providers involved in the scheduled service or procedure.

Payers need to make sure their CAPS system is prepared to meet regulations using a trial feature merged with existing EOB processes. The key piece here, again, is that they can use existing platform functionality and up-to-date, accurate information without triggering a payment.

If the scheduled service is with an out-of-network provider or facility, the EOB will note that and use qualified payment amounts to provide the anticipated cost. Plans may also have to recommend an in-network alternative to members on the AEOB.

AEOB Snapshot

Challenge: Prepare to meet AEOB requirements according to forthcoming rulemaking and implementation guidelines

Solution: A CAPS system with flexible claims functionality will help health plans aggregate details related to service codes and provider types, including:

1. Individual services costs
2. Episodes of care costs
3. Individual member-level details, including current accumulator data

With the right technology, health plans can generate anticipated claims payment detail in advance of a scheduled service. A full claims adjudication process takes advantage of all configuration details, calculating accurate – and not estimated – costs without triggering a payment.

Existing CAPS features generate EOBs for configurable and automated distribution that can be combined with the detail generated by the trial claim.

Concrete Step #4: Payer to Payer Data Exchange

Health plans using HealthRules Payer already meet the required relevant standards for this regulation, including:

• United States Core Data for Interoperability (USCDI)​
• HL7® Fast Healthcare Interoperability Resources (FHIR®) Release 4.0.1​
• HL7 FHIR US Core Implementation Guide (IG) Standard for Trial Use (STU) 3.1.1​
• HL7 SMART Application Launch Framework Implementation Guide Release 1.0.0​
• FHIR Bulk Data Access (Flat FHIR) (v1.0.0: STU 1)​
• OpenID Connect Core 1.0

Because we focus on regulation all day every day, we are also prepared with recommended implementation guidelines, such as:  ​

• HL7 FHIR CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) IG Version STU 2.0.0
• HL7 SMART App Launch IG Release 2.0.0 to support Backend Services Authorization

These implementation guidelines will also help health plans prepare for the upcoming prior authorization, such as:

• HL7 FHIR Da Vinci Documentation Templates and Rules (DTR) IG Version STU 2.0.0​
• HL7 FHIR Da Vinci Prior Authorization Support (PAS) IG Version STU 2.0.1​

Payer to Payer Data Exchange 

Challenge: Payer to Payer Data Exchange has been expanded. The original set of requirements were deferred, and now there are structure and implementation guides for January 2027. This criteria includes HL7 and specific implementation guides.

Solution: A CAPS system and technical partner with the expertise to apply implementation guides for meaningful results

1. Leverages existing technology for new Payer to Payer Data Exchange meeting Required Standards with the expertise to recommend the right implementation guidelines
2. Creates meaningful information by sending and receiving the right data elements in the right configuration to ensure transparency and continuity of care for members

Key Takeaways

Regulations require us to understand the compliance requirements and the intention of each rule, how it relates to the current state of the business process, and how it impacts both the upstream and downstream processes. Each rule dives into the “why,” and health plans should seek to collaborate with technology partners to create solutions that support the requirement.

1. New regulations build on recently passed regulations; a stepped approach will help payers stay on top of the evolution. Stay on top of all types of communication such as changing enforcement dates, FAQs, guidelines, etc., not just final rulings.
2. Cost transparency and the proposed mental health parity regulations build toward consumer protections and updated data exchange methods. Make sure you have the data and analytics established to report on pricing for the Parity regulations. Be sure to pull your reports well in advance of the January 2025 enforcement date so you can identify and adjust any non-compliant pricing issues.
3. The right CAPS will have the structure and configurability that help health plans prepare for and adapt to ever-evolving regulations. Make sure you have the right CAPS technology and are focused on the right functions for existing and future rulings and implementation guidelines. Your CAPS needs to have the structure that can pull together the right pieces of administrative data and the flexibility to support compliance as guidelines evolve. Plans will not be able to meet the evolving regulations without technology that can ensure compliance and automation.
4. Keep the big picture in mind and look for the next-best step that works for your health plan. Make sure your CAPS technology meets required standards for upcoming interoperability and prior authorization regulations. Ensure you have a good technology partner who can help you start to plan your implementation guidelines and start planning now.

To learn more about how HealthEdge solutions can help your organization navigate the evolving CMS regulations, visit www.healthedge.com.

Read the entire series at the links below:

• Automating regulatory compliance and accuracy
• Enabling automation with integration – coming soon
• Expanding new business opportunities – coming soon
• Optimizing value-based care & reimbursement – coming soon
• Delivering superior customer service – coming soon

Simplify regulatory compliance with HealthRules® Payer

Healthcare payers are facing pressure from all sides, with high member expectations, regulatory changes, staffing shortages, and rising costs among the top challenges. Many health plans are turning to digital transformation to gain a competitive advantage and better serve their members. A Core Administrative Processing System (CAPS) that meets these needs is one of the most significant investments your health plan can make.

HealthRules® Payer (HRP) is a modern CAPS solution that automates compliance regulation, enabling you to streamline existing workflows and respond to new opportunities in real-time. Using HealthRules Payer, your teams will spend less time manually adjusting payments—streamlining the claims editing process and making it easier to save money on retroactive changes. Regulatory compliance can also improve Star ratings, with 4.5-star health plans having a 5% revenue advantage over 3.5-star plans.

As an organization, HealthEdge® is dedicated to simplifying regulatory compliance and transparency through innovative solutions. For HealthRules Payer, that includes features payers need to maintain efficiency while satisfying the demands of members, providers, and regulators.

1. State and federal legislation monitoring 

HealthRules Payer continually monitors federal and state-level legislation across Medicare, Medicaid, and Commercial lines of business. This information is automatically updated within the system to ensure regulatory compliance and reduce the need for manual editing and resubmission. HRP customers regularly achieve auto-adjudication rates of more than 90%—and financial accuracy up to 99%.

Healthcare payers rely on HRP to automate regulatory compliance so they can focus on larger organizational goals.

2. Compliance-based strategic planning 

The intentional design of HealthRules Payer makes it easy for users to access the information they need to develop a comprehensive strategy. Customers can leverage controlled and comprehensive modeling of new product designs and provider pricing methodologies based on specific business rules and compliance programs. With HRP, health plans can establish modeling during employer negotiations, leading to quicker turnaround of new product offerings, better customer service, and increased sales.

3. Reliable collaboration and support 

Customers working with HealthRules Payer receive personalized support. Health plans can vet their support strategies with the HRP Steering Committee, as well as hold monthly meetings to assess progress toward key business goals.

For the third year in a row, HealthRules Payer was named “Best in KLAS®” for Claims & Administration Platforms. In the KLAS survey of existing HRP customers, 100% of respondents said HealthEdge solutions are part of their long-term plans.

4. Cloud-based delivery model 

A cloud-based repository makes it possible for health plans to communicate strategy and compliance artifacts within HealthRules Payer while tracking an annual+ roadmap of compliance initiatives. Cloud-based solutions also facilitate real-time integrations with third-party systems, leading to more cost-effective and lower-risk IT ecosystem maintenance. In addition, they offer continuous monitoring, remediation, and patching to free internal IT teams to focus on higher-value objectives.

Companies using cloud services are held to rigorous security and confidentiality standards, meaning member protected health information (PHI) and sensitive payer data are guarded.

Do you want to learn more about how HealthRules Payer can help your health plan stay compliant with the No Surprises Act and other regulations? 

Read our data sheet, “Navigating the No Surprises Act: The Right Tools for Health Plan Success” to see how our solution empowers customers to increase auto-adjudication, give members personalized cost-sharing information, easily configure out-of-network services, and more.

As a next-generation SaaS company, HealthEdge provides an integrated ecosystem of advanced solutions for core administration (HealthRules® Payer), payment integrity (Source), digital care management (GuidingCare®) and member experience (Wellframe). Our solutions enable health plans to leverage new business models, reduce costs, and improve clinical outcomes across member populations.

We firmly believe that maintaining product quality is a collective effort that extends beyond our quality engineers (QEs). HealthEdge’s Customer Satisfaction (CSAT) survey helps us measure the quality of the products we deliver to our customers—and how that affects their satisfaction. Used across industries as a key performance metric, CSAT score is based on a survey that asks customers how likely they are to recommend a product or service.

A culture of continuous improvement

Our approach to product development and innovation centers on delivering a high-quality digital solution that makes it easier for our customers to achieve their business goals. As an organization, HealthEdge is committed to continuous improvement, establishing quality standards and training to ensure consistent understanding and application of quality standards across the company.

The Quality Center of Excellence (QCoE) instills a culture of quality across scrum teams by adhering to industry standard testing practices and tooling. Some of the factors in this process include:

1.    Automation – first approach to product development and innovation

2.    Rigorous testing and quality checks

3.    Proactive issue identification

4.    Software development and feature planning

5.    Continuous integration and delivery

Automation-first approach to product development and innovation

HealthEdge utilizes an automation-first approach.

• Product developers ensure unit and integration testing is in place before code is merged (Test Driven Development).
• Quality engineers extend and create automated tests in close coordination with developers to ensure complete test coverage.

A robust automation suite ensures all functionality is automatically tested. This further allows additional manual testing efforts to focus on corner cases, sanity testing, and the user experience.

Rigorous testing and quality checks

HealthEdge products must pass several quality checks—including build, unit, integration, database verification, production transaction test (PTT), system integration test (SIT), static code analysis and performance testing—before reaching any customer environments.

Builds are triggered automatically for feature branches. Targeted integration tests including unit tests, integration, and static code analysis are run before any code is merged. Once these initial checks have passed, the code is merged. This triggers more complete and extensive sets of tests in downstream jobs. Multiple jobs, including Commit, DB verification and migration, Integration, PTT, SIT jobs, are run as part of continuous integration.

6. Once these jobs are successful, the distributions are made available to the Cloud Operations (Cloud Ops) team and for self-hosted customers as needed.

7. Cloud Ops and Customer Service Managers (CSMs) work with clients to schedule and deploy releases into SaaS (Software as a Service) lower environments where Post Deployment Verification (PDV) and Functional tests are run.

• Once all PDV and Functional tests are completed in one-to-many lower SaaS environments and in conjunction with testing from customers QA team, deployment is made to production and final sanity checks are performed

Proactive issue identification

The HealthEdge testing methodology is centered around proactively identifying issues, conducting thorough and detailed testing, bridging the gap between our team and customers, and consistently delivering the highest quality possible.

This structured approach aligns with industry standards, defining the precise automation of tests and their optimal execution environments. It serves to foster collaboration and understanding across the HealthEdge organization, emphasizing a commitment to comprehensive excellence and quality delivery.

The specific definitions are as follows:

• Unit Testing.
  • Validate individual components in isolation.
  • Ensure each unit functions correctly according to specifications.
• Integration Testing
  • Assess the interaction and collaboration between different components.
  • Identify and address issues related to the integration of modules.
• Functional Testing
  • Verify broader functionalities of the system.
  • Confirm that features work as intended from an end-user perspective.
• System Testing
• Examine the installation and verification of End-to-End system.
  • Upgrade time Quality Gate:
    • Identify database migration changes that cause long delays in the OLTP upgrade earlier and move the long-running scripts into either pre-migration or post-migration upgrade steps.
    • Detect and resolve any database migration errors discovered during upgrade testing.
  • Quality Criteria
    • Quality criteria ensure Functional Readiness, Interoperability & Compatibility, Serviceability, Performance & Scalability are validated for every release.
  • Production-like Testing
    • Creates a test environment that closely matches production for various customers.
    • Batch and UI Transactions are measured from version to version to detect any performance degradation.
    • PTT claims adjudication results are also compared against known results and detect any differences within a customer-like environment.
    • System Integration Testing on selected customer-like environments.
    • Specific feature testing on customer data.

Software development and feature planning

HealthEdge understands that quality is a driving force for software vendor selection. That’s why it is an integral consideration at every step of the software development lifecycle (SDLC). The following diagram highlights how we put this into practice—from feature planning through release.

Feature prioritization and planning

New features undergo a prioritization process, led by the product owner, before they are introduced for discussion within the scrum team. The product owner evaluates features based on their business value and the specific customer problems they address. Subsequently, the planning team engages in discussions to further refine the required functionality. As the requirements become better understood, the team then makes an estimation of how many story points this feature will take to complete .

Together, the team covers the following:

• Acceptance criteria
• Design Considerations
• Product Integrations
• Functional and non-functional testing (ex. performance & security)
• Story Point Estimation
• Documentation

Bug prioritization and planning

Bugs undergo a prioritization process, led by the product owner, before they are introduced for discussion within the scrum team. The bug fixing process allows issues to be scheduled and fixed on a predictable schedule.

Sprint planning

At HealthEdge we follow industry-standard, best agile practices, with sprint planning being an essential component. During sprint planning, features and bugs that are ready to be developed are added to the scrum board. The team then sets the assignments based on their historical completion rate (velocity).

• Feature Tickets: Features are discussed, broken down and tasks are created per assignee.
• Bug Fixes: Bugs are discussed, broken down and tasks are created per assignee.

8. QA only tickets: Where needed, performance and automation related stories are created and assigned to appropriate resources.

Feature test driven development

HealthEdge practices test driven development, where tests are written before the feature is coded. Subsequently, the code is written until the test passes. When the developer believes their feature is complete, a subset of tests is run to provide fast feedback and, if these tests pass, the code is merged automatically for downstream testing.

• Feature Grooming: Technical grooming sessions are conducted after business grooming is complete. This is a review of functional and technical aspects of the tickets in the backlog to verify they are complete and ready for development.
• Feature Development: Development team starts the design and architecture from the acceptance criteria listed by Product Owners in the ticket.
• Writing Unit & Integration Tests: Tests are written to validate key acceptance criteria for the feature.

9. Code Review: Once the above steps are complete, the code review will be done by subject matter experts (SMEs) to check that all standards and code coverage are followed.

Quality Assurance testing

Quality Engineers (QEs) write end-to-end tests and review them with the SMEs and Product Owners before execution. During execution, functional, regression, and impacted areas are covered as part of the testing. Additionally, QEs test specific tickets and features in customer-like environments when possible

• Research quality knowledge base: QEs investigate the internal quality knowledge base for existing functionality before preparing the test plan document.
• Test cases writing and review: QEs start writing the test cases based on acceptance criteria listed in the ticket. The test cases are reviewed with Product Owners and Development Leads. In some cases, test cases will also be reviewed with the client.
• Test environment setup: QEs set the test environment to the feature branch to test the above-mentioned test cases.
• Functional verification: During this phase, functional verification of test cases is completed, and any unexpected results will be raised.
• Writing integration tests: QEs contribute towards writing integrations test along with development team.
• Automation tests: QEs write automation scripts for all regression test scenarios.
• Customer data testing: QEs do a final round of testing in the customer–like environment to make sure the features work without any issues.
• Bug bash: Collaborative testing event on critical features that brings together QEs, Developers, Product Owners to “bash the product” to expose bugs.
• Customer demonstration: When the ticket is ready, a functional demo is given to internal stakeholders to make sure the acceptance criteria is covered.
• Functional demonstration: Demonstrations are also given to customers to further confirm expected requirements are met.

Continuous integration and delivery

Continuous Integration

At HealthEdge, we use a continuous integration workflow to ensure we create and test high-quality products quickly, securely, and efficiently. This workflow allows us to implement quality and security checks for every check-in. For quality checks, we run tests to provide rapid feedback. If there are test failures, developers are blocked from checking in additional changes until tests are passing again. For security checks, we leverage static code analysis and report any security vulnerabilities.

Types of Tests

• Unit Tests: Tests that focus on validating a very specific piece of code.
• Integration Tests: A comprehensive suite of product regression
• Database Verification Tests: Tests that verify new database schemas match upgraded database schemas.
• Production Transaction Tests: Production Transaction Tests use customer data and configuration to do A/B testing from one version to another and report any claim adjudication differences.
• System Integration Tests: System Integration Tests use customer data for specific test scenarios.
• Static Code Tests: Automated tools are used to identify code coverage, code violations, bug leakage, duplication on code, code smells, and vulnerabilities.
• End To End Tests (E2E): During System Testing, multiple products are installed together, and roundtrip tests are executed to confirm end to end processing.
• Database Migration Tests: Specific versions are selected based on expected paths a customer will take to ensure that the database migration scripts are successful.
• Performance Tests: A dedicated, production-grade system where key metrics are measured and compared from version to version to ensure that performance has either improved or not degraded.

Release Readiness

For every product release, HealthEdge Quality team follows a stringent Quality Criteria which comprises of below checks followed by a Go/No-Go meeting before giving a release sign off.

• Functional Readiness
• Interoperability & Compatibility
• Serviceability
• Performance & Scalability
• Stabilization Period Evaluation
• System Integration Testing (SIT)
• Data Migration Testing
• Real World Data Testing – Production Transaction Testing (PTT)
• Testing Improvements

Continuous Delivery

HealthEdge follows Continuous Delivery practices to deliver fully tested releases ready for customer environments through a general availability (GA) or a release candidate (RC) program. GA releases are available to all customers. The [VS31] Release Candidate (RC) program allows participating customers to test features and provide feedback within a defined 4-week window prior to GA.

Deployments in SaaS environments are scheduled into customers’ lower environments first and then, upon successful acceptance testing, releases are deployed into production. Post Deployment Verification (PDV) checks, User Acceptance Tests (UATs) and Functional Tests provide the necessary quality checks for each environment before code is promoted to the next environment. HealthEdge Customer Service Managers (CSM) and Cloud Operations (Cloud Ops) members work closely with clients and follow specific protocols for each deployment to ensure there is no negative impact to the customer experience.

Production monitoring

At HealthEdge, the Incident Management team uses AppDynamics to monitor hosted customers, and proactively views and escalates issues affecting performance. This allows us to maintain system availability, enhance the user experience, and resolve issues as soon as possible. Monitors are set up to continuously check metrics and alert the Incident Management team when critical shifts occur, allowing them to act quickly to resolve the issues.

In Summary

We truly believe that simplification and standardization have biggest impact on Quality. The above-mentioned practices lay a sturdy groundwork for our quality program. QCoE team ensures stringent quality criteria are met for releases and monitors Objectives and Key Results (OKRs) to gauge whether quality is trending in the right direction.

Authors: David Price, David Tauer, Karthikeyan Thirugnanam, Nischal Kondareddy, Rahul Jain, Sanchit Chavan

Some of the market forces shaping health plans’ priorities include:

1. Retail experiences shape consumer buying behaviors. Consumers expect a digital experience like online shopping and prefer healthcare services that provide virtual scheduling, services, and information access. They’re also looking for access to comprehensive information about healthcare quality and prices.
2. New entrants in healthcare bring innovation and enhanced services that elevate consumer expectations. New entrants in healthcare, including consumer-focused retailers, startups, and innovative care models, use digital technologies to improve the patient experience and fill gaps in the current medical infrastructure. They encourage innovation in care delivery and refine the consumer experience while bringing increased competition.
3. Growing participation in Medicare Advantage and individual marketplaces. Medicare Advantage enrollment increased steadily over the past two years, with over half of the eligible Medicare population opting for coverage. In 2022, the average MA beneficiary had access to 39 plans. The individual marketplaces have also seen insurers expanding their service areas, with the Accountable Care Act marketplace reporting over $16M members and an average of five insurers per state.
4. Regulation requirements evolve quickly, now with penalties. Healthcare regulations in the U.S. are constantly changing due to legislative mandates, administrative updates, and market trends. These changes make it challenging for health plans to keep up and result in increasing fines for non-compliance. While regulations aim to improve health coverage, consumer demands increase competition and require adaptation costs for health plans.
5. Availability of data and maturing interoperability standards. The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) set specific API requirements that help improve access to health records for patients, providers, and payers. This enhances data sharing, improves care quality, and increases competition among health plans. However, achieving interoperability is complex due to differences in data standard implementation in legacy platforms, which slows down progress toward compliance.

HealthEdge Accelerates the Journey to Becoming a Digital Payer and Achieving Transformational Outcomes

Our conversations with healthcare leaders focused on solutions and opportunities amid mounting industry disruption. Many payers are already unlocking transformational outcomes through HealthEdge solutions, anchored by its modern Core Administrative Processing System (CAPS), HealthRules® Payer.

Recently, CAPS modernization has surged to the forefront of funding priorities. In 2023, 59% of payers prioritize allocating resources to CAPS, a significant leap from the 17% reported in 20221. This shift underscores the urgency and strategic importance of enhancing consumer experiences and streamlining operations. Here are a few examples of how health plan leaders benefit from HealthEdge solutions to support their digital payer journeys:

1. Remaining agile, adaptable, and accurate in an ever-evolving regulatory landscape. HealthRules Payer addresses the rapidly evolving regulatory landscape by enabling health plans to adjust claims processing rules or modify payment protocols quickly and easily to ensure timely compliance. When regulations are updated retroactively, HealthRules Payer facilitates revisiting claims, ensuring compliance, and making necessary adjustments.

“HealthRules Payer helped our Medicaid group transition from a legacy platform where auto adjudication was significantly lower. Using the English-based configuration rules allows us to make significant changes relatively quickly and, as a result, improve auto adjudication and ultimately improve payment accuracy by eliminating the human factor in determining what needs to happen with a claim.”

Senior Vice President of Medicaid Operations at National Health Plan

 

2. Enabling automation and accuracy at the core of every process and workflow. The evolution of health insurance technology moved from initial integrated systems—which aimed for functionality consolidation but struggled with adaptability—to a best-of-breed approach that adopted specialized software, offering greater expertise and flexibility. However, this approach led to challenges integrating care management software and claims processing due to siloed functions, complex integration, and vendor fragmentation.

Today, health plans look to modern solutions that offer the efficiency of specialized applications and the seamless integration of a single vendor’s ecosystem, providing key advantages such as controlled integration. As the HealthEdge solution portfolio races toward integrated end-to-end solutions, barriers are coming down. This is allowing health plans to take full advantage of a best-of-breed approach while benefiting from a cohesive ecosystem. In addition to productized integrations between HealthEdge solutions—HealthRules Payer, HealthEdge Source payment integrity platform, GuidingCare® care management platform, and the Wellframe member experience platform—HealthEdge products themselves support an integrated end-to-end approach with numerous modules that are purpose-built.

“We outperformed our commercial platform within several months. Our Medicare business has been on a steady climb. When we launched it, we were expecting an auto adjudication rate of about 50%. But at the start, we actually hit 65% and very quickly got up to 82% or 83%, where we are right now. Our end users have grown, and we currently have over three million members on the platform.”

Executive Director, Product Management and Development, National Health Plan

3. Improving payer-provider collaboration on healthcare administrative spending and waste.  In 2020, health spending in the United States reached approximately 20% of the country’s gross domestic product. However, at least half of administrative spending is deemed wasteful. Collaborative efforts between payers and providers are essential to healthcare payment integrity and optimizing revenue cycles.

HealthEdge’s technology fosters collaboration and efficiency while addressing fraud and waste in healthcare. HealthRules Payer empowers health plans by streamlining administrative processes, enhancing efficiency, and ensuring accuracy. At the same time, Source revolutionizes claim payment through proactive business intelligence that prevents improper payments, saves time, and minimizes recovery efforts. With AI-enabled fraud detection, HealthEdge’s capabilities combat fraudulent claims, safeguard payer resources, and improve care outcomes.

“The health plan value proposition is losing, and the provider value proposition is being threatened by new entrants. Companies are either acquiring or incubating digitally focused healthcare start-ups or monetizing existing health plan platforms (analytics, claims processing, care management, sales, and marketing) by selling them as a service to other payers or into the emerging risk-bearing provider market. The demand for integrated end-to-end advanced automation across traditional payer and provider functions enables automation and accuracy at the core of every process and workflow.”

Leading Industry Analyst of Payer IT Strategies

4. Market expansion to beat the competition. The health insurance landscape in 2024 has significantly transformed, with new market expansion driving competition and growth. Providers have adapted to changing consumer preferences and the evolving competitive landscape. In this new consumer-focused era, health plans must appeal to diverse populations with unique needs, requiring flexibility and quick decision-making. With 62% of health plan leaders investing in digital transformation, modern systems such as HealthRules Payer are critical for supporting growth plans. To meet the demands of this new market paradigm, payers leverage modern technology in key areas like rapid benefit package creation, digital care management, and ASO arrangements.

“We use technology to solve the problems that you’ve had to solve for the past 30 years differently so you can go to market faster. So you can get to trends faster. So you can win new business faster.”

Alan Stein, Chief Product & Strategy Officer, HealthEdge

5. Managing and supporting Value-Based Care (VBC): The healthcare industry has shifted from a fee-for-service model to VBC, which aligns the interests of patients, providers, and payers by introducing financial incentives for healthcare providers to ensure patients stay healthy. As of 2023, 90% of CMS payments are linked to value, with 40% flowing through alternative payment models. However, fee-for-service arrangements persist. Many legacy systems cannot support this transformation, so the move to software solutions such as HealthRules Payer, which can support value-based care, is essential.

“Being a digital health plan for Highmark’s Medicaid segment means we are no longer in the era of calling our members between the hours of 9 and 5. They want to interact with us on their terms when they are available, whether through apps, portals, or web content. We have to meet the members where they want to be met. Highmark’s Medicaid members are looking for the Amazon experience. They want it simple.”

Senior Vice President of Medicaid Operations, National Health Plan

6. Exceeding member engagement expectations by providing a digital healthcare experience. Today’s healthcare consumers expect convenient and engaging experiences from their health plans. Therefore, payer leaders must adapt by offering self-service mobile tools and greater pricing transparency. Regulatory developments like the Transparency in Coverage Act and CMS’ Star Ratings changes emphasize the need for a strong focus on member experience.

In fact, two recent studies (the 2023 Consumer Satisfaction Survey of nearly 3,000 healthcare consumers and the 2024 HealthEdge Annual Market Report of 350+ health plan leaders) speak to this urgent need to focus on the member experience. Consumers expect health plans to leverage social determinants of health (SDOH) data to deliver more personalized services relative to their experiences. Customer service and self-service tools have emerged as top satisfaction enablers, along with a plan’s ability to adhere to members’ communication preferences.

“As a consumer, I focus on things that are important to me. When I am trying to order prescriptions or looking at lab results, what I would expect as a consumer is to have the right price, the right information about my quality of care, my claims, and my out-of-pocket expenses. Consumers feel the same way. It’s important that we give our members the same type of transformation to have access to a lot of good information, timely information, and quality information at their fingertips. We use HealthRules Payer, agile applications, and our network providers to make sure that the product is not only timely but also accurate.”

Vice President of Operations, Regional Health Plan

The Road to Becoming a Digital Payer

Digital transformation is a marathon, not a sprint. The critical steps in the change management and implementation process include:

• Defining Success: Clearly outline your goals and objectives.
• Plan and Prepare: Strategize and lay the groundwork.
• Design for the Future State: Create solutions that align with your vision.
• Build According to the Plan: Execute your strategy.
• Monitor KPIs: Track how you’re measuring against key performance indicators.
• Optimize and Customize: Continuously improve and adapt.

By automating business workflows and seamlessly exchanging data in real-time across the ecosystem, health plans deliver improved member experiences, increased quality, greater business transparency, ever-reducing transaction costs, and increased service levels. Through collaboration such as HealthEdge’s Leadership Forum, the company and health plan leaders are teaming up to ensure a path to success.

To learn more about how HealthEdge solutions can support an integrated end-to-end approach to your enterprise, visit www.healthedge.com.

The future of payment integrity is shifting towards Payment Accountability®, an enterprise-wide approach that brings together different business units to increase focus on measuring cost avoidance instead of just recovery. Payment accountability emphasizes creating transparency to address root cause inaccuracies so that payers can pay claims accurately, quickly, and comprehensively the first time.  

Industry experts claim that this enterprise-wide approach can reduce medical expenses by 10% or more, with the potential for significant reductions in administrative expenses. An enterprise approach to claims adjudication can shift processes upstream, solve root-cause issues, increase accuracy, and reduce provider abrasion.  

The Source Approach to Payment Accountability 

HealthEdge Source (Source) was specifically designed and intentionally built to enable payers to allow health plans to insource more functionality, derive valuable analytics, and increase transparency and interoperability.  

The Source platform, to meet evolving market demands, is focused on the following core areas: 

• Real-time integration expansion: Seamless integrations with third party solutions that expand payment integrity and reimbursement offerings and reduce the administrative burden on clients using multiple vendors. 
• Continued content expansion: To deliver added automation, savings, and accuracy, including additional Medicaid, Medicare, Cost Containment, and other specialty edits and pricers. 
• Improved accuracy: By including additional validating datasets such as prescriptions, medical records, and others. 
• Adoption of AI/ML technologies: To automate and/or assist manual and tedious workflows. 
• Efficient workflow and best-in-class user experience: Through self-service tools like policy creation, implementation, and management. 
• Creating insights for data-driven decisions. 

But the team doesn’t stop there. Our product investment strategy includes a multi-year roadmap focused on enhancing the content, features, and technology to drive continuous improvement in the solutions we deliver. We’re currently piloting an AI-enabled chat bot that allows users to type questions in natural language regarding the Source edits, pricers, functionality, and other capabilities. This results in quick and accurate responses, freeing auditors or provider relations team members from scouring through multiple user guides, worksheets, and other materials. The chatbot can provide the necessary information in seconds.  

Additionally, Source is streamlining the process of managing configuration by utilizing APIs to create, manage, and publish edit changes to production. This process reduces the need for manual user intervention, allowing the payment integrity and configuration team members to focus on other critical business tasks. 

A Guiding Hand from the Payment Integrity Experts 

Source experts are available to participate in a Payment Integrity Health Check as part of the implementation process. This helps our team gain a better understanding of your current processes, data, and internal expertise so that we can work together efficiently and provide a solution that enhances your health plan’s strengths and aligns with the long-term payment integrity goals. Source experts will also work with our customers continually after go-live, to review data and identify areas that can add value to your payment integrity program. 

Post-implementation, Source maintains close partnerships with our clients. We gather feedback and input on our product roadmap in many ways, such as conducting 1:1 user research and design sessions with the product and engineering teams, monthly user groups, semi-annual customer advisory boards, regulatory steering committees, bi-annual virtual customer events, and annual client conferences.  

From Payment Integrity to Payment Accountability 

At Source, our solution aims to redefine payment integrity by shifting the industry from a black box to an open-book approach. Unlike traditional payment integrity solutions that often operate retrospectively and give limited intelligence to health plans, Source is designed to deliver transparency in editing solutions. Our goal is to empower payers with technology that enables them to gain control of their IT ecosystems, address root-cause issues, and reduce waste in the healthcare system.  

Source accomplishes this differentiation by providing the following unique features:  

• The ability to configure contract reimbursement terms, edit and price claims, and run analytics in a single call to Source. 
• Extensive editing and pricing content libraries that are out of the box and always up-to-date and accurate through our two-week update cycle. 
• Configurable and customizable edits to make pre-payment claim decisions based on a health plan’s intellectual property. 
• Real-time analytics to monitor utilization and financial impacts of edits prior to enabling their impact in the live adjudication workflow. 
• Claims pricing based on negotiated fee schedules, including CMS and Medicaid methodologies, to ensure edits and reimbursement are accurate prior to adjudicating the claim. 
• Continuous member claims history analysis by the Source team to recommend new edits that solve recurring post-payment issues.  
• Integrated third-party content within the solution to improve accuracy, promote higher and faster automation, simplify workflows and vendor contracting, and keep all data in a single location. 

To learn more about how Source can help your organization successfully make the shift to payment accountability, visit the Source webpage.  

4 Unique Features of the HealthEdge Provider Data Management Solution 

Many PDM tools available on the market are disjointed, characterized by using assorted point solutions and custom-built systems among health plans. The HealthEdge Provider Data Management solution offers unparalleled features that set us apart, such as: 

• Provider Master Identifier: Allows health plans to uniquely identify providers and organizations, tailoring to specific business needs and requirements. 
• Data Mastering with Prebuilt Match and Merge Rules: Match-merge survivorship rules adeptly manage and maintain data from diverse channels, addressing and resolving conflicts efficiently. 
• Low or No Code Framework: Leveraging a generative AI-enabled framework, the PDM enables easy setup, source channel mapping, and configuration of downstream consumer systems with minimal coding effort. 
• Observability Dashboard: Offers a transparent view of provider data with valuable insights into processing status, duration, and data quality. 

Access the Full Value of Provider Data Management 

The HealthEdge Provider Data Management solution ensures no data loss, offering 100% coverage for provider demographics, user-defined types (UDT), and benefit network data. It also supports real-time provider Application Programming Interface (API) services for addressing any discrepancies in provider information. Our team ensured the PDM solution is highly configurable, aligning with customers’ master data identification as defined in HealthRules® Payer (if applicable). This enables your organization to streamline processes to enhance automation while reducing overhead costs and inefficiencies. 

3 Features that Enhance Health Plan Capabilities 

HealthEdge’s PDM solution stands out not only for its differentiators, but for its comprehensive capabilities that optimize workflows, distributions, and integrations for health plans: 

• Enrichment and Workflow Features: The solution provides data enrichment through validation checks and user-friendly workflows. It leverages a centralized framework with over 300 built-in quality checks and third-party validations, including National Plan and Provider Enumeration System (NPPES) and address standardization. 
• Distribution and Integration Features: We offer configurable data distribution and native Core Administrative Processing System (CAPS) integration, including a self-service module for scheduling and delivering extracts, support for real-time API, event-based distribution, and seamless integration with HealthRules Payer. 
• Platform Features: As a modern SaaS platform, the PDM boasts web-based workflows, high availability, unlimited scalability, seamless upgrades, role-based access, and a customer-extendable data model. 

As an organization, HealthEdge is not just joining in on the healthcare industry’s evolution—we want to actively help shape its future. The HealthEdge Provider Data Management solution exemplifies our commitment to innovation, efficiency, and reliability. By addressing the complexities of provider data management with progressive digital platforms, we’re empowering health plans to achieve operational excellence and deliver superior care. 

Do you want more information on how the HealthEdge Provider Data Management solution can help optimize business operations at your health plan? 
Read our data sheet

At HealthEdge®, we are committed to supporting our customers in achieving and maintaining compliance. Our mission is to empower your organization to become a digital payer, achieving key business goals—like improving the member experience and reducing costs—by leveraging innovative digital technology.

Introducing HealthRules® Machine Readable Files Suite

The HealthRules® Machine Readable Files Suite 3.x stands as a testament to our commitment to innovation, compliance, and transparency in the healthcare industry. Designed to address the requirements of the Transparency in Coverage final rule, our pioneering software solution offers a robust framework for generating machine readable files (MRFs) that detail negotiated rates for in-network providers and allowed amounts for out-of-network providers.

This initiative is not merely about complying with regulations; it’s about ushering in a new era of clarity and trust between health plans and their members.

3 Key benefits of using Machine Readable Files

Real-Time Reporting

Leveraging the power of cloud technology, our solution suite allows health plans to their own reports in real-time, ensuring your team has consistent access to the most up-to-date information.

Intuitive User Interface

The platform’s user interface was designed to make compliance as straightforward as possible and significantly reduce the complexity of generating machine readable files through the HealthRules solution.

Native Integration

As the only machine-readable file generation tool built natively into a Core Administration Platform Solution (CAPS), our MRF suite seamlessly integrates into your existing systems—minimizing disruptions and enhancing operational efficiency.

Key goals of offering an integrated MRF suite within the HealthRules solution are to clarify compliance needs, enhance transparency, and improve the member experience for our health plan customers. This innovative feature is just one representation of our dedication to not just meeting the needs of payers today but shaping the future of healthcare. Partnering with HealthRules can help your team work more efficiently to transform industry challenges and demands into opportunities.

Are you looking for more information on our advanced Core Administrative Processing System (CAPS) and how it can integrate with your health plan’s existing platforms? Visit the HealthRules® Solution Suite.

“Operating margin improvement is a top three critical outcome for digital investments in 2024 for 67% of U.S. healthcare payers.”
— Gartner®, Three Operational Excellence Best Practices to Optimize Costs for U.S. Healthcare Payers, 1 November 2023, Mandi Bishop 1 

Healthcare payers’ operating margins are being squeezed like never before. As many payers turn to technology and automation for answers, it is important to identify areas in the business where manual resources are being used to do work that modern technology can easily accommodate.  

According to the same Gartner report, “You and your IT team must rationalize applications, hyperautomate manual-intensive processes (such as provider data management) and improve business collaboration today. This will deliver meaningful positive effects on business outcomes, operating metrics and enterprise-wide effectiveness over the next 18 months.”  

Barriers to Margin Optimization 

The problem is that many payers are still dependent on legacy, outdated core administrative processing systems (CAPS), siloed claims pricing and editing solutions, and disjointed care management systems. These systems are not able to accommodate today’s: 

• Highly complex payment models, including value-based care 
• Ever-increasing demands from providers to get paid faster and more accurately with more customized contracts 
• Rising healthcare consumer expectations that are being shaped by their retail experiences. 

Again, referencing the Gartner report, “The prevalence of legacy IT systems and number of custom practices mean payers have significant human-involved processes.”  

As a leader in integrated digital payer solutions, HealthEdge has identified three main functional areas of the business where operational efficiencies can be gained to impact payer operating margins directly and positively.  

1. Claims Processing

Many payers are wasting valuable resources and time by manually reworking claims and reconciling inaccurate payments. In fact, according to a recent HealthEdge survey on the current state of payment integrity, the waste is pervasive:  

• • 90% of payers depend on two or more payment integrity vendors, which means multiple datasets, update schedules, and instances across lines of business. The IT burden and workflow complexities associated with this approach have become overwhelming for many health plans.  
  • 55% of payers report that more than 20% of their claims require rework due to inaccurate first-pass adjudication. Claims rework not only requires additional time and effort from the payment integrity team, but it also downstream work for other teams, such as provider relations. 

• • 70% of payers have more than 10 full-time employees (FTEs) dedicated to payment integrity, and 45% have more than 25 FTEs. When asked what the future looks like when it comes to dedicated resources, 56% say they expect that number to increase over the next one to two years, further compressing operating margins.

2. Contract Configuration

As healthcare providers attempt to manage many diverse contract types, the complexities continue to grow. This often requires hundreds of different configurations to be created, which results in additional manual oversight and administrative burdens to avoid compliance issues and payment inaccuracies. In the end, many payers find themselves wondering if these complex configurations are really worth the impact they have on operational efficiencies. 

3. Care Management

With rising healthcare consumer expectations for more personalized engagement and greater transparency, payers are struggling to assemble the right mix of digital solutions that support positive member experiences and compliance with new price transparency rules. According to the HealthEdge Annual Consumer Survey, only 55% of healthcare consumers are fully satisfied with their health insurance provider, leaving much room for improvement. And as CMS doubles the weight of the member experience when it comes to Star ratings for Medicare Advantage plans in the new year, it is more important than ever for payers to address the rising expectations. 

Striving for Operational Excellence 

There are modern, tightly integrated digital payer solutions on the market today that can help payers find new operational efficiencies in these three areas. As the only provider of integrated digital payer solutions, HealthEdge® offers payers the opportunity to identify these efficiencies through hyperautomation of manual process across multiple functions and lines of business.  

Here is a brief summary of those HealthEdge solutions and how they work together to help relieve some of the pressures on today’s health plan margins.  

• HealthEdge Source (Source), is HealthEdge’s prospective payment integrity solution. With Source, payers get one source of truth for payment accuracy and accountability across all lines of business. And because it is a cloud-based solution, fee schedules and policy changes are updated automatically every two weeks. Designed specifically to integrate through a single API to any core administrative processing system (CAPS) for improved speed and performance, Source helps minimize the IT burden of implementing, connecting, and maintaining multiple editing and pricing tools. Plus, with Source Platform Access, payers are finally able to identify the root cause of inaccurate payments and resolve issues upstream so the errors do not repeat month after month.  

“By investing in a prospective payment integrity solution that highlights inaccuracies before the payment is made, you can stop the costly retroactive repayment process that negatively impacts your providers and members through administrative costs.” 2 

• HealthRules® Payer is HealthEdge’s next-generation core administrative processing system (CAPS) that enables transformational outcomes and business agility for all types and sizes of health plans. Recognized as a Best in KLAS CAPS for the third year in a row, the platform helps payers unlock new efficiencies through a combination of modern technology and highly flexible solutions that support real-time automation of business processes, such as claims adjudication, enrollment, and billing. In addition, HealthRules Payer automates many of the workflows associated with rapidly emerging regulatory requirements and seamlessly integrates with other HealthEdge solutions through productized integrations like Payer-Source and Care-Payer, for improved transparency and interoperability. When it comes to contract modeling, the system allows health plans to easily configure and manage a wide range of contract types, including value-based care arrangements, bundled payments, and traditional fee-for-service contacts – for all lines of business in one system. 
• GuidingCare® offers comprehensive solution that bridges the gap between payer capabilities and member expectations by facilitating more personalized member engagement. The platform achieves this through a set of integrated solutions, including Population Health, Utilization Management, Appeals & Grievances, Authorization Portal, and Business Analytics. In addition, GuidingCare provides a robust set of tools that support the unique requirements and complexities of many different state Medicaid programs. GuidingCare also integrates seamlessly with HealthEdge’s HealthRules Payer (Care-Payer) to give utilization management staff and care managers seamless access to real-time benefits information.  
• Wellframe digital care management solutions offer care team members the ability to seamlessly connect with members through multiple channels to reduce inpatient admissions by an average of 17% and increase preventative medicine utilization by an average of 29%. Integrated with GuidingCare (Care-Wellframe) or used as a standalone application, the system delivers a framework for engaging members of target populations to help them get access to the support they need outside of traditional care delivery settings. Wellframe also supports self-service digital resources that empower members to proactively reach their health and wellness goals. With Care-Wellframe, care managers can work seamlessly within both systems to gain greater visibility into member benefit plans and utilization while also offering a closed-loop referral process for social care services. With greater member engagement, member satisfaction rates and outcomes increase while operating costs decrease.  

Looking Ahead 

When a series of integrated digital payer solutions, like those offered by HealthEdge, are in place, payers are able to achieve new levels of operational efficiencies and minimize administrative burdens of working with many different software vendors. These efficiencies relieve some of the pressure on payers so they can focus more on providing high-quality care and services to their members and develop collaborative relationships with their provider networks.  

Sources: 1 Gartner®, Three Operational Excellence Best Practices to Optimize Costs for U.S. Healthcare Payers, 1 November 2023, Mandi Bishop, GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved. 

To learn more ideas on how to navigate the growing pressures on payer operating margins, download this complementary Gartner Report or visit HealthEdge at www.healthedge.com.  

To address this challenge, HealthEdge developed HealthRules Promote, a revolutionary tool designed to restore power directly into the hands of health plan leaders like you. This platform is a testament to our dedication to disruption, offering a solution that is not only innovative but also empathetic to the hurdles your organization faces. With HealthRules Promote, we’re eliminating the technical barriers, enabling anyone within your organization to create configurations effortlessly.

Transforming Challenges into Opportunities with HealthRules Promote

HealthRules Promote isn’t just about easing the configuration process; it’s a catalyst for significant cost savings and improving efficiency. Medium-sized health plans can save up to $750K per year. Moreover, a health plan managing over 1 million lives was able to configure 81 plans in just 10 days with a four-person team. These figures showcase the profound impact HealthRules Promote can have on your operations and bottom line.

Real-Time Response to Market Needs

In today’s fast-paced healthcare industry, the ability to respond in real-time to new opportunities and market demands is invaluable. HealthRules Promote empowers you to quickly take on new business regardless of complexity, ensuring you’re always a step ahead. This agility is critical—not only for growth, but for sustaining relevance in a competitive landscape.

Streamlining Operations

Automating and streamlining existing lines of business—including Individual & Family, Commercial Group, and Medicare—are at the core of HealthRules Promote. By eliminating costly manual processing, we’re  improving operational efficiency while also enhancing accuracy and reliability. This shift towards automation frees up your resources, allowing you to focus on strategic initiatives that drive member satisfaction and growth.

Elevating Customer Service

At the heart of HealthRules Promote is a commitment to superior customer service. The platform enables your representatives to answer customer queries correctly the first time, fostering trust and loyalty. This level of service excellence is not just beneficial for member satisfaction—it’s a competitive advantage that sets you apart in the healthcare industry.

In a sector where change is the only constant, we understand the challenges health plan leaders face and offer a solution that makes it easier to respond to industry changes. Our vision is clear: to equip you with the tools necessary for agile growth, enabling you to care for your members effectively and efficiently. Let us embark on this transformative journey together, shaping a healthcare ecosystem that thrives on agility, innovation, and uncompromised care.

We recently sat down with Bobby Sherwood, VP of product development for the HealthEdge® care management platform, GuidingCare®. Sherwood offered his perspective on interoperability with GuidingCare and how his team is enabling HealthEdge customers to meet compliance requirements and thrive in this new environment of real-time data sharing across their ecosystems.  

Q: The topic of interoperability has been around for more than a decade. Why do you think it is now emerging as an urgent priority for many health plans?  

Sherwood: There are several factors that cause interoperability strategies to become a central issue for payers. First, CMS plays a big role in this by strongly encouraging a standard interface (HL7® FHIR®). While this has been in the works for several years, the final ruling on the Advancing Interoperability and Improving Prior Authorizations Act published earlier this year brought more clarity around the standards and what payers should expect. More aligned standards make it easier for stakeholders to connect and share information. 

Second, members play a role in pushing interoperability to the forefront of payers’ minds. As mentioned in the Healthcare Consumer Satisfaction Survey, members want more personalized interactions and digital communications. Today’s healthcare consumers expect more from their health insurance providers, and the availability of real-time data is key to supporting these expectations.

Lastly, there is a huge amount of data now available that enables payers to do more things, like embrace value-based care models, leverage AI and ML, and more. As the adoption of all things digital increases, so does the value of the data that supports these things. For example, with accurate and timely data, AI can dramatically reduce administrative burdens that payers have struggled to address for decades. These burdens drive up operational costs and limit a health plan’s ability to adapt to market dynamics.  

With greater access to data comes the opportunity to make better decisions faster and realize significant savings that can be applied to other areas of the business. When you add in the value that data can deliver to the clinical areas of the business—such as analyzing risks, developing more individualized care plans, and even interacting with members—interoperability quickly becomes a must-have for remaining competitive in today’s market.  

Q: What are some of the barriers you see health plans struggling with the most when it comes to enabling the exchange of healthcare data? 

Sherwood: One of the biggest challenges I see health plans struggling with is that it takes all stakeholders working together to exchange the data and extract the real value from their interoperability strategies. For example, a health plan must have the right systems to easily accept and share real-time data with providers and members. Your providers also must have systems in place, such as electronic health record (EHR) systems, that can push and pull data to and from your systems. That’s where standards like FHIR and initiatives like the Da Vinci Project that HealthEdge is participating in come into play. The Da Vinci Project specifically targets these challenges by establishing standards and resources available to all stakeholders so interoperability can happen on a much broader scale than ever before.  

Another barrier I see is the cost of making disparate systems actually exchange data. It takes work, time, and specialized technical resources (QA, development, etc.) to connect all of these systems—and not all payers have the resources available to embrace all that robust interoperability strategies can deliver. But, as we further define the standards and more use cases become available, I believe those costs will come down, and the workflows will become more attainable. The costs will never go to zero, but the ROI will continue to grow, and interoperability will become more accessible—and a more desirable lever for payers to pull. The use cases for interoperability are almost unlimited. Besides the penalties that will be incurred for not adhering to CMS regulations, the financial gain will become increasingly evident for use cases like improving care coordination, eliminating gaps in care, improving Star ratings, and driving member satisfaction.   

Q: Where do you think the health insurance market is on the maturity map of interoperability?  

Sherwood: The market is relatively mature from a technological standpoint. For example, at GuidingCare, we’ve been delivering highly interoperable solutions for years. We have over 75 pre-packaged integrations with other systems, and we’ve recently released native integrations with our HealthEdge solutions, HealthRules® Payer (Care-Payer) and Wellframe (Care-Wellframe).  

From a payer perspective, the maturity levels vary. With our larger customers, they are very advanced, most likely because they have more complex businesses, provider networks, vendor ecosystems, and IT departments. We’ve partnered with many of them for years to help them meet their interoperability goals. Some smaller payers may not have as much of a need or as many resources, so many are still in the early stages. That’s one of the great things about working with HealthEdge, though. We bring the expertise of working with larger payers and understand where the market will help payers of all shapes and sizes succeed. So, when their needs change, we are there to help them grow and mature in the most informed, efficient way.  

Q: What have you heard from health plans about their readiness for these new standards to be enforced?  

Sherwood: Our current customers are ready because our solutions are FHIR-ready. We’ve been working hard to keep them informed about the interoperability standards over the past several years. Since the final ruling came out a few months ago, every prospective customer we talk to wants to understand how we will support them and their ability to meet these regulations. They are starting to formulate their strategies and turning to solutions like HealthEdge because we have a strong reputation for market-readiness when it comes to all things regulatory.  

Q: How does GuidingCare support these emerging interoperability standards?  

Sherwood: We build, support, and maintain a variety of data exchange capabilities within HealthEdge and the GuidingCare platform because we want to meet our customers where they are along their digital transformation journey. For example, within GuidingCare, we: 

• Have a robust suite of more than 125 APIs that expose data entities so our customers can retrieve the data they need whenever they need it to interact with external vendors or their own data warehouses 
• Improve efficiency with modern event streaming 
• Support FHIR standards and address the CMS interoperability requirements, which makes it easier for health plans to connect to external vendor systems, like their provider network EHR systems 
• Are participating in the HL7® Da Vinci Project, a group of industry leaders and health IT technical experts working together to accelerate the adoption of HL7® FHIR® as the standard to support and integrate value-based care (VBC) data exchange 
• Partner with some of the nation’s largest health plans that help us all stay current with emerging interoperability rules and trends 

Our goal is to offer a broad range of interoperability solutions so that every customer can benefit from the real-time data exchange. 

Q: What value does a highly interoperable care management system bring to a health plan? 

Sherwood: All stakeholders in the care management workflow win when health plans use a highly interoperable care management system like GuidingCare.   

• Care managers: Interoperable solutions enable care managers to access a more complete picture of their members directly within their GuidingCare workflows. Access to this information at their fingertips enables care managers to make more informed decisions, such as which programs members should enroll in, what social services would be most helpful, what their medical history is, what medications they are currently using, and more. For example, suppose collecting and storing social determinants of health (SDOH) data is managed outside the care management platform. In that case, it can be difficult for care managers to identify and refer members to social services like transportation or meal services. More informed decisions lead to better outcomes and lower utilization costs.  
• Payers: By accessing both clinical data that exists in GuidingCare and operational data that exists in other systems, payers can get a more complete picture of their business, especially when it comes to managing value-based payment models. Plus, they can more easily identify operational efficiencies and better align care services with the needs of their members.  
• Members: When engaging with health plans, members often get frustrated with things like filling out the same forms for every medical interaction. It can be comforting for them to know that their care team has the information at their fingertips. By easily exchanging data between payers and providers, as well as other payers, members are more confident in their care plans. Plus, they have greater access to their health information, appointment scheduling, self-reported data, and more. The seamless flow of data supports better care coordination and better health outcomes.  

Q: Where do you think interoperability is going over the next 5-10 years? 

Sherwood: I think interoperability standards will continue to mature, and the number of use cases will expand. We will get higher adoption of the new real-time data exchange standards and move away from batch transactions over time. Real-time data exchange will be the norm, and data will likely become liquid and flow seamlessly through the system. We will see a premium placed on the volume and quality of data that supports further innovations, like AI in healthcare.  

Q: For those payers who do not have the right care management platforms in place today to support the interoperability standards, what should they be looking for in a new solution?  

Sherwood: The three most important things I believe payers should consider when evaluating a care management platform that can support both current and future CMS standards such as FHIR are: 

1. Look for the vendor to have a strong foundation of existing capabilities already delivering FHIR-ready solutions, so you are starting with someone who is already highly capable of taking your organization into the future. You want to find a vendor who is leaning into interoperability and focused not only on the now, but also on the ‘what’s next.’  

1. Look for a vendor who truly embraces a partnership approach to interoperability. Every payer is at a different point in their journey, and you want a partner who offers flexible options that meet your specific needs. 

1. Ensure you find a system that has a strong care management platform that sits on top of all of this real-time data so that it can be used effectively in executing those care management activities.  

To learn more about how GuidingCare can help your organization make the most out of your interoperability strategy, visit www.healthedge.com.  

In this article, we highlight areas where many legacy PDM solutions are falling short. Plus, see the 6 key features payer leaders are looking for in a PDM system.

Opportunities for Provider Data Management Solutions

One significant barrier is the lack of comprehensive integration capabilities between disparate platforms and systems. Many existing PDM operations are siloed, and don’t effectively communicate with other technologies—leading to inconsistencies in provider data and impairing effective decision making.

In addition to interoperability, PDM solutions must also be flexible in allowing payers to adapt to shifting healthcare regulations and policies. The healthcare landscape is continuously evolving and requires PDM systems that can swiftly adapt to new regulatory requirements and ensure compliance and patient data protection.

While many solutions claim to offer real-time data updates, the reality is that there is often a lag in the actual implementation of these updates. These delays result in outdated provider information that can impact patient care and operational efficiency. Lastly, user-friendliness and accessibility of PDM solutions remain a concern. Complex interfaces and technical requirements can hinder healthcare providers and staff from utilizing these systems to their full potential, leading to underutilization and inefficiency.

Acknowledging these challenges is essential to pave the way for the next generation of PDM solutions: technologically advanced and empathetic to the end-users’ needs, enabling seamless integration, regulatory adaptability, true real-time updates, and intuitive user experiences.

Health plan leaders are looking for a provider data management solution that aligns with their operational and strategic needs. Below are 6 key elements payers want in a PDM system.

Key Elements Health Plans Desire in a Provider Data Management Solution

1.Operational Efficiency:

Health plans aim to streamline their operations through efficient provider data management. They require solutions that collect, consolidate, enrich, and manage provider data from various sources to make informed decisions effectively.

2.Enhanced Analytics:

There is an emphasis on solutions that offer robust analytical capabilities that enable health plans to derive valuable insights from provider data for better decision-making.

3.Data Accuracy and Integrity:

Accuracy and integrity of provider data are paramount. Health plans require systems that ensure data quality, consistency, and reliability to support optimal performance and enhance consumer satisfaction.

4.Real-time Monitoring:

There’s a growing need for AI-driven systems that can monitor changes in provider details in real-time. This capability allows health plans to stay updated on any modifications made by healthcare providers promptly.

5. Secure Data Handling:

Data security and privacy are crucial considerations for health plans. They seek provider data management solutions that offer secure data storage, access controls, and adhere to stringent privacy standards to safeguard sensitive information.

6.Quality of Care Improvement:

Ultimately, health plans aim to enhance the quality of care provided to members. They look for solutions that not only ensure accurate provider data but also contribute to improving outcomes and quality metrics like HEDIS.

Health plan leaders are looking for comprehensive PDM solutions that can help them achieve key business goals. This includes enabling operational efficiency, data-driven decision-making, data accuracy and integrity, real-time monitoring, data security, and quality care delivery.

With provider data management through HealthRules® Payer, you can drive operational efficiency and cost savings at your health plan.

Learn more about the Source Prospective Payment Integrity system at our website: https://www.healthedge.com/solutions/prospective-payment-integrity

When it comes to implementing a technology solution, some leaders might overlook the human element—getting so caught up in the process and technological details that they forget about the people involved. Methods like the People Process Technology framework can help by encouraging health plans to identify the training, documentation, and skillsets the team will need to be successful. But there are other ways to set your health plan up for change management success.

To demonstrate effective change management, here are the stories of two different health plans as they implemented digital solutions.

What does change management success look like?

Our first example is a health plan that successfully implemented a digital solution and achieved a significant return on investment (ROI).

Health plan leaders identified their current processes and reviewed them alongside their employees to pinpoint opportunities to phase out manual, low-value tasks. To ensure they were making the best choice for their needs, stakeholders investigated multiple solutions. They included middle management in the decision-making process to ensure those who would use the system had a voice in its selection.

This health plan invested substantial effort into the design, testing, and training phases of their new systems. They went live on schedule, within scope, and on budget. This resulted in exceptionally high buy-in and an impressive return on investment.

What does unsuccessful change management look like?

The second example involves a health plan that did not achieve long-term adoption of their chosen digital solution.

In this case, a senior leader new to the organization selected a vendor based on their previous experience, and shared the expectation that the system would help cut costs and make their health plan more competitive. However, despite on-time and on-budget implementation, the project struggled to get buy-in and engagement from stakeholders. This lack of engagement led to an unwillingness to test the new platform and engage in training sessions.

Within two weeks of go-live, the system was abandoned because end users didn’t like the way the platform functioned or how it impacted workflows.

4 Steps to set your health plan up for change management success

There are a few key differences between the two health plans mentioned above. One plan focused on educating their internal teams and getting organizational buy-in, facilitating technology adoption and achieving ROI. The other plan allowed one person to take charge and implement changes from the top down without communicating or sharing information with their wider organization, resulting in low adoption and usage.

How can you develop a change management strategy that sets your health plan up for success? These are four recommendations based on experiences with our customer implementations.

1. Understand and support employees

Knowing the needs and capabilities of your team is crucial. Your health plan could find the perfect technological solution, but it won’t be successful unless you have organizational support. It is important to have clear, open channels of dialogue from the onset so stakeholders and users can understand the value of new technology solutions as well as what will be expected of them. This is a great opportunity to emphasize how the new technology can help automate low-value work and empower your team to accomplish higher-value tasks.

2. Focus on inclusion and transparency

Involve middle management in decision-making and foster transparency with regular updates and opportunities for participation. Getting buy-in from middle managers is essential to gaining widespread organizational support. Give your team an early overview and demonstration of the system as it’s being built and implemented—not when it’s fully formed. Showing the new solution to your team and engaging with them helps garner approval and improve adoption.

3. Answer the question, “What’s in it for me?”

Each member of your team needs to understand the personal benefits that the new solution will offer. By engaging with and educating employees on the new solution, you’re enabling them to have discussions about how they’ll be expected to use this new technology and the value it will bring to their roles. At HealthEdge, our Professional Services team can help facilitate transparency with our customers through continuous dialogue. We show your team how the new system functions and engage a larger group to understand the company’s perspective on the solution.

4. Establish a change management work stream

An important step is establishing a project work stream dedicated to change management. Doing so can help you understand where your health plan stands in onboarding and addressing challenges that surface along the way. It is important to engage with your employees and over-communicate. This can be achieved by using change management methodologies such as: engaging leadership, defining why change is necessary, communicating the vision, obtaining employee buy-in, and reporting progress. To be successful, your health plan must lean into change management—you know your organization best and can help set the trajectory for success.

Preparing for change in your organization

Change is an inevitable and necessary aspect of growth—especially in healthcare. We’ve seen which strategies work, and which don’t when it comes to implementing a new digital solution. Remember, the more you involve and support your team from the beginning, the more likely your digital solution will be adopted successfully.

Engage with your team, provide them with a clear understanding of what’s to come, and give them the resources they need to succeed, and you’ll have a team ready to leverage new digital tools and embrace digital transformation.

An integrated workflow management system like HealthEdge Source can centralize claims processing and facilitate payment accuracy by offering:

• Contract visibility
• Pricing tools and algorithms
• Analytics and benchmarking
• Custom and history-based editing
• Comprehensive audit trail
• Data modeling

The Data Reference module within HealthEdge Source brings editing and pricing capabilities together in one cloud-hosted platform. Payers get full-audit support and access to actionable insights that help improve payment integrity. Below are three ways a Data Reference tool can give your health plan a claims processing advantage.

Utilize clean, aggregated data from multiple sources

Keeping track of multiple payment schedules and maintaining their accuracy can be a challenge. The Data Reference feature within HealthEdge Source brings together the most up-to-date fee schedule information and is refreshed every two weeks—giving users one less manual task to remember and ensuring higher levels of accuracy. In 2023, the HealthEdge Source delivered more than 1,500 data updates to its users and made more than 350 updates to policy and pricing met—giving users one less manual task to remember and ensuring higher levels of accuracy. In 2023, the HealthEdge Source delivered more than 1,500 data updates to its users and made more than 350 updates to policy and pricing methodologies across all lines of business.

Data Reference delivers insights based on information such as:

• Medicare rates and prospective payment data
• CMS policies and statistics by provider, region, and system
• CMS provider rates and statistics
• ICD-9, ICD-10, and HCPCS codes

Adjust quickly to CMS updates and policies

Information about updated Centers for Medicare & Medicaid Services (CMS) policies and regulations is available in many formats and in multiple locations. Many of the documents containing key information are difficult to understand, and data is not easy to verify between documents. When it comes to provider rate data, for example, health plans have to cross-reference National Provider Identifier (NPI) and Online Survey Certification and Reporting (OSCAR) numbers to match providers and ensure accurate payments.

CMS is expected to make more than 600 changes throughout 2024. Make sure your health plan is ready to adapt to these changes right away. With the Data Reference tool, Source aggregates and aligns key data in a way that’s easier for payers to view, search, understand, and use.

Streamline fee schedule and contract management

When it comes to off-cycle payment updates, some health plans are forced to knowingly pay claims inaccurately because they don’t have the most updated payment information or internal resources to make timely updates. Prevent these issues from impacting your health plan by working with a payment integrity solution that gives you access to the most recent and accessible information—and see it all in one place.

Source users can update payment policy and pricing methodologies to improve fee schedule management, pricing transparency, and auditing. Instead of juggling multiple websites and documents, the information you need is gathered in a single view that allows users to sort data by region and other filters.

Adjust to policy changes, prevent payment delays, and improve provider relations at your health plan by using a payment integrity solution that gives you access to the most recent and accessible information. With the Data Reference tool, you can readily access essential payment information in an organized and searchable format.

It is critically important to leverage risk management best practices at the beginning of the process and throughout implementation to avoid and address potential risks. Based on my experiences with customer implementation, I’ve compiled a list of the most common risks health plans face—including successful risk management strategies we’ve applied.

1. Risk: Misaligned Expectations

Lack of engagement from key business & technology stakeholders may result in misaligned expectations.

Mitigation: Establish a formal Program Governance entity for the implementation to facilitate organizational and vendor communication.

Key executive stakeholders should be involved throughout the implementation and onboarding process—including provider representation. Engaging internal leaders helps to expedite decision-making and stay on schedule. If stakeholders are not part of the Program Governance group, your health plan runs the risk of losing organizational alignment.

Health plans can measure involvement and gauge buy-in by ensuring stakeholders are attending and participating in key strategic and educational meetings. How can your plan gain buy-in? Share the value the new solution will bring, and how it helps meet key performance indicators (KPIs). Establishing KPIs up front also helps your team understand how to best leverage the solution to meet their goals.

2. Risk: Delayed deliverables

Lack of scope management processes may result in scope-creep, delayed deliverable completion, missed business milestones, and increased costs to the overall program.

Mitigation: Implement a formal change control process, including a Change Control Board, to review and evaluate all proposed changes to assess their impact on the program timeline, budget, and business objectives.

Every step of the process should be directly tied to achieving key business goals. When a request arises, ask, “Is this a necessary capability, or is it a request based on a legacy concern?” Your plan can also provide a channel to help expedite and escalate critical changes requiring Program Governance reviews and approvals as needed. Implementing a new solution is complex—to keep the process manageable, start by solving the most widely applicable issues and fine tuning for new markets later.

3. Risk: Digital interoperability

Integration issues within the Enterprise ecosystem (such as system compatibility & readiness, solution selection, data quality & exchange, or missing capabilities) will impact end-to-end system verification and operational readiness.

Mitigation: Define integration requirements early in the planning phase and follow test-driven development practices with iterative delivery for early, ongoing cross-solution validation.

During program start-up, identify vendors and solutions that will work with and support the use of the enterprise ecosystem. Even with an integrated solution suite, your health plan will need to utilize third-party technology. Third-party testing and integration after implementation can cause delays and reduce functional efficiency. Reduce this risk by fully testing data exchange and other key digital interactions before go-live.

4. Risk: Undefined objectives

Lack of operational objectives without defined measurement will lead to competing or disconnected business stakeholders within the organization, leading to a failed implementation.

Mitigation: Define KPIs for your organization and the new solution at the beginning of the process so your organization knows what to aim for.

Once you’ve defined organizational objectives, regularly monitor your progress toward these new metrics. This makes it easier to identify when you’re getting off-track and adjust quickly to support your business objectives. As you implement the new ecosystem, continue to monitor KPIs for opportunities to optimize usage and performance to get the most value.

Risk management is a necessary part of implementation and is a dynamic process—risks change throughout the implementation and go-live process. To stay proactive, health plans must develop and maintain risk management strategies to stay on schedule and on budget.

Whether your health plan is replacing an existing CAPS solution or launching a new enterprise product to support an emerging market opportunity, implementation challenges will arise. By applying Risk Management best practices, like assessing potential enterprise blockers from the start and having documented mitigation plans, the chances of a successful implementation are in your favor.

“Healthcare organizations face increasing complexity in reimbursing care with value-based payments, self-funded business and more; however, claims-pricing software remains largely stagnant. U.S. healthcare payer CIOs need to procure claims-pricing software that addresses this complexity.”

— Gartner® “How U.S. Healthcare Payer CIOs Handle Effective Claims Pricing” Austynn Eubank, 5 December 2023

Complexity can be found everywhere you look in the healthcare industry today. But never before has there been so much pressure on payers to respond to providers’ rising expectations for timely and accurate payments while also addressing members’ rising expectations for more personalized and flexible benefit plans. 

When you combine these pressure points with the industry’s shift toward value-based care models, the growth in self-funded employer contracts, and evolving Medicare Advantage Star Ratings criteria, it’s easy to see how payers can become overwhelmed by the complexities of accurate and timely payments.   

In an attempt to address these challenges, payers have stacked claims editing and pricing solutions on top of each other, but many have found that their antiquated systems are creating more problems than solutions. In fact, in a HealthEdge research report, 90% of payers depend on two or more payment vendors. However, many of these systems do not afford the flexibility that is necessary to support payers’ ability to meet rapidly evolving provider and member demands.   

It’s Time to Reevaluate Claims Pricers 

“U.S. healthcare payer CIOs advancing healthcare digital optimization and modernization should: Build flexibility and efficiencies into the claims adjudication process by leveraging modular, cloud-native and API-first platforms for claims processing, pricing and editing that support members’ and providers’ needs.” — Gartner® “How U.S. Healthcare Payer CIOs Handle Effective Claims Pricing” Austynn Eubank, 5 December 2023 

Flexibility is the name of the game, especially for payers with multiple, state-managed Medicaid contracts, unique self-funded arrangements, or wide provider networks that require more flexibility and fee scheduling capabilities.  

HealthEdge Source (Source) delivers the flexibility today’s payers need to address complex provider contracts and multiple fee schedules, ensuring that payers can meet the needs of their providers while also optimizing operational efficiencies.  

How it Works 

With Source, payers can combine dynamic configuration capabilities with a smart hierarchy structure to reduce the overhead of maintaining and updating contracts. Source also automatically supports the consistency of terms across provider contracts without jeopardizing the unique requirements of each contract.  

Several health plans that have implemented Source have benefited from a 90% reduction in the number of managed configurations, leading to faster times to contract, more accurate payments, and less provider abrasion.  

A Flexible Future For Claims Pricing Solutions

As payers work to implement more flexible claims pricing solutions that can accommodate today’s fee schedule complexities and rising provider demands for more timely and accurate payments, Source delivers a modular, cloud-based solution supported by a robust set of APIs that can connect to any existing CAPS via a single instance. As a result, payers can develop more collaborative and trusting relationships with their provider networks that ultimately lead to better member outcomes and lower operating costs.  

To learn more about how HealthEdge Source can help your organization meet the evolving demands for more timely and accurate claims payments, visit www.healthedge.com.  

1Source: “How U.S. Healthcare Payer CIOs Handle Effective Claims Pricing” Austynn Eubank, 5 December 2023.  

GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved. Gartner does not endorse any vendor, product, or service depicted in its research publications and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner’s research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose. 

In contrast, Krupa and Mooney revealed how HealthEdge’s prospective payment integrity solution, HealthEdge Source, aims to correct errors before payments are made, emphasizing the importance of accuracy and efficiency from the outset. This forward-looking approach reduces the need for costly post-payment recoveries, minimizes provider abrasion, and improves payer-provider relationships.

From Black Box to Open Book

A key innovation of HealthEdge Source is its departure from the industry’s “black-box” methodology, where payment integrity processes are opaque, and solutions are proprietary, to an “open book” philosophy. This transparency lets payers see precisely where and how errors occur, facilitating root cause analysis.

The first solution to bring together contract configuration, reimbursement, editing, and analytics, HealthEdge Source provides the tools payers need to in-source capabilities to make real-time corrections—completing a virtuous cycle of payments.

This shift enhances operational efficiencies by empowering payers with the information they need to correct any process errors further upstream before the claim is paid. It also fosters a more collaborative environment between payers and providers, ultimately contributing to a more transparent and effective healthcare system.

The Payment Paradigm

• Post payment: You’ve already made a mistake, and the claim gets paid, leading to excessive recoupments and provider abrasion.
• Pre-payment: Let’s catch the mistake before it leaves the door, but its root cause is unknown.
• Prospective payment integrity: You can identify the root cause of the mistake and correct the issue to avoid the mistake entirely in the future.

The Solution to Payment Integrity: Payment Accountability®

Payment integrity transformation can inform various aspects of a payer’s organization enterprise wide. While traditional payment integrity solutions provide a quick fix to problems, HealthEdge Source delivers Payment Accountability with software that creates transparency to address root cause inaccuracies so payers can pay claims accurately, quickly, and comprehensively the first time.

With HealthEdge Source advanced analytics and machine learning algorithms, payers have the tools needed to identify and prevent payment errors. The cloud-based platform can quickly analyze large amounts of data from multiple sources to identify patterns and anomalies that may indicate payment errors and proactively correct them.

Here are a few examples of how HealthEdge Source also helps payers go beyond claims accuracy to gain greater insights and make more informed decisions.

• Retroactive change management identifies claims impacted by retroactive changes and reprocesses them, which helps improve provider satisfaction and performance during audits.
• Predictive Policy Modeling monitors any new payment policy edits before they are put into production to determine the impact prospectively. This enables health plans to make appropriate business decisions and improve provider-payer relationships.
• Contract Modeling enables a transparent analysis of the performance of contract changes or conversions to new contracted payment methodologies before implementation with a plan’s providers.

HealthEdge Source was recognized in the 2023 Gartner^®  Hype Cycle as a Representative Vendor for Prospective Payment Integrity Solution Category. From 2019 to 2021, HealthEdge was recognized as Burgess Group in the Gartner Hype Cycle for Payment Integrity (PPI) Solutions category. HealthEdge acquired Burgess Group in August 2020.

To learn more about how HealthEdge Source can help your organization get out of the black box and embrace an open-book approach to payment integrity, visit www.healthedge.com.

Gartner, Hype Cycle for U.S. Healthcare Payers, 2023, Mandi Bishop, Connie Salgy, Austynn Eubank, 10 July 2023

GARTNER and HYPE CYCLE are registered trademarks of Gartner, Inc. and/or its affiliates in the U.S. and internationally and are used herein with permission. All rights reserved. Gartner does not endorse any vendor, product or service depicted in its research publications, and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

1. Consumer buying experiences in other industries: Consumers now expect a level of engagement and convenience from their health plan providers that mirrors their experiences in other sectors, such as retail and banking. The days of primarily relying on phone calls for problem-solving are giving way to more digital and automated solutions. They want omnichannel communications that adhere to their lifestyles and interests.According to a recent HealthEdge survey of more than 2,800 healthcare consumers, the number one way health plans can improve member satisfaction is by adhering to members’ communication preferences. This shift underscores the need for insurance companies to adapt and equip their teams with modern, omnichannel engagement solutions.

2. Increased access to healthcare information: With more health and wellness information available on the internet, members have unprecedented access to healthcare information. They are more educated about their conditions, treatment options, and even the costs associated with healthcare services. They can more easily find doctors on the internet who meet their specific needs. When they do engage with their healthcare provider, they typically leverage digital tools, such as appointment reminders, portals, and even text messaging.

This newfound knowledge and availability of more modern tools empower consumers to play a more active role in managing their care. As a result, they also expect greater access from payers regarding benefit information, authorizations, costs, and even clinical guidance that can help them make better decisions about their health.

A New Generation of Members Requires New Engagement Strategies

Health plan leaders must be cognizant of the changing preferences of consumers in a post-COVID world.  According to the same HealthEdge consumer study, today’s members seek self-service mobile tools and prefer to engage with their healthcare plans and providers on their own terms. Furthermore, when assigned a care manager, members want care managers to:

1. Communicate with me in the ways I prefer
2. Enable me to actively participate in my care plan
3. Refer me to social services and resources
4. Help me get and manage my medications
5. Have my health information on hand when we communicate

Healthcare consumers are not the only ones pushing for greater transparency and better experiences. One significant regulatory development driving change in the industry is the Transparency in Coverage Act, which requires health plans and providers to provide members with greater visibility into the cost of services before they receive them. This transparency places additional pressure on healthcare payers to offer solutions that enable their members to access pricing information easily and make informed decisions about their care.

Additionally, CMS announced that it is doubling the weight of member experience when calculating payers’ 2023 Star Ratings.

Never before has there been a more important time for health plan leaders to address their members’  evolving demands when it comes to digital engagement strategies.

The HealthEdge Approach

HealthEdge recognizes these challenges and offers health plans a comprehensive strategy to address them. By providing both data and software solutions, the company aims to support healthcare payers in meeting the demands of the evolving healthcare market. From clinical engagement tools to benefit and health risk predictions, HealthEdge’s solutions are designed to enhance member experiences and improve overall wellness.

Here are some practical examples of how the HealthEdge portfolio of solutions helps payers create more personalized and meaningful member experiences:

HealthRules^® Payer

• • Enabling health plans to provide superior customer service with first-call resolution
  • Real-time data allows members and providers to make decisions at the point of care
  • Enable self-sufficiency for members seeking cost transparency
  • Faster and more accurate claims payments lead to higher member satisfaction

HealthEdge Source payment integrity platform

• • Delivering accurate and transparent claims payments reduces the clerical burden on clinicians, which leads to burnout
  • Minimizing clerical burden on providers by removing rework, review, and waste
  • Ensuring that member eligibility and benefits information is accurate and available
  • “Every minute they spend on administrative tasks reduces the time they spend practicing medicine”

GuidingCare^® care management platform

• • Drives secure member communication with their designated care team
  • Mobile clinician application enables offline access for care management staff in the field, enabling connection to members anytime, anywhere
  • Designed to meet NCQA health plan guidelines for Member Self-Management
  • View care plan goals and actions, access personal health records, track health and wellness data, complete health assessments, and more.

Wellframe member experience platform

• • Enables highest needs members to get access and support outside of traditional care delivery settings
  • Omni-channel communication seamlessly connects members
    to designated care teams, with an average of 34 digital touchpoints/member/month
  • Self-service digital resources empower members to reach their health
    and wellness goals proactively
  • Modern user experience increases both member satisfaction and engagement

Visit www.healthedge.com to learn more about how HealthEdge can help your organization engage with your members more personally and meaningfully, proactively reduce costs, and address ever-evolving regulatory requirements.

• Simplifying the Complexities of Healthcare Industry Regulations
• The Evolution of Health Insurance Technology: Embracing End-to-End Integration – Coming soon!
• New Market Expansion in 2024
• Value-Based Care in 2024
• The Changing Face of Healthcare Engagement in 2024 – Coming soon!

The Origins of Value-Based Care

Since the Institute for Healthcare Improvement (IHI) first articulated the Triple Aim in 2008, the healthcare industry has undergone a massive transformation over the past 15+ years, shifting from paying for services (fee-for-service or FFS) toward paying for quality (value-based care or VBC).

Initially, the Triple Aim provided a framework for “optimizing health for individuals and populations by simultaneously improving the patient experience of care (including quality and satisfaction), improving the health of the population, and reducing per capita cost of care for the benefit of communities,” according to the IHI. Several years later, it evolved to include a focus on the well-being of the healthcare workforce and advancing health equity, with some now referring to it as the Quintuple Aim.

With the passing of the Affordable Care Act of 2011, the concepts of healthcare providers and payers working together to embrace quality finally began to take hold. However, when the existing FFS payment structure was put to the test in the Medicare Acute Care Episode (ACE) Demonstration Project in 2018, the feasibility of value-based care became apparent. It ushered in a new era of bundled payment initiatives, including what we now know as value-based care.

The Financial and Care Incentives

Value-based care introduces financial incentives for healthcare providers to ensure patients stay healthy. Under this model, providers are financially rewarded for maintaining their patients’ well-being. The key lies in value-based contract arrangements that distribute funds to providers at a broader level, such as a “bucket” or global level.

When patients remain healthy, cost savings are shared with the provider, creating a win-win situation. Patients benefit from improved health, lower expenses, and better care coordination. Providers are incentivized to focus on preventive care and wellness, as it directly impacts their financial compensation. In this way, value-based care aligns the interests of patients, providers, and payers.

Value-Based Care Today

So, where do VBC payment models stand after all of these years? According to a May 2023 Healthcare Payer Intelligence report, CMS recently reported successfully linking 90% of payments to value, and 40% of all payments flow through alternative payment models (APMs). While the rest of the healthcare industry is transitioning toward value-based care contracts, fee-for-service arrangements still represent a significant portion of the market. However, administering these contracts and transitioning from traditional models to value-based care has proven challenging. This is where modern technology, like HealthEdge solutions, comes into play.

The Role of Modern Technology

Transitioning from fee-for-service to value-based care requires a fundamental shift in managing and reimbursing healthcare. Traditional systems designed for fee-for-service models must adapt, but unfortunately, many legacy and outdated systems cannot support this transformation.

It’s one thing to say you are going to move from fee-for-service to value-based care, but it is another to administer the many different forms of value-based care, such as shared-risks, capitated arrangements, and many different forms of bundled payments.

How do payers take a traditional system that was designed for the model of “patient gets sick, patient goes to the doctor or hospital, a hospital gets paid, repeat the cycle” and convert it to supporting new models that tie reimbursements to patient outcomes and experiences with the doctor/hospital?

The answer: They can’t. Modern, flexible systems are a must-have in value-based care.

A Brighter Future with Value for All Stakeholders

HealthEdge recognizes the need for an integrated approach that combines contracting, claims administration, and care coordination in a single entity. This holistic approach ensures that the financial and care components of value-based care align seamlessly. With HealthEdge’s ecosystem of these three essential components, payers can efficiently manage value-based care programs and control costs effectively.

With HealthEdge, digital health plans have a unique opportunity to make this transition highly successful for all stakeholders: payers, providers, and patients. They can do so by leveraging the advanced automation capabilities and real-time data insights readily available in modern core administrative processing systems (CAPS) like HealthRules^® Payer. With the right CAPS in place, the value of value-based contracts becomes crystal clear:

• Cost Control: Value-based care models can help health plans control costs over the long term by focusing on preventive care and early intervention
• Improved Member Health: By promoting healthier lifestyles and proactive healthcare management, value-based care can lead to improved health outcomes among members. This enhances members satisfaction and reduces the financial burden on payers.
• Competitive Advantage: Payers that embrace value-based care early gain a competitive edge. They can attract providers and members who appreciate the benefits of this approach.

Here are a few practical examples of how all HealthEdge solutions are helping health plans navigate this transformation successfully, improving patient outcomes and reducing healthcare costs in the process:

• HealthRules^® Payer
  • Agile & flexible HealthRules Language
  • Quickly configure new benefit plans and contract arrangements
  • Share actionable data
    with stakeholders
  • Make value-based reimbursement & improved customer satisfaction a reality
  • Up to 96% billing accuracy, including with complex value-based agreements
  • Learn more about our core administrative processing system.
• HealthEdge Source payment integrity platform
  • Accurately price claims based on complex contractual arrangements
  • Run in parallel with fee-for-service contract terms
  • Handle both prospective and retrospective bundles
  • Enable predictive modeling and impact reconciliation reports
  • Learn more about our payment integrity platform.
• GuidingCare^® care management platform
  • Facilitates complex workflows to manage care plans in value-based arrangements
  • Intuitive gaps-in-care analytics identify high-risk patients and potential health improvement opportunities
  • Evaluate performance across configurable measure sets such as HEDIS and Star ratings, plus state and custom measure sets
  • Learn more about our care management platform.
• Wellframe member experience platform
  • Assigned programs focus on whole-person health and improved care outcomes
  • Proven ROI in utilization management outcomes, with a 17% reduction in inpatient admissions** and a 23% increase in preventive medicine utilization**
  • Builds framework for assessing target population and managing clinical needs
  • Learn more about our member experience platform.

Health plans that want to remain competitive and win new business need to support value-based arrangements at every touchpoint in their ecosystem and have access to relevant data outputs for internal and external tracking and analysis.

To learn more about how HealthEdge solutions can help your organization successfully implement value-based care, visit www.healthedge.com.

Payers need to recognize the critical role modern technology solutions can play in supporting their growth plans, whether it be through membership growth, mergers, and acquisitions, or even the rollout of new products or geographies.

As the market becomes more complex and the competition heats up, industry leaders reported technology to be both their biggest challenge and their greatest ally in the coming year in the recent 2024 HealthEdge Annual Payer Market Survey [link to report when ready]. Among the 350+ health plan leaders surveyed, 62% said “investing in modern technology for digital transformation” was the number one way they intend to achieve their organization’s goals. However, their most significant challenge was reported to be “alignment between IT and the business.”

The Shift in Health Insurance Markets

Historically, health insurance primarily operated within group-oriented markets, catering to large employers and their employees. Players in this space often stayed within their established markets, with national plans dominating the scene. Smaller regional players, on the other hand, often focused on specialized networks to differentiate themselves. Medicaid and Medicare programs operated at the regional level, with large group-oriented plans utilizing Administrative Services Only (ASO) arrangements to manage their offerings.

However, a significant shift occurred roughly a decade ago, moving the focus from employers to consumers. The rise of public and private exchanges marked the beginning of a new era, where consumers started to take a more active role in choosing and purchasing their health insurance plans. This shift introduced a fundamental change in how health insurance providers needed to operate and compete.

Competing in a Changing Landscape

In this new landscape, health insurance plans, whether large national entities, smaller regional players, or government programs, found themselves competing differently. They needed to appeal to various populations with unique needs and preferences while facing a broader range of competitors. In this changing environment, flexibility and speed became critical factors for success.

• Flexibility: Health insurance providers had to adapt to the diverse needs of their target populations. What works for one group may not work for another, necessitating flexibility in plan offerings and services.
• Speed to Market: In a world where consumers are now shoppers and buyers, quickly bringing new offerings to market is a competitive advantage. Health insurance plans needed systems to respond rapidly to changing demands and opportunities.

The Role of Modern Technology

To meet the demands of this new, expanding market paradigm, payers must leverage modern technology that can support their efforts in several key areas:

• Rapid Benefit Package Creation: In the past, it might have been acceptable to take 3-4 months to create a new benefit package. However, insurers need systems that can swiftly design and build benefit packages to meet evolving consumer needs in today’s fast-paced market.
• Digital Care Management: Offering new care management programs and digital care management platforms is crucial for addressing members’ health needs. The speed at which insurers can deploy these programs can be a decisive factor in their success.
• ASO Arrangements: Health insurers often need to sign new ASO agreements with various entities that value health insurance offerings. The ability to do this quickly and efficiently is essential for expanding into new markets.

HealthEdge’s Approach to Supporting Payer Growth

At HealthEdge, we understand the importance of modern technology in supporting health insurance payers’ expansion efforts. We recognize that success hinges on what a system can do and how fast and flexibly it can do it.

• Empowering Customers: We enable our customers to build and administer their functionality. Once customers are trained on the value of our solutions, they can control their destiny.
• APIs and Testing: Everything we do focuses on the speed and efficiency of our technology’s tasks. Our emphasis on Application Programming Interfaces (APIs) and rigorous testing ensures that our systems can handle tasks quickly and reliably.
• User Experience: We prioritize the user experience, ensuring that our technology is powerful and user-friendly. A seamless and intuitive interface allows insurers to operate efficiently and respond swiftly to market demands.

Here are a few practical examples of how HealthEdge solutions support payers’ ability to expand their businesses and grow into new markets successfully:

HealthRules^® Payer

• • Create virtually any benefit plan or provider contract in hours and days versus weeks and months. Average set-up time for a new contract can be as little as 10-12 minutes
  • Mirror a plan’s actual world and setup
  • Ability to scale and keep up with the pace of membership growth. Up to 97% enrollment accuracy

HealthEdge Source payment integrity platform

• • Single API to support all claims systems and provider types
  • Easily create and customize contract configurations with synchronization of rules management across all LOBs
  • Designed to scale for your organization’s future growth, agility, and transformation

GuidingCare^® care management platform

• • End-to-end solution with flexibility and scalability
  • Highly configurable for specific health plan needs and wants
  • Consolidated member information in a single, comprehensive care record
  • Built to scale to millions of member records, millions of transactions per week and 10K+ concurrent users​

Wellframe member experience platform

• • On-demand member content and benefits resources, plus digital customer service advocacy solutions
  • Enables health plans ownership of the member relationship, mitigating competition
  • Proven 6x increase in member interactions and double the staff capacity for active caseload size

HealthEdge: Your Competitive Edge for Growth in 2024

The evolution of health insurance markets from group-oriented to consumer-focused has brought about a need for health plans to adapt quickly and efficiently. In this dynamic landscape, speed to market and flexibility are the keys to success. Modern technology plays a pivotal role in supporting health insurance providers as they expand into new markets.

HealthEdge’s commitment to delivering systems that empower customers, emphasize APIs and testing, and prioritize user experience positions for health insurance payers for success in a highly competitive environment. With the right technology partner, health insurance providers can navigate the changing landscape with agility, meet consumer demands promptly, and achieve their expansion goals in a fast-paced and consumer-driven industry.

To learn more about how HealthEdge solutions can support your organization’s growth strategies, visit www.healthedge.com.

• Simplifying the Complexities of Healthcare Industry Regulations
• The Evolution of Health Insurance Technology: Embracing End-to-End Integration
• New Market Expansion in 2024 – Coming soon!
• Value-Based Care in 2024 – Coming soon!
• The Changing Face of Healthcare Engagement in 2024 – Coming soon!

The Early Days: Integrated Systems

The landscape of health insurance has transformed dramatically over the last three decades, driven by advances in healthcare IT and back-office administration. From claims processing to digital care management, technology has reshaped the way health insurance payers operate. Now is the time for payers to explore emerging concepts and opportunities associated with end-to-end system integration to better support their 2024 clinical and operational goals.

In the early days of healthcare IT, the prevailing wisdom was to consolidate as much functionality as possible within a single system. The goal was to have everything in one place, minimizing the need for complex integrations. This approach had its merits:

• GOOD: Centralization was seen as a way to simplify operations, reduce administrative overhead, and gain better control over various processes.
• BAD: A single system could only do so much, limiting its ability to adapt to the rapidly changing healthcare landscape. As the industry evolved, it became clear that a single system could only address some of the specialized needs of health insurance payers.

The Shift Toward Best-of-Breed

Over the last several decades, the health insurance industry gradually shifted away from the all-in-one integrated systems to embrace a best-of-breed approach. Instead of trying to fit all functionalities into a single system, payers began adopting specialized software and systems tailored to their specific needs. This shift had several advantages:

• Expertise: Specialized systems allowed payers to leverage the expertise of vendors who focused exclusively on claims processing, care management, or other critical aspects of their operations.
• Efficiency: Specialized systems were often more efficient and effective in their respective domains, leading to improved performance in key areas.
• Flexibility: Health insurance companies could choose the best tools for each aspect of their operations, allowing for greater flexibility and adaptability.

The Challenge of Separation: Care Management and Claims

While the best-of-breed approach offered clear benefits, it also introduced new challenges, particularly in integrating care management and claims processing. Unlike integrated systems, where these functions naturally worked together, the best-of-breed approach separated them into silos and created several new challenges:

• Expertise: Claims processing and care management requires different skill sets and expertise. This separation led to administrative and technical challenges in bridging the gap.
• Complex Integration: Integrating separate systems, with their own data structures and communication protocols, proved to be a complex and costly endeavor. Companies faced difficulties in ensuring that these systems worked seamlessly together.
• Vendor Fragmentation: Another complication arose as health insurance companies started purchasing various products from different vendors to meet their needs. Each vendor had its own requirements for integration, further fragmenting the technology landscape. While technology improved over time, integration challenges persisted due to the diversity of systems and vendors.

The Path Forward: Integrated End-to-End Solutions

Today, health insurers are revisiting the concept of integration, but in a different way. Integrated end-to-end solutions are gaining traction, offering the best of both worlds – the efficiency of specialized, best-of-breed applications and the seamless integration of a single vendor’s ecosystem. This new approach delivers several key advantages:

• Controlled Integration: When a single vendor provides claims processing, digital care management, and other functionalities, they can control the level of integration between these applications. For example, automating claims and payment editing becomes more straightforward when one vendor owns both components.
• Real-Time Automation: Integrated end-to-end solutions enable real-time automation, improving the accuracy and efficiency of processes. This is particularly important to ensure claims are paid correctly the first time.
• Future-Proofing: The market seems to be returning full circle to the best-of-breed concept, but this time with the added benefit of integrated end-to-end automation. Health insurance operations can be more adaptable and better equipped to meet evolving needs and technology trends.
• Improved Member Engagement: Integrated end-to-end automation breaks down silos and fosters a smoother flow of data and processes. This results in better member engagement, creating a more satisfying experience for insurers and consumers.

The HealthEdge Advantage: Breaking Down Silos

Currently, many health insurance organizations operate in silos, relying on custom-built bridges between different components of their operations. The move towards integrated end-to-end solutions aims to break down these barriers, allowing health plans to take full advantage of a best-of-breed approach while benefiting from a cohesive ecosystem.

HealthEdge solutions were designed with integration in mind. As the HealthEdge solution portfolio moves toward integrated end-to-end solutions, they are breaking down barriers and allowing health plans to take full advantage of a best-of-breed approach while benefiting from a cohesive ecosystem.

In addition to productized integrations between HealthEdge solutions, including Care-Payer, Payer-Source, and the newly available Care-Wellframe, HealthEdge products themselves support an integrated end-to-end approach:

• HealthRules^® Payer

  • Auto-adjudication rates over 90%, with at least 99% claims accuracy
  • Highly automated features greatly increase productivity and transparency
  • Auto reprocessing capabilities
  • Hyper-automation supports remote operations

• HealthEdge Source payment integrity platform

  • Cloud-hosted solution with continuous content updates that are delivered automatically
  • Parallel processing of payment policies and pricing to enable real-time claims transactions
  • Source SMEs research, develop, and maintain content and IT infrastructure
  • Built to enable seamless technology, open APIs, and true interoperability

• GuidingCare^® care management platform

  • API integration suite with 75+ unique vendors for all use cases
  • Automation tools proactively build and sustain robust member care plans
  • Best-in-class rules engine automates business processes and workflows
  • Streamline and consolidate the full appeals management process across all levels and reviewers

• Wellframe member experience platform

  • Mobile delivery of 70+ pre-developed, automated care programs
  • Web-based staff dashboard with member prioritization, templated messaging, and 1-to-many workflows
  • Auto-generated SDOH and clinical risk survey questions and assessments routinely surfaced to members
  • Direct member access to self-service risk assessments

Moving Forward

The evolution of healthcare IT and back-office administration in health insurance has been a journey of trial and error. From integrated systems to best-of-breed approaches and now integrated end-to-end solutions, the industry has finally found the right balance between specialization and integration.

By combining the efficiency of best-of-breed applications with seamless integration, HealthEdge is enabling health plan operations to be efficient and adaptable to the ever-changing needs of the industry.

To learn more about how HealthEdge solutions can support an integrated end-to-end approach to your enterprise, visit www.healthedge.com.

The healthcare industry lags well behind other industries in adoption, which means there is tremendous upside if health plans can get this right. However, given the regulatory, privacy, compliance, and member service expectations, a measured approach is needed to ensure accuracy, ethical use, and privacy.

This blog explores the intersection of artificial intelligence (AI) and healthcare and then delves into how HealthEdge® helps health plans tackle the various opportunities and challenges that emerge in this domain.

The Promise of AI in Healthcare

Recent research from Harvard and McKinsey healthcare experts published in the National Bureau of Economic Research predicts wider adoption of AI could lead to a 5 to 10 percent decrease in healthcare spending in the US—about $200 billion to $360 billion every year. Researchers point out that the areas of greatest impact for administrative costs that are central to healthcare payers and providers are:

• Claims Management
• Member Services
• Corporate Functions

One of the more mature and impactful use cases is in claims management. Payers use AI-enabled core administration processing systems (CAPS) to improve auto adjudication rates, prior authorization outcomes, and fraud, waste, and abuse prevention.

Behind the frontline of provider-patient interaction, core processing and claims adjudication are inherently complex, forcing many health plans to rely on manual processes. As AI technology enters the health insurance space, payers can harness AI’s power to automate processes, improve accuracy, and enable data-driven decisions.

Examples of AI Applications in HealthRules^® Payer

Today, AI offers significant gains in efficiency, given it is effectively and responsibly leveraged within the healthcare technology stack. Within HealthRules Payer, HealthEdge’s CAPS, AI-driven claims automation, analytics, and reporting efficiencies are already available. Not surprisingly, Harvard/McKinsey research predicts there is the most opportunity for AI to do more work than humans in these areas.

Let’s look at some use cases, both benefiting health plans today and others on the horizon.

AI-Powered Analytics in Claims Automation

Within claims automation, AI algorithms within HealthRules Payer review and synthesize structured and unstructured data, including encounter details, medical records, and reimbursement policies. AI identifies patterns and anomalies, helping detect fraud or unusual claim behavior and surfacing opportunities to streamline the entire claims processing workflow. By supporting human reviewers and making auto-adjudication more intelligent, AI improves the accuracy and efficiency of complex claims reviews.

HealthRules Payer processes millions of claims. Health plans are under tremendous pressure to automate as much as possible to pay claims within 30 days or face steep penalties. Within HealthRules Payer, AI looks at all the claims requiring human intervention and understands the decisions being made. For example, the health plan can learn which combination of doctor, service, and dollar amount needs to be reviewed by a person. The AI models ensure maximum intelligent automation so that health plan staff can focus on the exceptions.

Therefore, auto-adjudication rates are optimized. Many health plans historically have averaged about 75+% auto-adjudication rates, but improving that by 5% would be optimal as they implement new technologies. HealthEdge found that a 1% increase in auto-adjudication is close to $400K in savings for health plans using HealthRules Payer. Traditional AI, or machine learning, in HealthRules Payer helps these organizations raise their auto-adjudication rates by identifying patterns and focusing on which to automate.

HealthEdge’s Payment Integrity platform Source is also implementing traditional AI algorithms to ensure that claims are paid accurately. According to estimates by the Centers for Medicare and Medicaid Services (CMS) approximately 9.5% of claims are paid inaccurately, which contributes to nearly $36 billion in overpayments. Reprocessing such claims and recovering payments increase the administrative burden on plans and also lead to abrasion in plan-provider relationships. AI algorithms are employed to find inaccuracies before a payment is made in order to improve accuracy.

Natural Language Reporting Queries

HealthRules Payer complements core reporting and analytics capabilities by allowing users to ask natural language questions about specific aspects. Each day, users have questions about vital operational metrics and want to dig deeper into these metrics better to understand information not readily available in existing reports. They may have specific inquiries that lead to curiosity to look deeper into things like daily claim volume, claims assigned to humans, auto adjudication rates, instances of overpayment, etc.

HealthEdge has put a spin on traditional reporting, which does a good job of answering the questions most health plan leaders want, but it doesn’t necessarily support human curiosity. If a report triggers a question such as “Why is that hospital billing the highest?” HealthRules Payer with AI allows the user to ask that question and instantly receive an answer. Similarly, if a user wants to know “Which services are the most expensive for this hospital in this time frame?” the application generates the answers.

Before AI, a business analyst or even a data scientist would get a long list of questions to explore, and those questions pile up, leading to delays in decision-making and insightful action. Now, HealthRules Payer eliminates those delays and instantly provides more insightful action. How many questions about data does a user have in a single day? Now, multiply that by all the leaders and users in a health plan. You start to see how powerful AI can be, making everyone more informed and streamlining decision-making.

Human-Friendly User Support and Training

Another powerful use case is for HealthEdge users who need to query our extensive product documentation, which spans approximately 8,000 pages. Traditionally, users would search through this documentation to understand product details. Getting to the answer can be cumbersome, involving trial and error to find what information is needed. Health plans often contact customer support or product managers to seek guidance on specific tasks, adding more time to solving the problem.

To address this challenge, HealthEdge developed an application in HealthRules Payer that leverages generative AI. This technology allows users to ask questions about the product using natural language, and the system provides accurate answers. Unlike manual searches, this approach is like interacting with a chatbot, streamlining the process and eliminating the need for time-consuming and exhaustive searches.

What is generative AI?

Generative artificial intelligence (generative AI) is a type of AI that can create new content and ideas, including conversations, stories, images, videos, and music. AI technologies attempt to mimic human intelligence in nontraditional computing tasks like image recognition, natural language processing (NLP), and translation. Generative AI is the next step in artificial intelligence.

Work in Progress: Generative AI for Member Services

A future application currently being explored demonstrates the potential efficiencies generative AI can deliver when it comes to care management with the HealthEdge GuidingCare^® member engagement solution.

When members contact a service representative, they often inquire about their health insurance benefits. For instance:

• The member asks how many physical therapy sessions they can be reimbursed for in a year or the cost of visiting a chiropractor.
• The service representative manually navigates through the system to retrieve this information, which takes time for both parties on the call and depends on a person to interpret.
• The member may be frustrated and feel that insurance coverage is a “black box” and a time-consuming burden to decipher.

Leveraging natural language processing in a chat-based interface will allow representatives to quickly access and provide accurate benefit details to members during live calls. Ensuring 100% accuracy is crucial, which HealthEdge is working toward now. Although the project is still in progress, HealthEdge believes this will streamline benefit inquiries, improve service, and enhance customer satisfaction.

A Bright Future: Streamlining Staff Workflowswith Summarization

Finally, there are future use cases that illustrate how generative AI can be used in healthcare. For example, when a patient requires a knee replacement, the health plan must approve the procedure through prior authorization. GuidingCare handles the case review during this, which involves a physician thoroughly examining a patient’s documentation. Often, these documents are hundreds of pages.

AI could be used to summarize the critical aspects of the documentation. By condensing the essential information, a physician can make a quicker decision, which leads to faster approval and more timely care. This efficiency is crucial because physician reviews are resource-intensive and critically important. Optimizing this process helps all stakeholders and can significantly impact the operational bottom line.

Similarly, the Wellframe team is planning to embed Generative AI summarizers into staff workflows such that case managers can rapidly and quickly catch up on the latest member activity across the Wellframe platform, including recent chats/inquiries, app activity, care program / assessment results without disrupting existing workflows​.

However, much work remains to ensure accuracy and address ethical considerations associated with summarization. Balancing efficiency with accuracy and ensuring transparency is a priority for HealthEdge.

The Challenges of AI in Healthcare

Despite AI’s current benefits and promise for health plans, HealthEdge is deeply mindful that a cautious approach, ethical considerations, and continuous monitoring are vital to reap AI’s benefits while minimizing risks. It’s imperative to:

• Mitigate ethical and legal risks with privacy
• Establish best practices in data and systems governance, and
• Monitor the potential for “bias” in AI algorithms

These practices are critical for reliable AI applications. Above all, patient safety and cybersecurity must be prioritized, and risks must be mitigated. Within HealthEdge, all AI/ML use cases are vetted from ideation to deployment by an AI Governance Panel, which has legal, information security, compliance, business, and engineering leaders within the organization.

Relative to the use cases above, there are key considerations for the use of AI:

Probability and margins for error

With the incorporation of AI into intelligence that drives auto-adjudication systems, for example, probability and margins for error must be considered. Of course, even human reviews have inherent inaccuracies, but health plans want to improve that performance baseline while maximizing efficiency.

With HealthRules Payer, health plans can select their desired accuracy level, such as 95% or 100%. For instance, if a customer is comfortable with a 95% confidence level for a certain process, there is a 5% chance of misclassification. This aligns with the reality that human reviews are also subject to errors due to imperfect data. HealthEdge communicates this to health plans, allowing them to adjust the risk-reward ratio according to their needs. Relative to emerging generative AI, this process is relatively straightforward with machine learning.

Mitigating generative AI risks

The situation changes when it comes to generative AI, which relies on large language models. These models can generate content beyond the input data (often referred to as “hallucinations”) because they are designed to create new material. While this is advantageous for tasks like video generation or fun consumer applications, it becomes problematic when dealing with critical healthcare information.

Consider member benefits. Here, there is no room for error. If a member is told they have six visits for physical therapy, but the actual data indicates only four visits, the consequences could be significant. Generative AI excels at recommendations and answering questions. Yet, accuracy becomes paramount when dealing with essential details like insurance benefits or product documentation, so HealthEdge has implemented extensive pre- and post-deployment validation procedures. While health plans are excited about the potential benefits sooner rather than later, they can have confidence that HealthEdge’s oversight of these innovative possibilities will ensure the application is ready to go when brought to market.

Conclusion

AI holds immense promise for health plans. As HealthEdge invests in innovating with AI, it prioritizes a close partnership with health plans to maximize the benefits and mitigate the risks. The bottom line is that AI is adding powerful capabilities today in HealthRules Payer, and HealthEdge is focused on diligence when adding generative AI into solutions. The result will be that healthcare works better for everyone.

To learn more about how HealthEdge’s solution can help your organization leverage AI to improve efficiencies, reduce costs, and stay on the leading edge of healthcare innovation, visit www.healthedge.com.

The Complex World of Health Insurance Regulations

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

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

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

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

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 www.healthedge.com.

Health Plan Challenges Overview

Throughout the survey, modernizing technology and aligning IT with business objectives emerged as common themes and top challenges.  These challenges stem from the unprecedented pressures that payers are facing from every corner of the industry.  Some of these pressures include:

• Rapidly evolving and ever-changing regulatory requirements
• New market entrants setting new standards for consumer-friendly experiences
• Clinical workforce shortages and staff burnout
• Changing payment models and the rise of value-based care
• Record-high healthcare costs
• Consumer buying behaviors influenced by retail experiences

Ranked in order of importance, the five biggest challenges for health plan leaders are:

1. Aligning business and IT resources
2. Workforce shortages/burnout
3. Business growth
4. Managing costs
5. Member satisfaction

These findings may not be surprising to many, but the order in which these challenges arose this year was interesting. In previous studies, aligning business and IT resources ranked anywhere from third to fifth place, or even lower. However, as the industry experiences a surge in changes and rapid transformation, health plans are acknowledging the importance of adopting modern technology that can help their organizations be more agile and responsive to evolving market demands.

Embracing Modern Solutions

Let’s explore how modern, highly interoperable technology solutions can solve health plans’ biggest challenges in 2024.

• Modern solutions can help health plans seamlessly align business and IT resources. These responsive systems require fewer dependencies on IT resources to adapt to the business needs.
• Workforce shortages are widespread across many industries, particularly in the healthcare sector. The pandemic has exacerbated this issue, leading to nearly 1 in 5 healthcare workers quitting their jobs. Shortages of clinical specialists, such as care managers, and a lack of highly trained billing professionals are negatively impacting health plans and members’ access to quality care. Furthermore, inaccurate claims pricing and processing lead to costly downstream re-work, over or under payments on claims, and dissatisfaction among members and providers. With modern solutions that facilitate automation and interoperability, health plans can achieve more accurate pricing and editing of claims, as well as advanced automation of manual processes. This will alleviate many frustrations that team members face in their day-to-day work.
• Health plan leaders are constantly focused on expanding their business, whether through membership growth, mergers and acquisitions, or introduction of new product lines. In today’s complex and highly competitive environment, this is no easy lift. According to the report, payers’ biggest obstacle when it comes to expanding their membership is being able to offer a variety of plans that meet their members’ needs. The ability to swiftly create new offerings and adapt to changing market conditions is now possible with modern core administrative processing systems. Additionally, these systems offer greater access to real-time data and insights into the potential impact of business decisions, such as new products, populations, or regulations. Real-time data allows payers to identify new opportunities more precisely and gain competitive advantages for growth.
• Managing costs has been a persistent challenge in the healthcare insurance industry. With the rise of complex payment models, new competitors, and evolving regulations, payers should consider leveraging advanced systems, such as core administrative processing systems (CAPS), care management solutions, payment integrity platforms, and member experience applications. These solutions enable the automation of business processes, reduction of overall cost per claim, increased nurse panel sizes, and smarter business decisions with greater visibility.
• Improving member satisfaction is becoming more difficult, especially as modern healthcare consumers’ expectations are influenced by personalized and meaningful retail experiences. Member satisfaction is crucial, especially for Medicare Advantage plans, as CMS doubles the weight of member satisfaction in its Star ratings program, effective this year. Modern digital care management platforms can offer deeper insights into member populations and improve care managers’ ability to reach more at-risk and rising-risk members.

The year ahead will bring new challenges for payers. Leaders who leverage modern solutions, such as the ones offered by HealthEdge, are better equipped to address these issues head-on. Download the HealthEdge Annual Payer Market Report to gain exclusive insights and discover actionable key takeaways. For a more personalized roadmap to success, explore HealthEdge solutions at www.healthedge.com.

The latest HealthEdge Annual Payer Market Report presents a fascinating picture of how technology is both the biggest challenge and the greatest ally for health plan leaders in the coming years. Let’s dive into the key findings from this report, shedding light on the role of technology in the healthcare payer landscape.

The Audience

This year’s survey garnered responses from over 350 health plan leaders and executives, representing diverse functional areas of the business and encompassing all types and sizes of health plans. Their collective insights offer a comprehensive view of the healthcare payer market.

The Dominant Themes

Throughout the survey, several dominant themes emerged, illustrating the impact of technology on the healthcare payer industry. These themes directly reflect the mounting pressures that payers are experiencing from multiple angles:

Evolving Regulatory Landscape:

Regulatory requirements are evolving at an unprecedented pace, aiming to address long-standing industry challenges such as cost, transparency, and value. Payers are required to adapt to these transformative regulations swiftly. To do so effectively, they must establish flexible and open technology systems.

Consumer Demand for Personalization:

Healthcare consumers today demand more personalized engagement and greater transparency, influenced by their modern retail experiences. Health plans must incorporate omnichannel communication capabilities to meet these consumer expectations.

Emerging Non-traditional Competitors:

Innovative, non-traditional competitors with tech-forward strategies continue to emerge, placing pressure on payers to excel in new member acquisition and member/provider satisfaction. System agility and high interoperability provide payers with a competitive advantage in this ever-changing landscape.

Workforce Challenges:

Workforce shortages and high turnover rates compel payers to automate their business processes further, empowering their current staff to achieve more with less. Modern solutions facilitate ease of use and higher levels of automation, ultimately reducing dependencies on manual resources.

Growing Complexity in Payment Models:

Changing payment models, such as value-based care and risk-sharing arrangements, contribute to the growing complexity of claims processing, performance measures, and plan configurations. Modern technology is pivotal in navigating these complexities efficiently.

Cost Management:

Managing costs has consistently been a top challenge for health plan leaders; this year is no exception. As business complexities increase, so do administrative costs. Leaders are focusing on strategies such as improving the financial accuracy of claims and increasing auto-adjudication rates to minimize costs.

Three Key Findings

1. A notable 62% of health plan leaders consider investing in modern technology for digital transformation as the number one way to achieve organizational goals in the new year.
2. Increasing interoperability across the healthcare ecosystem stands out as a promising strategy to reduce administrative costs, emphasizing the importance of seamless data sharing and efficient workflows.
3. Achieving alignment between IT and business ranks as the most significant challenge for health plan leaders, necessitating the adoption of modern solutions that support business agility. Other top challenges include:
   • Addressing workforce shortages and burnout
   • Facilitating business growth through membership growth, acquisitions, and market expansion
   • Managing costs by improving the financial accuracy of claims and increasing auto-adjudication rates to reduce administrative expenses
   • Improving member satisfaction by providing personalized communication capabilities in a landscape of expanding consumer choices
   • Ensuring provider satisfaction through stronger payer-provider collaboration to successfully implement value-based care models

The Changing Role of Technology in the Healthcare Payer Market

Given the growing complexities and the industry-wide shift towards digital transformation, it comes as no surprise that health plan leaders unanimously agree on the pivotal role of modern technology in addressing their major challenges in the new year.

As leaders search for new technology solutions, the survey highlights the top criteria for evaluating and finding the right solution, listed in order of importance:

Modern technology capabilities:

Modern technology can better support the future needs of organizations, enabling payers to be flexible and agile and do more with fewer resources as the market evolves.

Access to real-time data and analytics:

Health plan leaders need seamless access to up-to-the-minute information through robust APIs. Real-time data and analytics empower them to adopt value-based care payment models confidently, strengthen member-provider relations, and meet regulatory requirements.

Ease of doing business and customer service:

Modern technology companies should demonstrate flexibility in their product offerings, contracting processes, and support services to truly become partners rather than just vendors, enhancing the ease of doing business and elevating customer service to new heights.

Hassle-free configuration, upgrades, and implementation:

Every payer organization has its unique digital transformation journey, business processes, and growth plans. Modern technology platforms offer greater flexibility and faster deployment of new features, making it easier for payers to adopt innovations. This ensures that the system can accommodate each payer’s unique configuration requirements.

Automation and efficiency:

Vendors should be able to demonstrate how their technology can facilitate end-to-end process automation. Operational efficiency becomes even more crucial as payers’ requirements continue to rise.

Looking Ahead in the Healthcare Payer Market

The HealthEdge Annual Payer Market Report clearly shows the healthcare payer industry’s transformation driven by technology. As the industry continues to evolve, payers recognize the critical need for flexible, responsive, and highly interoperable solutions to thrive in this dynamic and competitive market. Technology is not just an enabler; it is becoming a mission-critical growth driver for healthcare payers in the future.

Download the full HealthEdge Annual Payer Market Report to learn more about these findings and gain insights from industry leaders.

Care management teams are given a tall order: Provide the highest-risk members with the most complete, whole-person care plans possible, all with the expectation that these members will adhere to their care plan and experience better health outcomes at a lower cost of care. Care managers are feeling pressure from every angle, struggling to balance the expectations of all stakeholders, including providers and care team staff, member families, government entities, and the health plan that employs them.

The reality is that care management is hard work. Care managers often work with the most complex and challenging members who are often hard to reach. These populations are multidimensional, meaning psycho-social factors and social determinants of health are almost always in play. In order to deliver whole-person care successfully, they have to build trusting relationships with these members, which is easier to do with access to the right data or the right technology solutions that can bridge communication gaps.

From an operational perspective, coordinating care across multiple, siloed care settings and community services is also difficult since most systems don’t talk to each other, and care managers have to log into multiple disparate systems to find the information they need. These outdated care management solutions hinder care manager productivity and efficiencies as caseloads continue to rise.

The Role of Modern Care Management Solutions

Modern care management solutions like GuidingCare can address these challenges and help health plans quickly see a return on their investment through extreme operational efficiencies and total cost of care savings. Here’s how it works:

1. Enhancing Care Manager Efficiencies:

GuidingCare streamlines care management processes by automating routine tasks, enabling care managers to focus on high-value activities and reach more at-risk members. With real-time data access and intelligent workflows, care managers are always equipped with the most up-to-date information to make informed decisions. The result? Improved care manager efficiency, reduced administrative overhead, and measurable time savings.

2. Cost Reduction and Expense Management:

GuidingCare’s predictive analytics and care coordination capabilities help payers proactively identify at-risk members, supporting early interventions and reducing expensive hospitalizations and emergency room visits. The care management solution provides transparent cost tracking, making it easier for payers to accurately quantify cost reductions and expense management achievements.

3. Optimal Allocation of Services:

GuidingCare’s data-driven approach ensures that services are allocated based on individual member needs. Payers can now measure the direct impact of their care management efforts on quality of care and member satisfaction.

Achieving Meaningful ROI with GuidingCare

In conclusion, GuidingCare represents more than just a care management solution; it is a strategic investment that empowers payers to successfully navigate the complexities of healthcare. By delivering measurable results, GuidingCare is the key to achieving better healthcare outcomes and effectively managing costs.

To learn more about how GuidingCare care management solutions can help your organization improve care quality while reducing costs, visit www.healthedge.com.

Today, change management is about effective listening and communication with your team—a strategy popularized by GE’s Change Acceleration Process. In times of change, employees are likely worried about job security or status and may not see why the change is necessary. Helping your team move from the current state to the improved future state requires managerial and structural support.

There are two questions your organization needs to answer before enacting change management:

1. Have we listened to employees and understood their pain points?
2. How will we communicate what we need each team to do?

This process doesn’t happen automatically—it needs to be proactive and intentional. We’ve identified 6 strategies that are essential for change management success.

1. Engage senior leadership.

One key indicator of effective change management is engagement from senior leadership. This is especially true when implementing new workflow technology or replacing a core administrative system. But what does it mean for leadership to be engaged?

To start, company leaders should be talking about the coming changes. Employees need to know why the changes are strategically important. Sharing this information helps them understand why adapting is worth the effort and gives them a sense of purpose beyond simply being told to adapt.

An objective way to measure engagement is by using the “calendar test.” Are executives attending project steering committee or other informative meetings? If not, it’s important to make sure they start. They should be able to speak about the ongoing project and understand how the implementation is progressing. This is also beneficial so senior leaders can see and appreciate the hard work middle managers and other employees are doing to ensure change management success.

2. Outline why change is necessary.

A common misstep that health plans make is assuming that employees know why you’re making this change. Many people won’t understand the need for new technologies or workflows when the original way seemed to work just fine. Your company leaders should be able to articulate the impacts in a way that helps employees feel involved in the decision-making process.

In what areas do you anticipate the most benefit from new systems? That could be paying claims faster or more accurately, complying with state audits, or modernizing legacy systems. Sometimes, the existing technology just isn’t viable any longer and can’t be properly maintained over time. Your employees want to work toward solving an important problem—so give them the information and motivation they need to do so.

3. Communicate the company vision.

Now that your employees and executives understand why change is necessary for your health plan, what is the vision for your organization over the next few years? Paint your team a compelling picture of the future state and where the company is headed. Ideally, your vision contains wording that speaks to both your team’s minds (i.e. intellect) and their hearts (i.e. emotion).

Make sure your team knows that with new technologies comes a chance to improve individual skills and maximize what they’re able to accomplish. In the case of HealthRules Payer, for example, the platform automatically handles adjudication and reviews for errors. This vastly reduces the need for manual reviews, giving employees time to focus on more complex, impactful tasks only they can do.

4. Gain internal commitment.

Encouraging your employees to commit to the change process is about more than education and passive acceptance. Identifying early adopters and internal influencers can be vital for gaining widespread support. These individuals already support the new adoption, which makes it easier for them to be engaged early in the project . They can then become a resource for other employees who have questions or need support during the process.

It is also beneficial to identify who might be resistant to change within your organization. Generally, areas of resistance fall into three categories: technical, political, and cultural. You don’t necessarily need to convert them into supporters, but it’s important to know why they might be hesitant and address their concerns so they’re not constantly pumping the brakes.

To help convince resisters why the change is important, turn to the three D’s:

1. Data: Use data, such as higher payment accuracy rates, to explain why the new system will be better.
2. Demonstrate: Show the new solution and share how other groups best utilize the platform.
3. Demand: Share regulatory requirements and customer expectations that convey why the new technologies are needed.

You do not need everyone at your health plan to be on board. In reality, when approximately one-third of your employees are supportive, the rest will follow and accept the coming change.

5. Adapt underlying systems and structures.

With new tools come new processes. So how can you encourage the change and not force the change?

First, have a plan for how processes will change with the new system and communicate it clearly to your employees. It is possible that the new tools will alter team structure and reporting, leaving some individuals without the support they’re used to. Knowing how they will be expected to work moving forward will help mitigate some of their apprehension.

Changing employee incentives can help with this process. Certain employees might have different goals because the organization can now sell to larger companies with bigger contracts. For others, it may be as simple as removing access to the legacy system and encouraging them to sign in to the modern user-friendly system. Once your team understands the structure of work, they can be more creative and accepting with how they get there.

6. Monitor progress with data.

What gets measured gets done, and what gets rewarded gets repeated. How is your organization measuring progress? What are the key milestones to reaching your goals? Your timeline will be unique based on your company goals, but it’s vital to add checkpoints along the way. Get comfortable with the idea of designing, building, and validating your processes before you go live—and then review and reiterate.

You will also need to know your leading and lagging indicators of project success, as well as how to break them down for iterative measurement. Once the project metrics are agreed on and in place, you can better align your employees to meet them.

Conclusion

Throughout this process, it’s important to remember: if you aren’t adapting and growing, you’re falling behind. Working with the right professional services team can support your organization in defining what change management success means for your organization. This includes steps like project planning to identify scope and milestones, meeting with senior executives to determine measures of success, establishing a steering committee, and enabling your team to continue building toward your objectives.

For more information about the HealthEdge Professional Services team and how it can impact your organization, click here.

More than 3 in 5 Medicaid members have felt overwhelmed by managing their health. The healthcare system can be confusing enough to navigate. For Medicaid members, it can be even more challenging in the face of financial, transportation, and social barriers. To better serve Medicaid members, health plans have to uncover and understand their key concerns.

59% of organizations listed “in-sourcing payment integrity functionality” as a . While outsourcing aspects of payment integrity can help organizations scale their operations, it can also lead to loss of data visibility, increased operating costs, and reliance on contingency vendors.

How can your organization promote greater payment accuracy while reducing costs?

Here are three ways a payment integrity solution like HealthEdge Source can impact your health plan.

1. Combine pricing and editing capabilities in one place.

75% of organizations said it would be “very valuable” to Consolidating solutions can help improve efficiency by bringing key information together, rather than taking extra time gathering fee schedules from multiple locations.

HealthEdge Source users, for example, can leverage native content including CMS, Medicaid, and AMA policies in one place—without the need for additional integrations. Having third-party best-of-breed content available within a single resource enables health plans to gain greater visibility into the payment process and organizational inefficiencies.

2. Improve visibility and analytics

Enable analytics by bringing pricing and editing information—for claims across all lines of business—into one place. See top providers, DRGs, CPT codes, and other insights that make it easier to understand how new policies could impact your claims.

It can be easy to fall into a pattern of relying on a vendor to detect certain issues and patterns without diving deeper into why these errors occur. Leveraging a single solution can reduce administrative burden and reduce the opportunity for mistakes, such as inputting incorrect fee schedules. Instead of trying to pull data from multiple cap systems and present it together, your organization could gain visibility into the root causes of inaccurate payments.

3. Reduce IT burden

Some organizations have reported spending up to a week updating fee schedules in 6 or more places. Each of these platforms has different upload requirements and requires IT support. If IT can’t deliver help in time and there’s an error, then you’d have to rely on a vendor solution to catch it later in the workflow.

This is where bringing pricing and policies together is important. If your team is managing fewer solutions, they’re able to work more efficiently and with a deeper knowledge of the platforms they’re using. There will also be less demand for IT and other internal stakeholders to keep software and other technology up to date.

This is not to say contingency vendors can be beneficial. However, eliminating more straightforward issues like reoccurring overpayments can open the door for vendors to focus on solutions for new and more complex issues. Once your health plan has a single solution in place, your teams can identify leakage in the workflow, understand why it’s happening, and move that information upstream to the primary editing space to ensure more accurate reimbursements.

Shifting from multiple solutions to a single platform doesn’t have to happen all at once. To learn more about the HealthEdge Source payment integrity solution, visit our guide, “Beyond the Basics: The Modern Approach to Payment Integrity Vendors With HealthEdge Source.”

Read the guide

How do we maintain this culture? We interviewed Wendi Ellis, VP of Talent and Learning, to learn about three strategies HealthEdge uses to encourage continuous learning across the organization.

Setting examples through leadership

One way we help build our company culture is leading by example. We set the expectation with company leaders that we prioritize ongoing education. Steve Krupa, HealthEdge’s CEO, is an excellent example of a continuous learner.

“He’s super supportive of recommending books and any of the programs we want to roll out,” said Ellis. “Our entire leadership team is. And I think that, because they’re setting that example at the top, it trickles down across the organization.”

At a structural level, in addition to communicating our learning expectations, we’ve adjusted how we solicit feedback from our employees. We send two engagement surveys every year to help us better understand how employees are being impacted by our new initiatives—and we make sure to take action quickly. This is especially important when it comes to questions about manager behavior and effectiveness.

“It can take up to 12 weeks to change a behavior,” said Ellis. “Not waiting 12 months to see how someone’s improved is a long time. Someone who’s disengaged with their boss will find a job within 90 days in that kind of environment.”

Being able to measure performance and impact every 3-6 months gives employees a chance to hear feedback, change their approach, and then check their progress.

Supporting people managers

Approximately 70% of employee engagement is tied to a person’s manager. Managers impact their employees lives every single day—and now that so many of us are working in a remote environment, we’re impacting people’s home lives as well. As such, Wendi sees being a manager as a responsibility and a privilege.

At HealthEdge, we are passionate about developing managers. We’ve worked hard to create an environment of continuous feedback. This means that we give managers the tools and the framework they need to be able to deliver meaningful and accurate feedback. In 2021, we found that employee performance ratings were overinflated. Managers tended to shy away from giving constructive feedback to avoid the conversations feeling like a confrontation. This was influenced in part by “the great resignation” that happened across industries

To help support managers in these discussions, we started by focusing on education. We gave managers a baseline of how we expect them to deliver feedback, including frequency and different ways to approach the conversation.

Improved feedback and review cycles

In addition to giving managers the tools to hold meaningful discussions with their direct reports, we also adjusted our annual performance review cycle. Instead of holding mid-year performance reviews, we now have mid-year check-ins. This shift allows mid-year conversations to center around what is going well for individual employees and where they’d like to continue improving rather than focusing on a rating.

“That conversation is going to be less threatening, more productive, and more empowering for our employees,” said Ellis.

To prepare members and individual contributors for performance conversations, we held training sessions to make sure everyone understood the core competencies they we’re being measured against. As part of this, we updated our descriptions of the behaviors we expect when it comes to those competencies.

And we don’t limit feedback to performance reviews. Another action we take is holding focus groups after every new initiative we launch. We ask employees what went well, what didn’t go well, and what changes they would like to see in the next iteration.

“That continuous improvement mindset is something we’ve built into everything we do,” said Ellis. “I’ve never worked for an organization where we have that level of respect, and where our voices can be heard the way that they are here.”

To stay up to date with TiC regulations, the HealthEdge Source team has developed a comprehensive solution that focuses on:

• Adherence to CMS mandate
• Recognition of customer nuances
• Customization of requirements including schedule to match system capabilities with customer needs
• Ability to generate MRFs that include rates specific to selected configurations
  • Rates are generated based on:
    • Medicare payment systems for Professional and Institutional Provider Types.
    • Commercial payment methodology, as configured in your Source environment.
    • Schedules and parameters that you configure within the Source application.

The TiC functionality within HealthEdge Source leverages existing configurations to adhere to the CMS mandate by automatically generating machine-readable files (MRFs) that are specific to those configurations. For example, if a customer is using a configuration that has 105% of Medicare professional rates, this would be reflected in that customer’s MRFs. Customers will be able to select the configuration, the state, the provider type, if necessary, and users can add subscribers to the message alerts when files are ready in a pre-determined location to be picked up by a SFTP process.

Below, I’ve addressed some common questions our customers have about working with MRFs in HealthEdge Source.

Q: What is an MRF?

A: An MRF is a digital representation of information. The TiC regulations require MRFs in an open-standard format that can be used for sharing with healthcare consumers, for example, on a portal or website. HealthEdge Source supports the JSON format, which complies with the CMS requirement.

Q: What is the basis for creating MRFs in Source?

A: MRFs can be created for contracts that have been set up as configurations in Source. The rates produced in MRFs will be based on configuration-specific provider type and payment methodology.

Q: Is HealthEdge Source able to produce rates more specific than configuration-based rates?

A: Yes. The system can produce rates based on services (billing codes) and modifiers included in CMS fee and data schedules.

Q: How frequently can MRFs be generated?

A: HealthEdge Source can generate files monthly per CMS mandate and per customer need. The generation of files may be scheduled in advance by product end-users to support timely delivery of rate updates.

Q: How will rates be accessed?

A: Rates that appear on an MRF will be accessed as JSON based files via SFTP. An email notification can be configured when files are ready to be picked up. Due to file size, the file itself will not be emailed; however, a link to where files are housed will be provided.

Q: What types of rates do MRFs contain?

A: TiC MRFs consist of rate schedules for healthcare items and services. These rate schedules are based on your HealthEdge Source configurations and include the in-network and negotiated rates per your provider contracts as well CMS rates and policy data for all localities and ZIP codes. Each rate schedule covers a type of billing code, including case-mix group (CMG), HCPCS, CPT®, HIPPS, MS-DRG, and revenue code (RC).

Q: Is this feature licensed?

A: The capability to generate MRFs is available for all HealthEdge Source clients; however, a license is needed to turn it on in your environment.

• Patients and payers
• Providers and payers
• Payers and other payers

Interoperability is taking center stage like never before. With the rapid advancement of technology and the increasing importance of patient-centric care, the Centers for Medicare & Medicaid Services (CMS) has introduced a set of regulations and rulings that are set to transform how healthcare information is shared and utilized.

Let’s explore these regulations to understand better why interoperability is crucial for payers and the healthcare industry as a whole.

Understanding Interoperability Regulations

Interoperability refers to the ability of different healthcare systems and software applications to communicate, exchange data, and use the information that has been exchanged. In 2024, CMS is implementing a series of regulations aimed at enhancing interoperability, with the key components being:

• Patient Access: CMS mandates that payers provide patients with access to their health information through standardized application programming interfaces (APIs). APIs mean that patients can securely access their health data, including claims and clinical information, through mobile apps or web portals. HealthRules Payer makes it easy for payers to leverage its robust set of APIs to meet these mandates.
• Provider Directory: Payers are required to maintain and update a comprehensive provider directory, ensuring that patients have access to accurate and up-to-date information about healthcare providers in their network. This directory must be made available through APIs, enabling third-party applications to incorporate this data. HealthEdge recently delivered its Provider Data Management solution to help payers meet this challenge and ensure all provider directories stay up-to-date and remain compliant.
• Data Exchange: The CMS is promoting the use of Fast Healthcare Interoperability Resources (FHIR) standards for data exchange. This will facilitate the sharing of patient data across different healthcare systems and applications, improving care coordination and reducing administrative burden. HealthEdge APIs are all consistent with these new CMS standards for sharing data.

5 Reasons Why Interoperability Matters

1. Improved Patient Outcomes:

Interoperability ensures that healthcare providers have access to a patient’s complete medical history, enabling them to make more informed decisions about their care, leading to faster diagnosis, more effective treatment plans, and, ultimately, improved patient outcomes.

2. Enhanced Care Coordination:

With interoperable systems, different care settings and providers can seamlessly share information, reducing the risk of duplicative tests and treatments, leading to better-coordinated care and a more efficient healthcare system.

3. Empowering Patients:

The ability for patients to access their health data empowers them to take a more active role in their healthcare journey. It fosters transparency and allows patients to make informed decisions about their care, leading to better engagement and satisfaction.

4. Reduced Healthcare Costs:

Interoperability can significantly reduce administrative costs by streamlining data exchange and reducing paperwork, which translates to cost savings for payers, providers, and patients alike.

5. Regulatory Compliance:

Adhering to CMS interoperability regulations is not just a matter of compliance; it’s a strategic imperative. Payers who embrace interoperability early on will be better positioned to thrive in the evolving healthcare landscape.

Examples of Interoperability Success

HealthEdge^®, a leading enterprise solution provider for payers, is fully prepared to guide its more than 100 payers who depend on HealthEdge solutions, including HealthRules^® Payer (core administrative processing system), GuidingCare^® (care management), HealthEdge Source (prospective payment integrity), and Wellframe (digital member engagement), to not only be compliant with emerging interoperability regulations but also leverage its highly interoperable systems to improve member outcomes, reduce cost and administrative waste, as well as deliver exceptional member experiences.

Payers can use the HealthEdge solutions as standalone next-generation software or deploy them as an integrated platform of digital solutions. Here are a few examples of how HealthEdge solutions help payers leverage their highly interoperable systems to achieve considerable success.

The HealthRules Payer Core Administrative Processing System (CAPS):

Dramatically reduces costs and administrative waste by delivering 90%–97% first-pass auto-adjudication rates and 99%+ accuracy. It opens the door to new value-based reimbursement models, benefit plans, and provider contracts and provides business insights that improve outcomes, lower costs, and increase transparency.

GuidingCare:

With 75+ unique vendor integrations, 12 productized integrations, and 75 API endpoints, GuidingCare offers payers a comprehensive solution for achieving interoperability within care management and across the healthcare ecosystem. By embracing such platforms, health plans can bolster their care management strategies, align with evolving industry demands, and ultimately provide better experiences and outcomes for their members.

Care-Payer Integration:

This unique pre-integrated solution that combines the power of HealthRules Payer and GuidingCare provides the API-based integration that enables the continuous management of member care and core administrative processes, further demonstrating how interoperability plays a big role in successful care management strategies.

Payer-Source Integration:

The integration between HealthRules® Payer and HealthEdge Source creates operational efficiency and accuracy in claims pricing and editing, which improves payer-provider relations and member satisfaction. Source is the first digital prospective payment integrity solution to natively bring together claim payment automation with proactive business intelligence, enabling payers with Medicare, Medicaid, and commercial lines of business to have better relationships with providers, reduce waste, and improve their financial performance.

Looking Ahead

As we look ahead to 2024, providing transparency, reducing costs, creating seamless and efficient care coordination, and improving health outcomes are the backbone of the CMS Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P), requiring payers to continue to integrate system functions and coordinate across the healthcare ecosystem in 2024.

Those payers who embrace modern, highly interoperable solutions and a solid digital transformation platform, like HealthEdge, are uniquely positioned to succeed when it comes to interoperability mandates and delivering higher quality, member-centric care, and services.

To explore how HealthEdge® can help you create transformational consumer experiences, deliver payer business agility, and accelerate your digital health payer strategy, visit www.healthedge.com.

The driving force behind many of the regulatory changes is CMS’s push to accelerate the digital transformation of the health insurance industry, similar to what CMS did nearly 15 years ago with the acute and ambulatory provider segments with the Health Information Technology for Economic and Clinical Health (HITECH) Act. Let’s take a closer look at five major regulatory requirements that are sure to keep payers on their toes in 2024.

1. Transparency in Coverage

Originally announced in 2020, the Transparency in Coverage Act has continued to expand in scope and reach over the past several years. As of January 1, 2022, payers were required to make pricing data on all items and services, for both in-network and out-of-network providers, made available in a format that computers could read, called Machine Readable Files (MRFs) free of charge. In 2023, CMS mandated that cost-sharing information be made available. By January 1, 2024, payers must provide cost-sharing information for all items and services available to members.

Transparency in coverage was a heavy technical lift for many payers. But those who are on more modern core administrative processing systems (CAPS), like HealthRules^® Payer, have been able to leverage HealthEdge’s APIs and tools, such as the company’s Price Comparison Tool, to meet the regulatory requirements with ease.

Transparency in coverage was a heavy technical lift for many payers. But those who are on more modern core administrative processing systems (CAPS), like HealthRules^® Payer, have been able to leverage HealthEdge’s APIs and tools, such as the company’s Price Comparison Tool, to meet the regulatory requirements with ease.

Making pricing data available in a consumer-friendly format and driving engagement with members who want to “shop” can be viewed as both a challenge and an opportunity in 2024.

• The challenges center on making the data easy for the everyday person to search for and understand, and presenting an accurate, real-time picture of each specific member’s cost-sharing responsibilities. For example, the system needs to say, “You are covered, and because it is a screening service, there will be no cost to you,” or “Because this is a diagnostic procedure, and because you have not met your deductible, there will be a cost of $X to you. There is a huge potential for members to become confused and highly frustrated, driving more calls to the support centers and contributing negatively to member satisfaction. Payers who depend on HealthRules Payer and HealthEdge Source benefit from an integrated solution called Payer-Source that delivers higher levels of accuracy because the responses are based on the negotiated rate and the claims data instead of just the negotiated rate.
• For forward-thinking payers, this creates endless opportunities to strengthen member engagement with those coming to their websites and member portals to “shop.” In 2024, these payers will seek to optimize this online shopping experience to inform members of missed screenings and vaccinations, promote healthy behaviors, and encourage more member responsibilities, all contributing to HEDIS scores and Star ratings. HealthEdge products and services support the needs of the portal through the real-time ability to provide personalized cost-sharing data specific to the member’s benefit plan, benefits used, and provider(s) selected.

CMS Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule

While interoperability is not a new topic within the healthcare industry, a wave of proposed rules focused on facilitating the exchange of health data between patients, providers, and payers are proving to be formidable challenges for payers dependent on legacy or outdated technology. The proposed rule focuses on the following:

Establishing data exchange standards among patients, healthcare providers, and payers:

• • According to CMS, the proposed policies in this rule will enable improved access to health data, supporting higher-quality care for patients with fewer disruptions. These policies include expanding the current Patient Access API to include information about prior authorization decisions, allowing providers to access their patients’ data by requiring payers to build and maintain a Provider Access FHIR API, to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship; and creating longitudinal patient records by requiring payers to exchange patient data using a Payer-to-Payer FHIR API when a patient moves between payers or has concurrent payers.HealthRules Payer customers can use the advanced set of APIs from HealthEdge to comply with the final rule. Plus, for Medicare Advantage plans, advancing interoperability leads to visibility and exchange of data, which can result in strategies for better outcomes and lower costs, leading to improved Star Ratings.

Improving the prior authorization process through policies and technologies:

• • The rule requires payers to implement an electronic prior authorization process, which will shorten the time payers can take to respond to prior authorization requests and establish policies to make the prior authorization process more efficient and transparent. The rule also supports the development of standards that payers will follow when exchanging data, making it easier to ensure complete patient records are available when transitioning between payers.The mechanism the rule uses to enforce the mandate will be APIs. More specifically, the proposed rule will require health plans to use a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorizations. By providing standards that all health plans must use, it is likely that in the long run, the rule will be more effective. HealthEdge’s robust API enables payers to meet all the interoperability standards and facilitates adherence to emerging prior authorization requirements.

2. Advancing health equity and improving access to care:

CMS recently released an updated framework, called CMS Framework for Health Equity, for further advancing health equity, expanding coverage, and improving health outcomes for its more than 170 million individuals supported by CMS programs. The framework sets the foundation and priorities for CMS’s work, strengthening its infrastructure for assessment, creating synergies across the healthcare system to drive structural change, and identifying and working to eliminate barriers to CMS-supported benefits, services, and coverage. There are five health equity priorities that CMS has stated for this new framework that is focused on reducing health disparities:

• Expand the Collection, Reporting, and Analysis of Standardized Data
• Assess Causes of Disparities Within CMS Programs and Address Inequities in Policies and Operations to Close Gaps
• Build Capacity of Health Care Organizations and the Workforce to Reduce Health and Health Care Disparities
• Advance Language Access, Health Literacy, and the Provision of Culturally Tailored Services
• Increase All Forms of Accessibility to Health Care Services and Coverage:

Previously, the health detriments and outcomes data primarily included geography/zip code and gender. Now, requirements include capturing and measuring health equity data such as gender, race, ethnicity, sexual orientation, gender identity, social, economic, and geographic area.

CMS strives to improve its collection and use of comprehensive, interoperable, standardized individual-level demographic and social determinants of health (SDOH) data, including race, ethnicity, language, gender identity, sex, sexual orientation, disability status, and SDOH.

Payers who depend on HealthEdge’s GuidingCare care management platform are already capturing this information to get a more holistic view of their members. Others who are using outdated technology will continue to struggle.

3. No Surprises Act

Introduced in 2021, the No Surprises Act was designed to protect consumers against surprise medical bills from out-of-network providers and high health plan cost-sharing policies. It has evolved over the past several years, and that trend will continue in 2024. In fact, on October 27, 2023, a rule was released proposing new processes and policies related to the Federal independent dispute resolution (IDR) process operation. This proposed rule would serve to expedite the processing of disputes by certified IDR entities. Read the Federal IDR Process Operations Proposed Rule to learn more about the proposed requirements. A fundamental piece to avoiding surprise billing is the ability for payers to maintain complete and up-to-date provider data directories. HealthEdge is delivering on its commitment with its new Provider Data Management solution (PDM).

4. Changes in Star Ratings for Medicare Advantage Plans

According to a 2023 article in Modern Healthcare, “Earlier this year, the Centers for Medicare & Medicaid Services (CMS) announced several changes to Medicare Advantage that will take effect in 2023. The changes aim to advance CMS’s vision for health equity, drive comprehensive, person-centered care, and promote Medicare affordability and sustainability. They include updates to Medicare Advantage capitation rates, Part C and Part D payment policies, and Star Ratings.”

Changes in the way Star ratings are calculated are of particular interest to health plans because Star ratings are directly tied to CMS bonuses payments and incentives. They are designed to reflect the quality of care a health plan delivers, and a large portion also reflects a patients’ experiences with health plans. By doubling the weight placed on the member experience for Star ratings, CMS is encouraging payers to focus on improving the member experience.

Data collected in 2024/2025 will greatly impact 2027 Star Ratings. With HealthRules Payer, payers can run modeling in 2024 to project their 2027 outcomes and develop corrective adjustments. The combination of HealthRules Payer and Guiding Care, along with the open APIs on the HealthEdge platform, provides payers with a comprehensive platform that can help them identify necessary adjustments that must be made now before these new calculations take effect.

More details of the Star rating changes planned in 2024 can be found in this fact sheet posted on the CMS website.

The Bottom Line

Regulatory trends will continue to push payers to accelerate their digital transformation journeys in 2024. Modern technology solutions from HealthEdge, along with the company’s dedicated team of regulatory specialists, are helping more than 100 payers to prepare for and optimize these regulatory changes to create competitive advantage and greater business insights.

To learn more about HealthEdge, visit www.healthedge.com.

That’s where population health software solutions come in – powerful tools that help payers address these challenges head-on. When leveraging modern population health solutions, payers can expect the following seven business advantages:

1. Improved Data Management and Analysis:

One of the key advantages of population health software is its ability to aggregate and analyze vast amounts of healthcare data. Payers can harness this capability to gain deeper insights into their member populations, identifying trends, patterns, and risk factors. This comprehensive view of data allows payers to make informed decisions, such as developing targeted interventions, forecasting healthcare utilization, and allocating resources effectively. It also gives care managers the ability to deliver more personalized care plans that address the specific needs of members, especially those at risk for costly complications from chronic diseases.

2. Enhanced Care Coordination:

Effective care coordination is essential for improving patient outcomes and reducing costs. Population health solutions facilitate better communication and collaboration among healthcare providers, enabling seamless coordination of care plans. Payers can leverage this advantage to ensure their members receive the proper care at the right time, reducing unnecessary hospital admissions and readmissions. For example, the GuidingCare^® Population Health Management module incorporates gaps-in-care analytics that enable clinical staff to identify high-risk patients and potential health improvement opportunities.

3. Risk Stratification and Predictive Analytics:

Population health solutions employ advanced algorithms to stratify members based on their health risks and needs. By categorizing members into risk tiers, payers can prioritize interventions for high-risk individuals, ultimately reducing costs associated with chronic conditions and preventable hospitalizations. Predictive analytics can help payers anticipate future healthcare trends and allocate resources accordingly.

4. Enhanced Member Engagement:

Engaging members in their healthcare is critical to improving health outcomes. Population health software provides payers the tools to create personalized health plans, offer wellness programs, and send targeted health information to members. Modern population health solutions can easily exchange information with member engagement solutions. For example, the GuidingCare care management platform is enhanced with the capabilities of Wellframe, a digital member engagement platform also from HealthEdge. Payers earn members’ trust by delivering a more personalized and compelling member experience. They can amplify and scale member support, access real-time member insights, unify the member experience, and consolidate staff workflows.

5. Efficient Claims Processing:

Streamlining claims processing is essential for reducing administrative costs and improving overall efficiency. Population health solutions, like GuidingCare’s Population Health Management module, often integrate with existing claims management systems, enabling payers to identify potential billing errors, fraud, and waste more effectively. For example, Care-Payer, the productized data exchange between HealthEdge’s core administrative processing system, HealthRules® Payer, and its care management platform, GuidingCare, enables the continuous management of member care and core administrative processes between the platforms. Care-Payer gives staff, care managers, and providers unparalleled access to near-real-time benefits information. Upon submission of the authorization in GuidingCare, users are assured that the authorization will flow through HealthRules Payer without error.

6. Compliance and Reporting:

The healthcare industry is heavily regulated, with numerous reporting requirements and quality measures to meet. Business intelligence capabilities within modern population health solutions can automate tracking and reporting these measures, ensuring that payers remain in compliance with government and industry standards. This reduces the risk of penalties and demonstrates a commitment to quality care.

7. Cost Savings and Revenue Generation:

Ultimately, the goal of any payer is to control costs while maintaining or improving the quality of care and member experiences. Population health software solutions enable payers to identify cost-saving opportunities, such as reducing hospital readmissions, preventing unnecessary tests and procedures, and negotiating favorable contracts with healthcare providers. Additionally, by improving member satisfaction and engagement, payers can potentially attract new members and generate additional revenue.

Population health software solutions have become critical tools for payers seeking to navigate the complex healthcare landscape effectively. Payers can control costs and improve the health and well-being of their members by harnessing the power of data analytics, care coordination, risk stratification, and member engagement. As healthcare continues to evolve, population health software will remain a critical component of payer strategies for delivering high-quality care while maintaining financial sustainability.

To learn more about GuidingCare population health management solutions, visit www.healthedge.com.

It can be easy to implement a new platform and think, ‘Phew! Glad that’s over’. But in the world of digital transformation, it’s a journey, and Go-Live  is not the destination.

Build continuous optimization into your plan. We always recommend an annual optimization assessment where we have a team of SMEs sit with you and evaluate how you use the product. From that evaluation, we identify recommendations to improve workflows, take advantage of new features, and add integrations or automation to remove manual or time-consuming activities. In addition, planning for upgrades enables you to stay current on the platform, giving you more features to drive your business to continuous improvement.

Follow these optimization best practices and avoid these common pitfalls:

Optimization Top 3 Best Practices

1. Adopt a Strategic Operating Model

Plan to move from Project Governance to a Strategic Operating Model with your ecosystem partners. Share your roadmap with HealthEdge so that we can consider the best ways to support your success and ongoing growth plans.

2. Annual Optimization Assessment

Plan for an annual optimization assessment. Evaluate how you are using the solution and develop a set of recommendations designed to drive optimization. Software improves, business evolves, and your needs may change. Adopt a continuous improvement approach to the operation.

3. Quarterly Business Reviews

Conduct quarterly business reviews (cross functional with CSE, Services and Product leadership). Maintain tight alignment of business and product roadmaps, upgrades, enhancements, and support needs. Consider any blockers to your success and how we can help remove them in the upcoming quarter. Set partnership goals to ensure the best path to success.

3 Common Optimization Pitfalls

1. Disbanding the “Project”

The project completion is just the beginning. Don’t stop fostering partnerships and influencing roadmaps. Don’t adopt an implemented and “done” mentality. Continue to use our partnership to meet your goals through consulting or customization.

2. Diminishing Return on Investment

Don’t allow your investment value to decrease, your software to get outdated, or your teams to struggle. Be proactive rather than reactive.

3. Lagging Behind

Waiting too long to upgrade results in additional cost and effort. Don’t miss out on improvements requested by the customer base. Take advantage of our technical-only upgrades that can be completed in 4-5 months. Actively review release notes for features that may enhance your business and ask for help in identifying and implementing new features that fit your needs.

HealthEdge & Healthcare Payer Digital Transformation

By implementing the HealthEdge solutions you will transform your business and operations. Our solutions will automate your business workflows and seamlessly exchange  data in real-time across the ecosystem, allowing you to experience the business benefits of: 

• Improved End-User & Consumer Centricity
• Ever Reducing Transaction Costs
• Ever Increasing Quality
• Ever increasing service levels
• Business transparency

HealthEdge Professional Services

HealthEdge’s Professional services provides expertise and support to accelerate your digital transformation. To become a next-generation health plan, you need a digital foundation that enables you to provide a transparent and person-centric experience at lower cost, higher quality, and higher service levels. HealthEdge® solutions provide that foundation – and HealthEdge Professional Services deliver the expertise and support to make the process swift, sure, and effective.

Learn more about HealthEdge Professional Services.

Join us for the rest of the Healthcare Payer Digital Transformation series

• Healthcare Payer Digital Transformation: Navigating Change Through Strategic Planning
• Healthcare Payer Digital Transformation: Prepare & Plan
• Healthcare Payer Digital Transformation: Design Excellence
• Healthcare Payer Digital Transformation: Execute
• Healthcare Payer Digital Transformation: 3 Critical KPIs
• Healthcare Payer Digital Transformation: Optimize

Undertaking a healthcare payer digital transformation, such as migrating to a new CAPs or Care Management System is one of the biggest business transformations you might ever be involved in. With change and impact of this magnitude, it’s critical to constantly monitor the success of these changes.

This kind of change is a marathon, not a sprint. It requires ongoing measurement and optimization. Be prepared to measure your progress so you can quantify success and know when to pivot. To do this, organizations must identify what is important to them and set target goals.

Top 3 Measurement Metrics:

1. Legacy Benchmarks

Know your legacy KPIs. Consider initial KPIs to legacy such as transaction turnaround time, auto adjudication rates, authorization turnaround time, claims backlog, etc. Good questions to ask include:

• Are your auto adjudication rates better than your legacy rates?
• Are you getting better than average auto adjudication rates?
• Are you able to measure customer satisfaction and tie it back to specific improvements you’ve made? Such as faster access to information for your customer service teams or a better member portal.
• Have your authorization turnaround times improved?

2. Project Metrics During Implementation

Monitor project metrics weekly so that you can adjust proactively based on what your project is trying to achieve. Include KPIs to benchmark project metrics such as on time, on budget, in scope and employee satisfaction. If a project metric is go-live by end of year, that will affect project decisions such as adding additional scope or functionality that is not needed day 1.

3. Ongoing Quarterly Operational Metrics

Keep your metrics front and center. Use them to motivate the teams, adjust, and improve.

Top 3 Measurement Mistakes:

Don’t make these common mistakes:

1. Unable to prove it.

Take the emotion out of evaluating success. Stick to the facts. Don’t rely on ‘trusting your gut’. Determine how the metric will be calculated, how often and by whom.

2. Perception over Reality

Let the data tell the story, measure the project health and guide changes. If you miss the target, determine the reasons why and create an action plan to get you back on track.

3. Getting Complacent

Stay vigilant and adjust as needed. Your business will evolve – keep pace.

Sample Measurement Dashboard

Showcasing your KPIs on a dashboard is a quick and easy way to showcase your progress on your digital transformation journey and rally your team. Share it with the project team and wider organization to bring everyone along on the transformation journey.

HealthEdge: Healthcare Payer Digital Transformation and Professional Services

HealthEdge’s Professional Services provides expertise and support to accelerate your digital transformation. To become a next-generation health plan, you need a digital foundation that enables you to provide a transparent and person-centric experience at lower cost, higher quality, and higher service levels. HealthEdge® solutions provide that foundation – and HealthEdge Professional Services deliver the expertise and support to make the process swift, sure, and effective.

Learn more about HealthEdge Professional Services.

Join us for the rest of the Healthcare Payer Digital Transformation series

• Healthcare Payer Digital Transformation: Navigating Change Through Strategic Planning
• Healthcare Payer Digital Transformation: Prepare & Plan 
• Healthcare Payer Digital Transformation: Design Excellence
• Healthcare Payer Digital Transformation: Execute 
• Healthcare Payer Digital Transformation: 3 Critical KPIs – coming soon!
• Healthcare Payer Digital Transformation: Optimize – coming soon!

Once you have your digital transformation plan, the next step is to execute against that plan. It’s critical to follow it, document changes, assess impacts, and communicate. Governance, clear communication, and effective decision-making infrastructure are critically important. Do not underestimate the need for an Enterprise Program Management or Strategic Operating Model.

Top 3 Execution Best Practices

1. Project and Business Artifacts

Align on a standard set of projects and/or operational artifacts that you will use to track progress. Leverage schedules, reports and RAID logs to ensure that everyone involved and interested is following the same plan.

2. Change Management

Change is inevitable. Establish your internal change management processes to reach the grassroots. Change managements starts from the top and cannot be one & done. Plan on having a series of touch points (townhalls, weekly newsletters providing progress etc.) to continue to generate excitement about the new software at all levels.

3. Metrics

Keep your metrics front and center. Use them to motivate the teams, adjust and improve. Metrics need to drive your decisions. Test and stick to your benchmarks for an acceptable pass rate. Metrics also ensure accountability.

Top 3 Execution Mistakes

1. Limited Visibility

Limited visibility into progress, issues, and decisions that need to be made can multiply disruption in schedules and resolution. It can also build distrust amongst the teams involved. Always overcommunicate and ensure everyone is following the same plan. Sharing key artifacts across teams helps mitigate risk and disruption.

2. Confusion and Bad Decisions

Understand any impacts of the change to the overall project or business operations, reporting, timing, staffing, and support. The fastest way to sink a good plan is by not managing change effectively. Without a change management process, you will likely miss details around the impacts of the change.

3. Gut Decisions

Rely on metrics and data to inform decisions throughout the execution. Cutting corners on the time you dedicate to testing to hit a date means you will have to cut scope. Cutting scope means you are introducing unnecessary risk to your business. If you have a plan to test 100 E2E test scenarios that cover your critical business operations, and you reduce that to 50 E2E test cases you can expect at least half of your critical operations will likely have an issue that you discover in Production.

HealthEdge: Healthcare Payer Digital Transformation and Professional Services

HealthEdge’s Professional Services provides expertise and support to accelerate your digital transformation. To become a next-generation health plan, you need a digital foundation that enables you to provide a transparent and person-centric experience at lower cost, higher quality, and higher service levels. HealthEdge® solutions provide that foundation – and HealthEdge Professional Services deliver the expertise and support to make the process swift, sure, and effective.

Learn more about HealthEdge Professional Services.

Join us for the rest of the Healthcare Payer Digital Transformation series

• Healthcare Payer Digital Transformation: Navigating Change Through Strategic Planning
• Healthcare Payer Digital Transformation: Prepare & Plan
• Healthcare Payer Digital Transformation: Design Excellence
• Healthcare Payer Digital Transformation: Execute
• Healthcare Payer Digital Transformation: 3 Critical KPIs – coming soon!
• Healthcare Payer Digital Transformation: Optimize – coming soon!

You are not investing in this transformation to rebuild your legacy system on a new technology. You are modernizing and improving your business operations, driving increased quality, better service and driving cost out of the transactions. Design based on best practices to meet your goals and objectives. Don’t be handcuffed by lack of feature/functionality of your existing solution – encourage curiosity and question why.

Design for your future: Top 3 Best Practices

1. Organizational Change Management (OCM)

Organizational change management plans are a critical success factor. Invest in this area and focus on communication plans, processes, staffing, and desk level procedures. Ensure the people, process, and technology components are identified and accounted for in the design plan.

Define and deploy strategies for successful user adoption. If the end users are not on board, health plans are unable to realize the full ROI of their investment.

2. Ecosystem Design

Finalize and design your ecosystem in its entirety. Design for goals and objectives and identify workstream leaders that are excited about the future changes. Embrace best practice designs. Remember – the “Just because we’ve always done it this way” mentality won’t deliver a transformation. Instead, ask yourself, “why did we do it this way?” Give yourself the time and space to reflect on why things were done in a certain way and how they can be enhanced.

3. Centered on Goals and Objectives

Design decisions in support of desired outcomes. Reinforce the goals and objectives frequently. Address the fears that people will be replaced with technology. They are being freed from manual processes so that they can use their expertise to focus on things that have a bigger impact.

Design for your digital transformation future: Top 3 Mistakes

Be sure to avoid the following missteps:

1. The “Surprise” Factor

The list of people, processes, and technology changes is extensive. Develop an OCM plan to mitigate risk. Don’t underestimate the data clean up that will be required.

2. Disruption

Changing ecosystem partners will impact data, integrations, timelines, and budgets. Avoid changing key vendors while the project is in flight. This can cause disruption and rework to data requirements.

3. Rebuilding Legacy Workflows

Legacy workflows are not delivering on your future state goal and objectives. Don’t let the notion of ‘perfect’ get in the way of ‘good enough/better’ than today.

HealthEdge: Healthcare Payer Digital Transformation and Professional Services

HealthEdge’s Professional Services provides expertise and support to accelerate your digital transformation. To become a next-generation health plan, you need a digital foundation that enables you to provide a transparent and person-centric experience at lower cost, higher quality, and higher service levels. HealthEdge® solutions provide that foundation – and HealthEdge Professional Services deliver the expertise and support to make the process swift, sure, and effective.

Learn more about HealthEdge Professional Services.

Join us for the rest of the Healthcare Payer Digital Transformation series

• Healthcare Payer Digital Transformation: Navigating Change Through Strategic Planning
• Healthcare Payer Digital Transformation: Prepare & Plan
• Healthcare Payer Digital Transformation: Design Excellence
• Healthcare Payer Digital Transformation: Execute – coming soon!
• Healthcare Payer Digital Transformation: 3 Critical KPIs – coming soon!
• Healthcare Payer Digital Transformation: Optimize – coming soon!

Top 3 Most Common Digital Transformation Planning Mistakes

1. “Filling in the Blanks”

Insufficient information and lack of goal communication can cause people to make up information in the absence of details. Executive decisions can also be misunderstood by the project/operational teams without sufficient information and context. Proactively share information and bring people along on the journey. Always overcommunicate.

2. Scope Creep

Adding/changing scope without considering its impact to your goals and objectives can cause budget and operational consequences. Establish your scope based on your objectives and goals and stick to it.

3. Job Security Mindset

The fear of being replaced by technology is real for a lot of people. This can cause people to not share legacy information so that they can’t be replaced by technology.

Plan for the Digital Transformation

Don’t fall victim to the “Ready, Fire, Aim” approach. Slow down and build the plan, prepare to initiate the next phase, gather requirements, think about the organizational change that will need to occur, be mindful in your decisions, and build in mitigation plans for critical dependencies and dates. Comprehensive preparation empowers your team to pivot and keep going rather than losing even more time having to do that work later, or possibly redoing it.

Ensure your people, processes, and technology are fully aligned before the project commences. Include the following considerations:

Top 3 Digital Transformation Planning Best Practices: Goals, Objectives, and KPIs

In the words of Stephen Covey, begin with the end in mind. What do you want to achieve? Why do you want to achieve it? What will achieving it mean to your members, your staff, your organization?

Define why you have decided to do this, your business goals and objectives, the current KPIs, and what you expect to achieve after implementing this new solution.

1. Define the Why

What are the business and technology goals behind the decision?

2. Evaluate impact on decisions

What are your goals and objectives? Will this have a positive impact on them? How will this change impact your technology, process, and people?

3. Establish a communication plan

Transparency and communication support the change. Focus on building cascade, transparency, and consensus. Document and publish it. These goals and objectives should become core to how you make decisions about scope and changes throughout the implementation and ongoing management of the solution.

HealthEdge: Healthcare Payer Digital Transformation and Professional Services

HealthEdge’s Professional Services provides expertise and support to accelerate your digital transformation. To become a next-generation health plan, you need a digital foundation that enables you to provide a transparent and person-centric experience at lower cost, higher quality, and higher service levels. HealthEdge® solutions provide that foundation – and HealthEdge Professional Services deliver the expertise and support to make the process swift, sure, and effective.

Learn more about HealthEdge Professional Services.

Join us for the rest of the Healthcare Payer Digital Transformation series

• Healthcare Payer Digital Transformation: Navigating Change Through Strategic Planning
• Healthcare Payer Digital Transformation: Prepare & Plan
• Healthcare Payer Digital Transformation: Design Excellence – coming soon!
• Healthcare Payer Digital Transformation: Execute – coming soon!
• Healthcare Payer Digital Transformation: 3 Critical KPIs – coming soon!
• Healthcare Payer Digital Transformation: Optimize – coming soon!

If you are reading this blog, you are likely somewhere on your journey to becoming a Digital Payer. In fact, you are likely already a digital payer in some areas and continuously looking to optimize and expand your digital transformation.

Five key Digital Payer characteristics:

1. Improving Member Experience

You are working to improve the end user/member experience through access to information and digital tools, maybe through your member portals, price comparison tools, online PCP selection, etc.

2. Reducing Transaction Costs

You are always looking to reduce transaction costs; increasing your auto adjudication rates, eliminating manual intervention in claims processing, digital authorizations, etc.

3. Improving Quality

You are constantly on the hunt to improve quality; in how you operate the business, ensuring your staff is trained and taking advantage of all the ways they can leverage available technology, managing to key metrics and using data to identify improvement areas.

4. Enhancing Service

You are constantly working on improving your services levels; maybe through digital survey tools that allow you to capture data, analyze feedback, and adjust.

5. Increasing Transparency

You are operating your business with transparency; leveraging platforms and digital tools to provide information, self-service, and online collaboration tools to improve communication and information sharing.

Navigating Change

A key factor to consider, regardless of where you are in your digital payer life cycle (thinking about implementing a change, in the middle of an implementation, or actively running your business on HealthEdge) is that you are transforming your business.

The reality is that if we put our “continuous improvement” hats on we never really reach “the end”. This is why it’s imperative that we talk about how critical planning is to success.

Business Transformation is a Marathon…Not a Sprint

Adopting a “Marathon Mindset” is a critical mindset. When you decide to implement a new enterprise software solution, you are initiating one of the biggest business transformations you might ever be involved in. Typically, a health plan will migrate to a CAPs or Care Management system once in a generation

It’s important to prepare the team for a marathon not a sprint…meaning we have got to start to think “continuous improvement” and this approach will serve you regardless of where you are in your digital transformation.

Six Main pillars of Digital Payer Transformation

There are 6 main pillars of a successful digital transformation:

1. Define your Success
2. Plan & Prepare
3. Design the future state
4. Execute the plan
5. Measure key performance metrics
6. Optimize for continuous improvement

HealthEdge & Digital Transformation

By automating business workflows and seamlessly exchanging data in real-time across the ecosystem, HealthEdge customers experience the business benefits of: 

• Improved end-user experience
• Decreased transaction costs
• Increased quality
• Increased service levels
• Increased business transparency

HealthEdge: Healthcare Payer Digital Transformation and Professional Services

HealthEdge’s Professional services provides expertise and support to accelerate your digital transformation. To become a next-generation health plan, you need a digital foundation that enables you to provide a transparent and person-centric experience at lower cost, higher quality, and higher service levels. HealthEdge® solutions provide that foundation – and HealthEdge Professional Services deliver the expertise and support to make the process swift, sure, and effective.

Learn more about HealthEdge Professional Services.

We will be exploring these in depth through an upcoming healthcare payer digital transformation series:

• Healthcare Payer Digital Transformation: Prepare & Plan
• Healthcare Payer Digital Transformation: Design Excellence – coming soon!
• Healthcare Payer Digital Transformation: Execute – coming soon!
• Healthcare Payer Digital Transformation: 3 Critical KPIs – coming soon!
• Healthcare Payer Digital Transformation: Optimize – coming soon!

To help HealthRules Payer customers optimize system configurations and ensure further optimized business performance, the HealthEdge Global Professional Services team offers specialized services for HealthRules Payer configuration. Both new and existing customers can leverage our expert team complemented by an optimized mix of global resources, when appropriate, to accelerate the time-to-value during new implementations or system expansions into new lines of business or geographies.

Overcoming Industry Challenges

• Workforce shortages on both the IT and business fronts make it challenging for some health plans to move at the pace required to remain competitive in today’s rapidly changing market. HealthRules Payer experts ensure health plans have the resources they need when they need them to adapt and meet their ever-changing landscape.
• Technology innovations and new features are constantly being made available by HealthEdge and its partners. The Professional Services team of experts helps customers quickly embrace and implement these advancements to gain competitive advantage and optimize efficiencies.
• As health plans grow, so does the complexity of the systems that support the growth. HealthEdge experts help health plans identify new ways HealthRules Payer can enable, accelerate growth strategies, and support peak performance of both the system and the organization.

Unmatched Expertise in the Industry

HealthEdge Configuration as a Service is powered by the healthcare innovation experts at HealthEdge. The combination of HealthEdge’s technology, strategic leadership, best practices, and its experienced configuration teams and optimized U.S./global resource model, ensure health plans can achieve their goals in a timely and cost-effective manner.

• In-depth knowledge of the HealthRules Payer solution capabilities and architecture
• Expertise gained through hundreds of HealthRules Payer implementations
• Instant connections to HealthRules Payer software architects and developers

For projects where it is appropriate, additional resources can be sourced from global locations, giving payers extreme flexibility and cost savings while benefiting from workforces in multiple time zones that expedite time-to-value. A key attribute of these services is our ability to dynamically flex to a hybrid model of onshore and global resources to best support the project’s requirements, timeline, and budget while maximizing both quality and timeliness.

Health Plan Configuration as a Service

HealthRules Payer configuration often drives the cost and timeline of implementations, upgrades, expansions, or support projects. As a result, health plans may reduce the scope, preventing the organization from realizing the full possibilities of their CAPS system. Configuration as a Service provides expert resources and services to enable health plans to reduce delivery risk, increase quality, and maximize the cost-efficiency of projects associated with implementing, maintaining, and expanding the use of HealthRules Payer.

Configuration as a Service Features:

• Implementation services
• Line of business expansions
• New services
• Expanded capabilities
• Upgrades
• Migrations
• Other growth needs

Health Plan Benefits

Providing deep HealthRules Payer expertise in a cost-effective model, the Configuration as a Service delivers powerful assurances:

• Successful configuration through a standardized, scalable, & mature process framework
• Minimize costs through strategically optimizing resources
• Shorten delivery times for implementations, upgrades, and line of business expansions
• Reduce risks associated with implementations and system expansion
• Improve outcomes to ensure health plans optimize HealthRules Payer functionality

To learn more about how HealthEdge Configuration as a Service can deliver predictable, cost-effective services for your organization, please reach out to your HealthEdge representative or email info@healthedge.com.

Challenges of Non-Participating Provider Claims

A large, non-profit health plan has a robust network of contracted providers within the northeast region, facilitating local care access for their members. But, as health plan members seek care with non-contracted providers due to travel beyond the health plan region or for other logistic or personal reasons, the health plan receives claims from providers not contracted with their health plan. With multiple lines of business and almost four million members, these non-participating provider claims stack-up quickly and the health plan must be prepared to pay these claims accurately and efficiently, even without the benefit of contractually negotiated payment terms.

“We didn’t have many different pricing arrangements, but because of the differences in products and how those products wanted to message differently, it ended up being 75 different rate configurations for only six edit mapping rules.” – Health Plan Reimbursement Initiatives Manager

CMS Fee Schedules

The Centers for Medicare and Medicaid Services (CMS) maintains a fee schedule, which is a complete listing of maximum fees used to reimburse providers on a fee-for-service (FFS) basis. There are different fee schedules for:

• physicians
• ambulance service
• clinical laboratory services
• and more

Further, these fees can vary with modifications based on patient, provider and location factors; for example, urban, rural or low-density qualified areas.¹

CMS fee schedules are not only important for Medicare and other government lines of business – they are also important for commercial lines of business. These fee schedules are often used by non-participating providers who submit claims using a percent of CMS FFS. Using CMS fee schedules can simplify the number of payment arrangements across these different provider types, but as this northeast health plan well knows, they still need to develop claims configurations and claims-payment messaging to account for varied provider characteristics. Configurations and messaging must be aligned with modifiers for government and commercial providers and in-network and out of network status. Further, the Plan must be able to edit these configurations to comply with ongoing policy updates, including retroactive change mandates.

“CMS pricing is not just a simple fee schedule. There are many different ways that CMS prices different types of claims, providers, bonuses, outliers and new technology payments. It’s very complicated and [to get claims right, we have to] understand the nuance.” – Health Plan Reimbursement Initiatives Manager

Solution = Source

Source was specifically designed as a single instance that connects with any claims system. Today, Source offers existing integration with over 10 claims systems, ensuring that implementation isn’t waylaid by key technology integration challenges. Source also supports the Plan with hierarchical edit capabilities to structure the six different enterprise-level configurations overlaying mapping rules for the 75 different rate configurations for the Plan’s commercial and Medicare Advantage products and lines of business using a percent of CMS FFS schedules.

“It’s helpful that updates are deployed so quickly. It’s helpful that HealthEdge puts edits right in [to the Source platform], so the brunt of validation and testing is already done in advance. This is a big advantage over other experiences that were not as positive – that we’ve had with other vendors.” – Health Plan Reimbursement Initiatives Manager

The Plan also faces provider-specific arrangements with non-participating providers whose pricing does not follow a percent of CMS schedule. As a true tech partner, Source was also able to help the Plan navigate this additional complexity. The Plan’s Reimbursement Initiatives Manager described reaching out to Source representatives who were able to show her how to configure pricing for these unique provider payment arrangements – leaving her confident in her ability to make other such configurations in the future.

“I have found the HealthEdge Source system to be very robust and flexible with regards to all of the different types of CMS and non-CMS based pricing methodologies that it offers.” – Health Plan Reimbursement Initiatives Manager

Takeaways

Non-participating providers are a critical extension of any plan’s network – and accurate and efficient payment despite the lack of contracted pricing, is an important component of effective health plan operations.

• Non-participating providers play an important role in ensuring member care access in and out of their home region
• Many non-participating providers use a percent of CMS FFS pricing
• While CMS pricing offers a standardized base reducing the number of payment arrangements, plans still need a platform such as Source that facilitates many configurations and specific messaging based on provider type and other factors
• Investing in a platform whose pricing includes ongoing, automatic updates keeps plans on-top of policy changes without additional resource demands
• Choosing an industry-specific tech partner like HealthEdge gives plans the support they need to optimize automation and accuracy despite the complexity of provider arrangements

¹https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo

Janelle has been struggling with knee pain ever since she sustained a basketball injury in college. Her finances are pretty tight, so when she finally decides to schedule a needed knee surgery, she is careful to make sure it is with a surgeon who is a participating provider in her health plan, YourHealth.

When it’s time for the surgery, Janelle checks in at Midtown Surgery Clinic, a participating facility and pays an expected co-pay. The surgery goes well and once the anesthesia wears off, she heads home to recover. Janelle does not anticipate any additional bills as she and her surgeon fulfilled all prerequisites of her coverage.

Prior to the No Surprises Act

Two months later, Janelle receives a $600 bill from Midtown Anesthesiology. After waiting on-hold with the clinic, then her health plan, Janelle finally speaks to customer service and learns that while her surgeon was in-network, the anesthesiologist was not. Now, she is responsible for a cost-sharing bill she can’t afford.

Behind the scenes, Janelle’s surgery results in multiple, separate claims to YourHealth. Midtown Surgery bills YourHealth for the surgery and Midtown Anesthesiology bills $600 for an anesthesiology service. During claim adjudication, YourHealth identifies the anesthesiologist as an out-of-network provider and processes the anesthesiology claim with out-of-network deductible and co-insurance responsibilities for Janelle, which results in her receiving the $600 bill.

This process takes over 60 days, leaving Janelle with a significant, unexpected bill that arrives months after a service she expected to be fully covered. The process leaves Janelle surprised, confused and angry with her health plan, the doctor, and the healthcare system in general.

She becomes disinclined to engage in the recommended follow-up services and may try to avoid everything but emergency services in the future.

After the No Surprises Act

Prior to the scheduled surgery, Janelle uses the price comparison tool through her member portal and easily confirms the cost of the surgery and what her cost sharing responsibilities will be.

Following the visit, the Midtown facility and physicians bill YourHealth for the surgery and a $600 anesthesiology service, minus the collected co-pay. The out-of-network anesthesiologist claim is processed applying in-network cost sharing, holding Janelle harmless from the higher out-of-network cost sharing amounts.

The facility and physicians who provided Janelle’s care send their service claims to her health plan. YourHealth, has prepared for No Surprises Act (NSA) compliance, leveraging the flexibility of HealthRules Payer to:

• Configure out-of-network claims using NSA criteria
• Auto-adjudicate the out-of-network claim appropriately using the Qualified Payment Amount for the service
• Populate price comparison tools with provider and member-specific details using HealthRules Payer’s Trial Claim Feature, so Janelle was able to get personalized cost information well before surgery.

Later that year, YourHealth negotiates a slightly higher contracted fee schedule with Midtown Anesthesiology–expanding their network and improving provider and member satisfaction. They continue to monitor evolving NSA rulings, knowing that with the flexibility of HealthRules Payer they can prepare for future rulings like those anticipated for advanced explanations of benefits (AEOBs)–using the Trial Claim Feature and existing explanation of benefits processes to generate individualized claims detail for anticipated services.

Janelle receives no additional bill and engages in important physical therapy follow-up. By continuing to engage in preventive healthcare and treatment, Janelle optimizes her health outcomes and reduces lifetime health costs to herself and her health plan.

No Surprises Act, Regulatory Compliance, & HealthRules Payer

HealthRules Payer from HealthEdge, is a modern core administrative processing system with existing features that support plans in maintaining regulatory compliance. Designed for easy configuration, HealthRules Payer gives health plans the tools and support they need to succeed, even as transparency regulations evolve.

Learn more about how HealthRules Payer gives plans the tools to succeed as the No Surprises Act and industry regulation evolves.

Challenges

HealthEdge® representatives recently talked to two members of the provider reimbursement team from a large non-profit health plan in the northeast. At the time of interview, the Plan was primarily using Source for pricing and reimbursement, leveraging the extensive library of pricing edits and bi-weekly updates that come standard with the Source platform. The conversation focused on two common and critical health plan challenges related to provider reimbursement. First, was the need for the Plan to replace an older tech platform while assuring the new platform would integrate with other legacy components of their tech stack. Second, was the need for the provider reimbursement team and other health plan system users to be able to audit claims and address ongoing retroactive claims inquiries from internal and external stakeholders.

Solution = HealthEdge Source

In 2021, the Plan began a phased implementation process, sunsetting an older payment and pricing platform and upgrading to Source. While Source is a modern payment integrity platform, the Plan was still working with a legacy core administration processing system (CAPS) and had concerns about platform integration especially given the significant complexity inherent in their hierarchical provider payment arrangements. Fortunately, Source has built-in integration with 10+ claims systems, ensuring that implementation wasn’t waylaid by key technology integration challenges. Source also offers hierarchical edit capabilities, enabling for example, the six different enterprise-level configurations overlaying mapping rules for 75 different rate configurations used just for one (Centers for Medicare and Medicaid; CMS) fee schedule at this particular health plan.

Not only was Source able to integrate with the Plan’s legacy CAPS system and accommodate complex hierarchical pricing configurations, but the integration and upgrade also led to a significant improvement in their first-pass claims adjudication rate. As noted by the Plan’s Reimbursement Initiatives Manager, prior to integrating their CAPS system with Source, their first-pass rate averaged about 80% and is now near 98% according to their CAPS measurement criteria. She noted that improvements are tied to both the Source product and the improved integration with their CAPS system, which has streamlined a variety of reimbursement processes.

“The overall end-to-end process was improved from the way it worked before, when we had to use robots, compared to how we’re using Source now… There are a lot of things we can do in Source now that we couldn’t do before.” – Health Plan Reimbursement Initiatives Manager

Retroactive claims inquiries and adjustments are another ongoing challenge for the Plan, particularly for providers who bill using a percentage of CMS fee schedules. CMS fee schedules are subject to ongoing policy updates and payment changes, but because only a small percentage of the Plan’s contracted providers use the CMS fee schedules, the Plan does not automatically make claims adjustments based on retroactive CMS change policies. Instead, issues usually come to their attention following a claims complaint or audit.

While the reimbursement team noted how helpful Source’s automated and bi-weekly updates are, they also noted that CMS release data gives limited information about when retroactive changes should impact reimbursement for specific types of providers. An example was when they received a complaint about 50 different claims payments across different hospital facilities that they contract with using the CMS fee schedules. In this situation, with multiple and dispersed claims issues, it was difficult to trace a payment change back to a specific CMS release.

The Reimbursement Initiatives Manager noted how critical Source’s audit feature is to address these types of provider complaints. It enables her to download relevant claims from the production to the pre-production environment and reprocess them, compare the two side-by-side, and identify changes like a capital payment amount or wage index change, that could drive such dispersed claims complaints.

“One of the best features of Source that I love is the ability to download a claim from one environment to another environment. That’s very handy.” – Health Plan Reimbursement Initiatives Manager

It is easy to see how this regional plan serves to benefit from this type of automation, and this addition may be a next step on their payment integrity journey. But Source is designed to support plans at all stages, and the audit feature (one of the Plan’s most widely used Source features) enables the Plan to meet their retroactive claims inquiries and audit needs manually. Source’s audit feature is critical for the Plan’s customer service team members who access claims detail to answer questions from providers and members, and for the audit team who hold claims audit responsibility. Further, the provider reimbursement team regularly uses the audit feature to respond to inquiries from Plan leaders.

For example, the Reimbursement Initiatives Manager was recently asked to explain to the Plan’s leadership team how ambulance services (a particularly expensive line-item for plans), are priced by CMS. It was easy for her to use Source’s audit feature to search for hospital outpatient provider type, filter by an ambulance code to narrow down the results, then find examples of claims that contained the ambulance code. With this information, she was able to provide a detailed response to Plan leadership about how CMS reimburses those ambulance services

Takeaways

• Pre-existing integration capabilities minimize challenges inherent in integrating new platforms with legacy tech stack components
• Optimizing automation will drive accuracy while minimizing resource-intensive and manual work and re-work for prospective and retroactive pricing changes
• Retroactive pricing updates aren’t going away; the right tool will enable plans to leverage robust audit features for inquiries and manual adjustments while considering more automated solutions
• Choosing an industry-specific tech partner like HealthEdge gives plans the support they need to optimize automation and accuracy despite the complexity of diverse pricing and provider arrangements

I have found the HealthEdge Source system to be very robust and flexible with regards to all of the different types of CMS and non-CMS based pricing methodologies that it offers.” – Health Plan Reimbursement Initiatives Manager

Wins and Losses in 2023:

Wins:

1. Enhanced Digital Experience:

The integration of digital platforms and telehealth into benefit plans improved access to healthcare services. Insurers made strides in offering user-friendly apps, enabling policyholders to view their coverage, schedule appointments, and access medical records effortlessly. Some of these advancements were the direct results of regulations taking effect.

2. Value-Based Partnerships:

Payers embraced value-based care models even more, forging deeper partnerships with providers. The continued shift incentivizes better outcomes and promotes cost-effective, quality care.

3. Preventive Care:

Payers continued their focus on preventive care, offering incentives and reduced premiums for policyholders who proactively engaged in wellness programs and screenings. This approach aims to mitigate future healthcare costs by preventing diseases, benefiting the entire system.

4. Streamlined Claims Processing:

Technological advancements, like those of HealthEdge’s core administrative solution, HealthRules® Payer, led to faster and more accurate claims processing, reducing administrative burdens for both providers and payers. This improved efficiency in healthcare delivery and reduced claim disputes.

Losses:

1. Rising Premiums:

Despite efforts to improve efficiency, health insurance premiums continued to rise in 2023. This posed a challenge for individuals and businesses trying to balance the cost of insurance with adequate coverage.

2. Narrower Provider Networks

Some plans opted for narrower provider networks to control costs. While this helped in cost containment, it limited the choices available to members, leading to dissatisfaction and potential delays in care.

3. Data Privacy Concerns

The increasing use of digital platforms raised concerns about the security and privacy of healthcare data. Instances of data breaches and unauthorized access underscored the importance of robust data protection measures. Data breaches were felt by both payers and providers at varying levels of severity.

Looking Ahead to 2024

Anticipated Trends:

1. Personalized Healthcare

Consumers are still hungry for a retail experience from their healthcare partners that is personalized to their specific needs. Artificial Intelligence (AI) is set to revolutionize healthcare by enabling personalized treatment plans based on an individual’s unique health data. But in an industry known to trail others, we may still be years away from being able to utilize AI to tailor coverage and support.

2. Virtual Reality in Telemedicine

Virtual Reality is poised to enhance telemedicine experiences, providing immersive consultations and medical training. Payers may integrate Virtual Reality into their offerings to improve patient engagement and understanding. However, like AI, this may be decades in the making.

3. Global Telehealth Access

Improved infrastructure and cross-border agreements may lead to global telehealth access, allowing individuals to consult with healthcare providers from different parts of the world, expanding their healthcare choices. Global telehealth access is more important now than ever as unrest rumbles in parts of the world.

Next-generation, digital core administrative processing systems, like HealthRules Payer, can help health plans better prepare for the future and respond to regulations and market trends. Across the industry, HealthRules Payer is known for its simplified but comprehensive configuration, allowing payers to move quickly and take advantage of new growth opportunities.

The relationship between payers and providers continues to evolve, presenting both challenges and opportunities. The shifts in 2023 indicate a growing focus on enhancing the digital experience, promoting preventive care, and streamlining processes. Looking forward to 2024, exciting advancements are on the horizon, promising a more personalized and accessible healthcare landscape. Learn more about our core administrative processing solution.

Following the end of the COVID-19 public health emergency this spring, states began the process of redetermining which residents are eligible for Medicaid coverage. As of early this August, KFF reports that nearly 4 million Medicaid enrollees have been disenrolled based on data reported from 41 states and the District of Columbia. Further, the U.S. Department of Health and Human Services (HHS) projects that 15 million people will lose Medicaid coverage once redeterminations are complete.

As health plans adjust to this new reality, proactive measures must be taken to offset the reduction in Medicaid enrollment. The below list describes effective medicaid redetermination strategies that health plans can adopt to ensure continued coverage for vulnerable populations while maintaining their commitment to providing accessible healthcare services.

1. Enhanced Communication and Outreach

Engage in targeted communication campaigns to educate existing and potential enrollees about the importance of maintaining Medicaid coverage. Leveraging modern technology, such as HealthEdge^®’s Wellframe^® digital engagement platform, to take an omni-channel approach to beneficiary communications, can improve connectivity and effectiveness. In these communications, payers should highlight the array of benefits Medicaid offers and emphasize how it positively impacts their health and financial well-being.

2. Streamlined Enrollment Processes

Simplify the enrollment and renewal processes to minimize administrative burdens on beneficiaries. Provide user-friendly online platforms that guide enrollees through the application process. Utilize technology, such as HealthEdge’s HealthRules^® Payer core administrative processing system, to streamline enrollment and even pre-populate application forms and ease the documentation requirements, ensuring that the process remains as hassle-free as possible.

3. Collaboration with Community Organizations

Forge partnerships with community organizations, local clinics, and non-profits to increase awareness about Medicaid and support beneficiaries in navigating enrollment challenges. Community-based assistance can play a pivotal role in helping eligible individuals complete applications and renewals accurately. Payers who depend on HealthEdge’s GuidingCare modern care management platform are able to easily create and manage these partnerships with its extensive API services and more than 75+ pre-built integrations, including some with services for social determinants of health (SDOH).

4. Personalized Assistance

Offer personalized assistance through customer service representatives or enrollment specialists. Provide dedicated helplines to address enrollees’ questions and concerns, helping them navigate the complexities of the enrollment process.

5. Outreach to Lapsed Enrollees

Implement outreach strategies aimed at lapsed enrollees. Send reminder notifications about re-enrollment deadlines, emphasizing the potential risks of going without coverage and the ease of reinstating benefits. Once again, an omni-channel approach to beneficiary communications has the potential to drive higher levels of engagement.

6. Education on Benefits

Conduct education campaigns to inform beneficiaries about the range of benefits available through Medicaid. Highlight services such as preventive care, prescription medications, mental health support, and pediatric care. Demonstrating the value of these benefits can incentivize individuals to maintain their enrollment.

7. Data Analytics for Targeted Outreach

Utilize data analytics to identify trends and patterns in disenrollment. This data can guide the creation of targeted outreach efforts, focusing on areas or demographic groups that are experiencing higher disenrollment rates. For example, care management systems like GuidingCare – which have dynamic business intelligence capabilities – grant greater access to real-time data and analytics to make this process easy for care teams and business leaders.

The Medicaid disenrollment trend following the expiration of the Emergency Act presents a challenge that health plans must address with urgency and compassion. By implementing a combination of enhanced communication, simplified processes, community partnerships, personalized assistance, and targeted outreach efforts, health plans can offset the reduction in Medicaid enrollment. These strategies not only help maintain coverage for vulnerable populations but also underscore health plans’ commitment to ensuring access to quality healthcare services for all.

To learn more about how HealthEdge is helping health plans architect and execute their Medicaid redetermination strategies, visit www.healthedge.com.

When it comes to home repair, there isn’t a lot of tool flexibility. A 1/8” Allen wrench cannot be substituted for a 3/16” Allen wrench and a Phillips head screwdriver won’t help with a flathead screw.  Every home renovation project seems to add another tool to your toolbox.

Digital tools, however, are a different story. Consider even a common tool like Microsoft Excel. While many of us use this software to perform basic calculations, we are barely scratching the surface of its capabilities. Excel is a powerhouse, and users who have taken the time to unlock more of the tool’s abilities are running advanced analytics and macros to feed critical business decisions.

From the health plan perspective, the constant evolution of health care practices, policies and communication standards can be much like the never-ending stream of repairs and renovations faced by homeowners. Health plans that invest wisely in their technology, however, can avoid an overflowing ‘toolbox’ and leverage the power and flexibility inherent in existing solutions – even as their operational and process renovation projects evolve.

The Challenge of Regulatory Evolution: The No Surprises Act

A particularly timely example is the No Surprises Act (NSA). This recent legislation requires significant revisions to the current administrative processes of most health plans, requiring plans to:

• limit member cost-sharing responsibilities
• manage out-of-network provider bills with federally regulated qualifying payment amounts
• establish web-based provider directories and price comparison tools for healthcare services
• prepare for anticipated guidelines around providing members with advanced explanations of benefits (AEOBs) detailing both pricing and individualized accumulator information

For some plans, this may feel like an overwhelming list of processes to develop and/or overhaul. But the tools for the job may already be at hand. For example, HealthRules Payer is a Core Administrative Processing Solution (CAPS) with existing technology to:

• manage conditional payment structures
• combine provider-level pricing information with individual level plan and accumulator data
• generate accurate claims data after, or in advance of a scheduled service, without triggering a claims payment

These are the foundational functions underlying many of the NSA requirements, and many plans may not be aware of the functionality that already exists in their HealthRules Payer solution. For example, HealthRules Payer has Trial Claim feature, used to prospectively review various claims payment arrangements in a test environment. This same function can be used to populate price comparison data and accurately generate claims information in advance of scheduled services. In addition, HealthEdge is continuously adding new platform features.

HealthEdge is an industry-specific technology partner and is staffed by leaders passionate about technology and healthcare – including policy. The HealthEdge team is continually innovating, serving clients with new features and platform upgrades that occur automatically with no disruption to day-to-day operations. With the NSA top of mind across the industry, soon-to-be-released HealthRules Payer features will make it even easier for plans to succeed in the existing and evolving regulatory environment.

Building on Success

With a robust and flexible CAPS, payers can meet new regulatory requirements using existing and flexible features. And, much like complex home repair projects, it will pay off to have the right partner on board. HealthEdge clients have the benefit of our deep industry expertise and technical know-how at their fingertips, making it easy to nail regulatory compliance now and into the future.

What can HealthEdge do for you? See how in our No Surprises Act Data Sheet.

About HealthEdge

HealthEdge® is the health insurance industry’s first digital nervous system to provide automation and seamless connectivity between all parts of a payer’s administrative and clinical systems. HealthEdge provides modern, disruptive healthcare IT solutions that health insurers use to leverage new business models, improve outcomes, drastically reduce administrative costs, and connect everyone in the healthcare delivery cycle. Its next-generation enterprise solution suite is built on modern, patented technology and is delivered to customers via the HealthEdge Cloud or onsite deployment. In 2020, funds managed by Blackstone became the majority owner. HealthEdge and its portfolio of mission-critical technology assets for payers, including HealthRules Payer®, Source, GuidingCare® and Wellframe are collectively driving a digital transformation in healthcare. Follow HealthEdge on Twitter or LinkedIn.

The Frequency of CMS Updates 

CMS plays an important role in administering healthcare programs for more than 150M Americans according to CMS Fast Facts for CY 2022. As part of this responsibility, CMS continually reviews and revises its fee and policy schedules. The frequency of these updates can be daunting:

• Annually: CMS routinely publishes updates to various fee schedules and policies on an annual basis. These annual updates are eagerly anticipated by healthcare providers and payers, as they often involve significant changes to reimbursement rates and regulatory requirements.
• Quarterly: Beyond the annual updates, CMS also releases quarterly updates to fee schedules, which can include changes to payment rates, coding guidelines, and coverage policies. These quarterly updates are aimed at addressing emerging healthcare trends and issues.
• Ad Hoc Updates: In addition to the regularly scheduled updates, CMS may issue ad hoc updates in response to urgent healthcare needs or changes in legislation. These updates can have immediate and profound effects on the healthcare industry.

The Impact of CMS Updates on Payers

These updates encompass changes to reimbursement rates, policies, and regulations that directly influence how payers operate.

Reimbursement Rates:

One of the most significant aspects of CMS updates for healthcare payers is the adjustment of reimbursement rates. CMS sets rates for services covered under Medicare and Medicaid, which serve as benchmarks for many private payers. When CMS updates reimbursement rates, it affects the revenue that healthcare payers receive from government-sponsored plans and, subsequently, the rates they negotiate with providers.

Financial Sustainability:

CMS updates can pose financial challenges for healthcare payers. Reductions in reimbursement rates or changes in payment methodologies can impact the profitability of managing government-sponsored plans. Payers may need to adapt their cost structures, premium pricing, or network strategies to maintain financial sustainability.

Compliance Burden:

CMS updates often come with changes in documentation, coding, and billing requirements. Healthcare payers must invest in compliance efforts to ensure they meet the evolving regulatory standards. This can increase administrative costs and necessitate ongoing training and education for staff.

Network Management:

Changes in CMS policies can also impact payer-provider relationships. Negotiating contracts with providers may become more complex due to changes in reimbursement rates and performance-based incentives.

Member Services:

CMS updates can directly affect the services and benefits offered to members of government-sponsored plans. Changes in coverage policies, eligibility criteria, or access to certain treatments can influence member satisfaction and retention. Healthcare payers must communicate these changes effectively to members and provide support to navigate evolving plan options.

Care Coordination:

CMS emphasizes care coordination and value-based care models in its updates. Healthcare payers need to align their strategies with these priorities to improve patient outcomes and control costs.

Regulatory Compliance:

Staying compliant with CMS updates is paramount for healthcare payers. Non-compliance can lead to penalties, reputational damage, and potential legal issues. Payers must continually monitor CMS changes, update their policies and procedures, and ensure that staff members are well-versed in the evolving regulations.

Navigating CMS Changes 

One of the ways many payers are choosing to navigate all of these changes is through the use of modern technology. Payers who use HealthEdge’s core administrative processing system (CAPS), HealthRules® Payer, have the unique opportunity to leverage the company’s award-winning prospective payment integrity solution, HealthEdge Source, as a secondary editing solution.

This productized integration, called Payer-Source, is now available as a secondary editor, which means claims can go through another layer of validation so inaccurate and inappropriate claims are more likely to be caught before they are paid. This not only reduces the risks of overpayments and underpayments, but it also helps minimize provider abrasion.

And the good news is, there is no need for payers to replace or change their primary editing solution, which can be HealthRules Payer or other primary editing vendors, to take advantage of this new capability. It simply slips in the payment workflow after the primary editor but before the claim has been fully adjudicated. Users have complete flexibility and control over whether they want to accept the Source recommendations or not.

Powerful Savings Identified 

The Source Data Study team recently completed several data studies with payers, using the Payer-Source integrated solution as a secondary editor, and the savings opportunities the solution identified were significant:

• A national health plan was able to generate $8.7M, or 1.1% in incremental savings, on 5.1M claims, representing $790M in spend from its Medicaid and Dual-Eligible populations
• A regional health plan was able to generate $9.1M, or 1.6% in incremental savings, on 2.1M claims, representing $571M in spend
• A mid-sized regional health plan was able to generate $11.1M, or 1.6% in incremental savings, on 1.7M claims, representing $684M spend

Learn more about how payers can future-proof their claims editing for real savings here.

For example, if a new modifier is posted for Medicare, teams must figure out which claims are impacted and what impact those changes may have. Then, they must determine what actions should be taken: overpayments that may require recoupments or underpayments that may surface during a CMS audit or spark a series of calls from providers, all contributing to provider abrasion. And the same process must be followed for changes at the state Medicaid level, which can be even more taxing and time-consuming since each state is unique.

Managing CMS policy and fee schedule changes is an enormous burden on everyone. Most payers have entire teams of business and technical resources dedicated to reacting to these changes.

However, at HealthEdge Source, we are actively working with our customers to solve this problem using modern, prospective payment integrity solutions. We’re enabling payers to take a proactive approach to retroactive changes with Source Retroactive Change Manager.

Because the pricing and editing data is in a single instance, Source can automatically identify and assess which claims are impacted by the changes and capture the price/policy used when the claim was processed. Knowing the new price/policy, the system can then analyze the impact of the retroactive changes and help business leaders easily understand potential risks for over/under payments.

The Results Speak for Themselves

The Source Data Study team recently completed a study with a regional plan with home and host capabilities. The Source Retroactive Change Manager evaluated 67,916 claims from Q1 2023 and identified $2.67M in overpayments. The health plan was also able to use the solution to reduce several administrative burdens and costs, including:

• Automate timely identification, repricing, and reporting of retroactive changes
• Remove contingency vendors
• Ease provider abrasion
• Improve compliance
• Reduce waste

A separate regional health plan with 200K+ members was looking to strengthen confidence in its pricing accuracy, compliance, and readiness for external audits. In a 90-day study, Source Retroactive Change Manager identified 95,830 claims with pricing changes, resulting in over/underpayments totaling $20,921,901.

For more information on how Source can help your organization take a proactive approach to retroactive changes to CMS policies and prices, listen to this webinar, “Preparing for CMS Updates and Retroactive Changes,” presented by Jared Lorinsky, chief strategy officer, and Carl Anderson, senior product manager for HealthEdge Source.

However, several payers, including Independent Health, a New York-based not-for-profit health plan with 387,000 members that leverages HealthRules^® Payer as its core administrative processing system (CAPS), appear to have discovered the secrets to success. In fact, Independent Health now has 98% of its primary care practice members in full capitation contracts, with solid alignment of goals with its provider network.

So, what’s the secret?

According to Dave Mika, Vice President, Enterprise Core System Operations at Independent Health, it comes down to the flexibility and power of technology.

“When we give providers data that shows how they are performing relative to required or recommended services for members within various demographics and disease states, we’re doing so with the ability to drill down to the individual patient level.

When we understand where a single patient stands relative to utilization of inpatient and outpatient services, we can offer clarity into everything from who needs to be more active in managing their own care to how cost calculators and digital health tools can be better utilized – by providers and their patients.”

The Role of HealthRules Payer

With HealthRules Payer, health plans can quickly address market opportunities and stay in front of competition. All this while achieving high levels of customer satisfaction and transparency by providing accurate, real-time information to everyone involved in the care continuum. HealthRules Payer has also significantly lowered administrative costs for our customers by simultaneously automating critical manual business processes, resulting in an enhanced bottom line.

“HealthEdge allows us to achieve speed to market with our products in the rapidly changing healthcare environment, with the capability to configure and implement products quickly and on the fly,” says Mika. “The solution also gives us the capability to drive alternative reimbursement models for our customers, now and in the future, as evolving needs – and regulations – dictate.”

With results like this, it’s no wonder that HealthRules Payer has been named “Best in KLAS” by KLAS Research for Claims & Administration Platforms for the past two years.

Finding the Value in Value-Based Care Contracts

As the healthcare industry continues to undergo transformation away from fee-for-service models to value-based payment models, digital health plans have a unique opportunity make this transition highly successfully for all stakeholders: payers, providers, and patients. They can do so by leveraging the advanced automation capabilities and real-time data insights that are readily available in modern CAPS like HealthRules Payer. With the right CAPS in place, the value of value-based contracts becomes crystal clear:

• Cost Control: Value-based care models can help health plans control costs over the long term by focusing on preventive care and early intervention
• Improved Member Health: By promoting healthier lifestyles and proactive healthcare management, value-based care can lead to improved health outcomes among members. This not only enhances members satisfaction but also reduces the financial burden on payers.
• Competitive Advantage: Payers that embrace value-based care early gain a competitive edge. They can attract providers and members who appreciate the benefits of this approach.

By harnessing the power of automation and aligning incentives with value-based care, health insurance companies can play a pivotal role in transforming the way healthcare is delivered and financed, ultimately benefiting both patients and the industry as a whole.

To learn more about how HealthRules Payer helped Independent Health, read the full case study today, and reach out to see how HealthEdge can help your organization embrace value-based care contracting by visiting www.healthedge.com.

How HealthEdge Customer Operations Team Supports Health Plans

This team is comprised of four different groups that work cohesively together to ensure customers have the best possible experience:

1. The infrastructure operations team ensures the company’s private cloud, networks, and operational spaces are secure and available.
2. The technical support services team manages the response to all inbound customer product inquiries and support tickets by coordinating with customers and product team members to facilitate fast responses and resolutions to any issues that may arise.
3. The customer success management team is ultimately responsible for understanding the current and future needs of HealthRules Payer customers and prioritizing the work for the rest of the organization. They are the customer “captains” who understand each customer end-to-end from an operations perspective.
4. The business intelligence team works with the data to enable the rest of the team and customers to gain actionable insights so they can proactively address opportunities for improvement.

Although much of this work sounds technical, the “north star” for this group of hard-working, seasoned professionals is all about helping HealthEdge customers give their members access to the healthcare benefits and services they need when they need them.

The internal tagline of being “Customer Obsessed” is ever-present among all team members who constantly strive to learn more about their customers’ business to provide a more personalized experience.

Equally important is the team leaders’ focus on humanizing the healthcare technology experience for employees. The work is more than just solving a technical problem. It’s about making sure that the eligibility file goes through correctly so that the mother gets access to the medications her sick child needs or the grandmother can get the medical procedure she needs to experience the joys of playing with her grandchild.

These scenarios remind the HealthRules Payer customer operations team members of their purpose: to always do what is best and suitable for their customers so their customers, in turn, can do what is best and ideal for their members.

The Future is Bright

As the HealthEdge customer community continues to expand, the customer operations leadership team is also looking to improve the lives and experiences of their employees. By establishing more standardized processes and proactively addressing the demand for unplanned work items, they are giving employees more time to focus on discovering innovative ways to support the growing customer base – all for the betterment of HealthEdge customers.

In addition, the team is working toward more standardized processes and a more integrated experience for customers of multiple HealthEdge solutions, including GuidingCare^® for care management, Source for payment integrity, and Wellframe^® for digital member engagement. As more integration points across these solutions become available, customers will have a more seamless experience working with HealthEdge.

Finally, as the organization encourages and enables health plans to become digital payers, HealthEdge is adopting more digital-centric capabilities that automate repetitive, manual tasks and improve productivity. Modern technologies that proactively monitor and adjust server capacity are also being implemented to benefit team members and customers alike.

The HealthEdge Customer Operations team is more than just a group of engineers and technical resources who support clients. They are members of a dedicated group focused on making a difference in people’s lives by enabling high-quality healthcare at the right time and the right place.

To learn more about the HealthEdge customer experience, visit www.healthedge.com.

• 60% of respondents are moving their core administration system from on-premises to the cloud.
• 34% are consolidating to a common platform.
• 26% are replacing proprietary solutions with commercial off-the-shelf (COTS) solutions.
• 17% are re-platforming to a modern architecture.”

However, the report also warns that the business goals associated with transitioning to more real-time claims processing are in jeopardy if CIOs do not simultaneously consider the capabilities of their claims editing solutions.

“With the modernization of claims administrative processing systems (CAPS), new business requirements and a heightened focus on real-time operations and interoperability, you need to reevaluate your claims editor’s performance.”¹

This report provides detailed questions CIOs should use to evaluate claims editing solutions and ensure they can be prepared for the future. The Source team offers these answers in response to the Gartner proposed evaluation criteria.

Modern Claims Editing Solution

Core Capabilities of Source Editing Solution

• Supports all lines of business in a single platform,
• Seamlessly integrates with virtually every major CAP system and offers complete interoperability with its sister product, HealthRules Payer (Payer-Source).
• Cloud-based solution means all maintenance and support costs are included in the monthly subscription fee, and all pricing and policy updates are proactively applied every two weeks, reducing IT and administrative burdens.
• Clients average a 30+% increase in first-pass adjudications.
• Clients find cost savings through many different edits, including validation, reimbursement, payment and billing guidelines, and medical necessity.
• Supports 39 months of claims history to help identify improper payments.
• Clients can easily customize any existing edit in Source libraries or build a custom edit in minutes.
• And much more!

Advanced Capabilities of Source Editing Solution to Support Future-Proof Initiatives

• By design, Source includes a real-time Analytics module that models claims after the editing, pricing, and audit processes occur for our client’s core claims adjudication. Source real-time analytics are run continuously and automatically.
• Source features a centralized advanced audit trail with rich data and reporting to provide complete transparency for audit and provider relations teams.
• Source allows users to set an edit to Monitor Mode to review its impact before it is put into production.
• All new edits/policies are delivered to the non-production environment where they can be tested, promoted to production in the “off” mode, and then instantaneously turned on through the system and published by the end user as needed for their required timelines.
• And much more!

Claims editing solutions’ critical role in enabling a real-time claims processing environment cannot be overstated. But even if organizations are not undergoing massive system transformations, the Source Editing solution can deliver powerful savings without changing anything in the existing editing stack.

For example, in recent data studies conducted by the Source team, millions of dollars in savings were identified when Source was placed in front of third-party editing solutions.

• 7M Medicare Advantage claims spend $648M, resulting in a $11.1M savings opportunity for a mid-size regional health plan
• 1M Medicaid claims spend $571M, resulting in a $9.1M savings opportunity for a large regional health plan
• 1M Medicaid and Dual Eligible claims spend $790M, resulting in a $8.7M savings opportunity for a national health plan

To read more about the Gartner recommendations on future-proofing your claims editing, click here for complimentary access to this report.

¹ Source: Gartner, How U.S. Healthcare Payer CIOs Can Future-Proof Claims Editing. Austynn Eubank, 20 April 2023. GARTNER is a registered trademark and service mark of Gartner, Inc. or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved. Gartner does not endorse any vendor, product, or service depicted in its research publications and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner’s research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

For the 13^th consecutive year, HealthEdge, has been recognized as a Sample Vendor in the report, under the category next-generation core administrative processing solutions (CAPS).

We believe this recognition underscores HealthEdge’s commitment to innovation, excellence, and its unwavering pursuit of transformative solutions.

The Power of HealthRules Payer

HealthRules Payer is more than just a solution; it’s a catalyst for transformation in the healthcare payer domain. Its unparalleled flexibility empowers health plans to embrace new business models, adapt to changing regulations, and expand into new markets seamlessly.

Elevating Business Impact

Next-generation CAPS like HealthRules Payer can have substantial influence across multiple facets of the healthcare insurance industry, including:

• Efficiency Enhancement: HealthRules Payer reduces transaction costs, improves access to real-time data, and streamlines operations, ushering in a new era of operational efficiency.
• Modern Architecture: HealthRules Payer supports real-time data and transaction processing through its modern architecture, bolstering the agility and responsiveness of health plans.
• Adapting to Change: With HealthRules Payer, health plans can now embrace new business models, such as value-based payment arrangements, and capitalize on cloud technology’s economies of scale and security.
• Simplified Integration: HealthRules Payer supports multiple interfaces that are configurable and user-friendly to ease the integration process with both payer and third-party applications.
• Reducing IT Dependence: HealthRules Payer’s cloud-based infrastructure and advanced automation minimizes the reliance on IT resources, resulting in increased autonomy and operational efficiency.

Recommendations

In the report, Gartner analysts provide user recommendations to payers about considerations they should make when selecting a next-generation CAPS. These recommendations include:

• Prioritize strategic versus commodity CAPS capabilities to evaluate investment decisions. The former include FHIR enablement, real-time processing or effective-now configuration to accommodate scenarios such as the Dobbs decision’s regulatory fragmentation.
• Analyze whether licensed applications, SaaS or business process outsourcing (BPO and BPaaS) solutions for each CAPS capability are best.
• Evaluate new versions of CAPS as greenfield. Old CAPS versions are not representative. However, weigh prior experience with vendor delivery heavily.
• Search for modular CAPS components that allow a partial or phased implementation and prioritize solutions that offer configurable interfaces.
• Validate the vendor’s primary market. Some CAPS have their most significant footprint in a segment like provider-led health plans, third-party administrators or dental. Consider whether influencing a vendor’s product roadmap outweighs the early adopter risk.
• Address the diminishing resource pool available to support legacy systems. Updated technologies will entice job candidates.

A Brighter Future

To us, HealthEdge’s recognition in the Gartner Hype Cycle for U.S. Healthcare Payers, 2023 under the category next-generation CAPS reflects its dedication to shaping the future of healthcare payer operations. As the industry marches towards next-generation CAPS adoption, HealthRules Payer will undoubtedly continue to serve as a benchmark for excellence, innovation, and transformative solutions in the health insurance industry.

To learn more about how HealthRules Payer can help your organization adopt a next-generation CAPS, visit www.healthedge.com.

¹ Source: Gartner, Hype Cycle for U.S. Healthcare Payers, 2023. Mandi Bishop, Connie Salgy, Austynn Eubank, 10 July 2023. GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally, HYPE CYCLE is a registered trademark of Gartner, Inc. and/or its affiliates and are used herein with permission. All rights reserved.. Gartner does not endorse any vendor, product, or service depicted in its research publications and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner’s research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

A health plan’s internal culture can make or break an implementation.

As a business consultant, I have worked on several different implementations throughout my career. Every internal culture is so vastly different from one project to the next.

My role requires me to ask the right questions to understand the company culture and quickly adapt to ensure a successful implementation. Whether a customer is switching to an entirely new system or performing an upgrade, the project will shift how the company operates to some degree.

When it comes to change, there will always be natural pushback, so it is an important step at the beginning of the project to understand why there may be hesitancy. Some clients are ecstatic; they’re ready for a better solution that will take care of the pain points they’re experiencing. On the other hand, some people are comfortable with their routine and not ready to change from the status quo.

In a recent Accenture Research global survey of business and IT leaders worldwide, 77% of executives said that their technology architecture is becoming critical to the organization’s overall success.

The Importance of Collaboration for Successful Health Plan Implementations

When it comes to significant initiatives to transform a health plan’s business, like a system migration, it requires buy-in from the executive level down to the teammates who will work on the new platform. Without buy-in and collaboration, the implementation process is always much more challenging for health plans.

I understand when plans are mindful of time and resources and say, for example, “I don’t think we need a technical person to join this part of the process.” However, if a project is understaffed from the onset, customers will spend more time and resources doing catch-up. Ramping down is always easier than ramping up mid-project. The entire process goes much smoother someone at the table can quickly solve an issue or answer a question to keep the project moving forward. Otherwise, clients will spend valuable time scrambling to find the right people and getting them up to speed.

The most successful projects I’ve worked on are those where the team includes expertise from all facets of the project. When health plans have everyone aligned―project managers, account executives, consultants, financial analysts, IT, etc.―from the beginning, they will achieve the best result.

Health plans face financial decisions every day that impact their bottom line. What terms will make a new provider contract more beneficial? How should a new payment policy be implemented for Medicare Advantage or Commercial business? To answer these questions well, health plans need solutions that enable them to overcome the limitations of their existing technology and leverage claims analytics insights for business decisions and negotiations.

But some health plans run on multiple core claims systems that use several disparate pricing, editing, and payment integrity point solutions to try to pay claims accurately. Claims administrators spend hours looking at data from disparate sources and compiling information.

Historically, claims analytics can be disjointed. A payer may need to export claims from multiple sources, then process them in multiple batches using a separate solution to get the analytical data they need. This back-and-forth process produces old information that cannot be relied on for accurate analysis. It causes delays for everyone involved, and if decision-makers do not have quality information in a timely manner, there is less confidence for those in medical management and contracting when they make crucial decisions for a health plan’s financial success.

How Claims Analytics Can Help CFOs

It is time for health plans to invest in integrated systems that allow data, and therefore analytics, to land in one centralized place. There is an opportunity to simplify the entire payment ecosystem and seamlessly connect to multiple claims systems and third-party solutions. Rather than connecting individually with different systems for Medicare and Medicaid pricing or specialty systems like genetic testing, the data should be available in a single location.

To gain a competitive edge in the evolving health care market, health plan CFOs need access to real-time claims analytics data and the ability to view and analyze all claims as they are processed. Imagine that you could look at scenarios quickly with accurate data and evaluate “what if” modeling to discover better ways to do business. This information can transform a business, delivering immense value — like predicting the potential savings from structuring a contract differently.

Financial decisionmakers need a modeling tool that can take claims from one provider and run those claims through another provider’s contract to see how they would have priced differently. Imagine heading to the negotiation table armed with this data. A simple payment term could hold up an agreement – on the surface, one might assume this would deliver a big financial hit, but what if the data said otherwise? What if the data showed that there would not be a significant impact? Then the payer and provider could quickly agree to a contract that satisfies all parties without a contentious debate.

With the right technology and business intelligence tools, payers can model and forecast different pricing scenarios. They can make customizations and edits to see how different pricing rules calculate down to the cent. Reliable, real-time, integrated analytics unlock new possibilities and enable complete business transformation.

How many resources does it take to run the core configuration of your enterprise?  What type of custom external tools are required to build and maintain the configuration?  What are the financial impacts associated between the complexity of the configuration in a system and the cost per member per month (PMPM) in healthcare or total cost of ownership (TCO) figures?

As we evolve into the next generation of core systems, these types of questions top the list for the potential vendors looking to modernize a core platform for a prospective health plan.  One thing is clear, as we continue forward in the market, the time of the core systems that require high administration costs in terms of the number of resources and custom solutions it takes to configure and maintain is coming to an end.

Currently, the savviest health plans in the market are shifting from the predominant solutions for configuring the system with offshore-based services and/or custom-developed utilities and toolsets to ones focused on out-of-the-box automation enabled by best-in-class configuration.

Can a system be both flexible and provide streamlined next-generation configuration capabilities?  Putting myself in the shoes of any given health plan in the market today for a core modernization and the surrounding ecosystem, one key focus would be on the core configuration and the level of automation that the system brings.

Is the system’s configuration overly complex, disparate, and requires custom external tools to build and maintain?  Can my current staff pick up the complexity of all the aspects of a system that need to be considered when implementing and maintaining my business?  Consequently, what does that ramp-up time look like?  The steeper the learning curve, the greater the chance staff will likely resist adopting the new technology, and the project suffers or fails outright.

In my career, I have seen far too many health plans that implemented their solutions 20 years ago and are faced with complete re-implementation of the existing platform.  Their current systems do not possess the flexibility nor the automation to provide the ability to implement enhancements to optimize existing configuration over time. The level of effort and analysis is simply too high when maintaining production states are the operational primary focus.

Historically, HealthEdge has focused on optimizing the transactional side of the payer business. As a core administrative solution provider, we touch all parts of our customers’ workflow, and this requires us to store and host volumes of data. By better understanding the data, we can use it to drive value for customers.

With a data lake, any kind of data, irrespective of structure and source, can quickly provide valuable insights that improve our customers’ business outcomes and operations.

With a traditional data warehouse, users must transform data into a well-defined schema before storing it in the warehouse.  In order to generate insights from the data, one is limited to the particular schema design. Furthermore, these traditional schemas face design challenges when new sources of data become available for ingestion.

With a data lake, there is no longer a barrier. The data does not need to be clean and perfect or come from a single source; it can come from anywhere. A data lake allows for the storage of data from core admin systems, pharma, EHRs, or other proprietary sources in its original format until it’s required for analysis. Furthermore, a data lake is scalable and can easily support large volumes of data at once or incrementally, enabling analysis that would not be possible with traditionally pre-defined hardware constraints. With the data lake’s distributed systems, a user can ask extremely complex questions as well as create computationally intensive predictive models.

For example, a model could be built to determine how to process claims more efficiently and improve auto adjudication rates using machine learning techniques. With a data lake, a user can perform complex data transformation of millions and millions of claims—including the claims history, adjustments, processing on reason codes, and more —and do it in a fraction of the time of a traditional SQL-based data warehouse.

A second example of leveraging data lake technologies for health plans is with predicting membership churn. Retaining members is a significant issue for health plans, but they can only compare the return rate versus the percentage of people leaving. With a data lake, there may be enough historical data to model member characteristics and behavior before they left the health plan in the past and use this knowledge to predict if current members will leave a plan in the future. With that information, health plans can adjust their offerings accordingly to improve retention rates.

This year, HealthEdge built a data science team that is currently pursuing these and other hypotheses. Through close collaboration with our customers and a series of near-term proofs-of-concept, we anticipate unlocking new types of value for the health insurance market not possible five years ago.

The good news is that for many years, access to real-time data has been a guiding principle in the HealthEdge product investment strategy. In fact, all the HealthEdge applications are built with high-quality, highly available data in mind.

HealthRules Payer® contains valuable claims data shared via real-time APIs with other HealthEdge and third-party applications. HealthEdge Source incorporates payer edits and pricing content from other systems and updates its contents and rules every two weeks. GuidingCare® grants care managers access to important member benefits information so they can make smarter decisions on appropriate care plans for certain patient populations.

As we at HealthEdge help our customers aggressively pursue their digital transformation strategies, we consider access to real-time data the gateway to success in healthcare.

We acknowledge this access is critical to many constituents, including providers, members, and even brokers, who live outside of the four walls of the health plan. As such, we continue to actively invest in new ways to make more real-time data available to stakeholders who need it.

Why Real-Time Data Matters in Healthcare

As health plans seek to drive smarter clinical and operational decisions that result in better outcomes and greater efficiencies, access to real-time data is a must-have. In addition, regulatory bodies are consistently pressuring health plans to up their game when it comes to data access and transparency in recent years:

• The 21st Century CURES Act requires payers to provide access to all claims and clinical data, including care management data and certain documents within one day of having the information available in their system via FHIR-based APIs. It also sets new standards for the recency and accuracy of provider directories. Maintaining accurate provider data and exposing data to others is a significant challenge for many payers who operate on outdated, legacy systems.
• The No Surprises Act requires health plans and providers to make good-faith estimates for healthcare costs available to consumers and sets boundaries for out-of-network emergency care services. Information that is not available in real-time can misinform these estimates. This requires new levels of transparency and accuracy around pricing data.
• Implementation of the Consolidated Appropriates Act (CAA), as part of the Affordable Care Act, demands additional levels of pricing transparency, requiring plans to make certain pricing information publicly available to participants, beneficiaries, and enrollees via the internet and paper forms upon request.

In addition, consumers expect greater access to real-time data as they continue to play a bigger role in their health plan purchasing decisions. Providers expect greater access to data across their networks to help ease the administrative burdens associated with claims processing. And care managers expect greater access so they can provide more effective care plans that are appropriate for the different populations they serve.

The HealthEdge Plan to Enable Real-Time Data in Healthcare 

The HealthEdge approach to enabling greater access to real-time data centers on three main principles:

• Accurate data: We cannot talk about real-time data without also talking about data accuracy. The main idea is that more recent data is likely more accurate data. Not only does inaccurate data erode trust among providers and members who access it through portals or IVR systems, but it also can lead to higher operational costs when health plans have to chase down over-and under-payments. Our systems have data quality improvement capabilities within them to help minimize the burden of maintaining accurate data. For example, HealthEdge’s Source researches, manages, and maintains data (current and historical fee schedules, rates, payment policies, and provider-level data) and publishes updates every two weeks.
• Organized data: Making the real-time data accessible requires an easy-to-understand data structure. HealthEdge data closely models the real world, so the relationships of the data elements are more easily understood by other systems and provide more complete models for looking at providers, suppliers, subscribers, and members. This supports better network management and facilitates more informed contracting.
• Accessible data: APIs establish a common language by which disparate systems more easily share data with each other. As we recently announced at our annual customer conference, IMPACT 2021, we are continuing to expand access to all types of data through advancing our API framework. In addition, we are establishing an ecosystem of partners where our customers can be assured that the integration between our system and certain third-party systems, like EDI gateways, enrollment systems, member engagement, and analytic systems, will be fast, easy, and continuously supported by our team.

“Customers can be members, providers, brokers, whatever the constituent is. And the ability to surface the information and the needed response in real-time is the fundamental piece that outlines the success of what we do. Friday Health Plans has been able to leverage its claim system (HealthRules Payer) and underpinnings of technology and data to have a better customer experience.” Kevin Adams, CEO, UST HealthProof

To learn more about how we are working to give our customers, our applications, and our partners’ unprecedented access to real-time data, visit www.healthedge.com or contact us at sales@healthedge.com.

In the continually evolving landscape of healthcare, digital engagement is becoming increasingly significant for health plans. Additionally, with the rise of telehealth and virtual care, innovative ideas are getting a big push forward.

I recently moderated a webinar with HealthEdge customers Eric Decker, SVP of Information Technology and CIO at Independent Health and John Church, VP and CIO at NeuGen to discuss the results of the Voice of The Market Survey- Modernizing Infrastructure the New IT Mandate, shedding light on their organizations’ strategic and innovative initiatives.

While most health plan IT leaders who responded to the survey are focused on improving key business metrics such as auto-adjudication rates, Eric mentioned Independent Health is fortunate to have high auto adjudication rates—in the low 90s. Instead, his primary focus is on enhancing the consumer digital experience.

Why is digital engagement important for health plans?

“We’re trying to remove as much technical debt and manual labor as possible,” said Eric. “We’re retiring legacy systems, then leveraging infrastructure software as a service. We’re not doing those things to save money, but to allow my team to focus on more transformative priorities, rather than say, patching a server or updating a database.”

Eric continued, “The overall increase in the consumer digital experience will require us to move faster and require more capacity from my team in the future.”

NeuGen is launching a massive digital transformation. John Church’s team was looking at NeuGen’s overall digital engagement process. As COVID-19 hit, they realized they needed to accelerate their timelines to get offerings to market quickly.

As part of the long-term digital engagement, NeuGen is moving to offer more services like psychiatry, nutrition, and others as part of the telehealth platform. The organization is also focused on getting its current providers on the platform to provide a primary care virtual experience.

Without the burden of a legacy system in place, their resources are freed up. “We’re focused on the customer experience,” said John. “As we think about innovation, we’re looking at how to package this together in a way that won’t require members to download seven different apps to engage with both our plan and the physicians.”

He continued, “We’re trying to create that seamless experience for everyone such that we can get a higher degree of digital engagement on the front end to hopefully lower costs on the backend.”

Similar to NeuGen, Independent Health understands the importance of a streamlined customer experience. In January, the organization started working on a digital-first mobile app with a local physician group set to launch in 2021. The app will offer a chat capability, where the physician group can provide telehealth consultations, and Independent Health can answer administrative questions about co-pay and medical costs in one location.

“We’ve had a telehealth benefit in place for the past few years but saw very low utilization,” said Eric. “That utilization went up dramatically in 2020. We got lucky with the timing with this app, as we were already on the path of development, now this product will be the start of other telehealth-driven products.”

According to Gartner, “At a minimum, claims editors are meant to reduce appeals, decrease payment inaccuracies and ensure compliance. Additionally, changes within your lines of business and future needs can lead to more extensive requirements and expectations of claims editors. Situations that can point to growing complexity in claims editing include:

• Increasingly complex value-based payment agreements.
• Providers’ growing use of alternative coding methods for revenue cycle gain.
• Self-funded employers’ demands for greater transparency.”

At HealthEdge^® Source, we help health plans navigate these claims editing and payment complexities with our modern Source Editing solution. Now is the time for health plan CIOs to re-evaluate existing claims editing technologies to ensure they are prepared to meet the future demands of real-time claims processing.

Evaluation Considerations for Future-Proof Claims Editing Solutions

In addition to the core capabilities of claims editing solutions, it is essential for claims editing solutions to support customized edits. Source not only delivers out-of-the-box edits, but the solution also supports the ability for users to customize edits that meet their unique contract and business requirements.

It is also essential for users to have clear visibility into the edits applied to different groups through user-friendly dashboards. Source delivers edit results via dashboards through its Audit Trail and Retroactive Change Manager capabilities. This transparency reduces dependencies on editing vendors, minimizes contingency fees, and empowers health plans to eliminate recurring errors.

In a future-proof claims editing solution, users should also be able to perform proactive reviews of edits before placing them into production. With Source, health plans can process claims in Monitor Mode to run what-if scenarios and better understand the impact of edits.

As more health plans transition from legacy core administrative processing systems (CAPS) to more modern, cloud-based platforms, claims editing solutions must be able to keep pace with the higher levels of interoperability these CAPS can facilitate. Source integrates with virtually every major CAPS on the market today. Plus, the new Payer-Source solution, which is the productized integration between HealthEdge’s CAPS (HealthRules Payer) and HealthEdge Source, delivers seamless integration, a more consolidated vendor stack, a single source for customer support, and a more unified long-term vision.

The Future of Real-Time Claims Processing

At Source, we are disrupting the mature space of claims editing by providing pricing and editing in a single call to deliver more comprehensive, accurate results. We are enabling payers to resolve issues further upstream for continuous improvements and significant savings on contingency fees from claims editing vendors.

By ensuring your claims editor aligns with your current and future needs, you can mitigate the risks of inaccurate claims processing, streamline operations, and provide better experiences for members and providers alike.

For further thought on the topic of future-proofing your claims editing solutions, download your complimentary copy of the 2023 Gartner How U.S. Healthcare Payer CIOs Can Future-Proof Claims Editing report today.

Gartner, How U.S. Healthcare Payer CIOs Can Future-Proof Claims Editing, Austynn Eubank, 20 April 2023. GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved. Gartner does not endorse any vendor, product or service depicted in its research publications, and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

During the webinar, more than 100 AHIP members joined to hear HealthEdge experts discuss key findings from the research, which included:

• Only 45% of healthcare consumers, on average, are fully satisfied with their current health plan, leaving much room for improvement. When a care manager is involved, member satisfaction increases by more than 10%.
• The top three things consumers want when shopping for health insurance include: benefits and coverage that meet their specific needs, the ability to keep their doctors, and the lowest costs available. However, generational differences are worthy of further review.
• The top ways health plans can improve member satisfaction include more personalized engagement, better customer service, and more self-service tools that empower consumers to play a more active role in their healthcare journey.
• 4 out of 5 consumers say that when health plans or care managers adhere to their communication preferences, it positively impacts overall member satisfaction, demonstrating the need for payers to adopt omni-channel communication capabilities.

But why is member satisfaction so important these days? On the webinar, HealthEdge executive Christine Davis described these times as the “perfect storm” for member satisfaction:

• In our post-COVID world, healthcare consumers’ expectations have been shaped by their retail experiences, where interactions are often online, highly targeted, and personalized. Online reviews also play a larger role in the shopping experience these days.
• Healthcare IT has historically lagged behind other industries, so as new market disruptors like CVS, Walmart, and Amazon enter the healthcare space, their tech-savvy platforms and loyal consumer following will require health plans to embrace modern technology to keep pace.
• Competition within the traditional health plan space has also heated up, with the average Medicare Advantage beneficiary having 39 different plans from which they can choose¹. Of the 16 million participants now on the ACA Exchange Marketplace, the average individual has three or more plan options from which they can choose². And competition across all lines of business is expected to continue to increase.
• Regulations continue to push toward member satisfaction and appear to support a sense of empowerment for consumers. For example, for the 2023 rating year, CMS is doubling the weight of member satisfaction in its Star rating system³. Interoperability mandates also play a role in health plans’ ability to adopt modern technology systems that can support transparency and data sharing across care settings and with members.
• With the growing trend of high deductible health plans, more consumers are aware of the rising healthcare costs and are demanding greater transparency. These demands are supported by new legislation such as the No Surprises Act.

The webinar focused on highlighting the key findings, and the full research report is filled with useful insights, including generational differences, that can help health plan leaders better understand what matters most to today’s healthcare consumers and how to plan for future generations.

In addition, the report analyzes the market’s perception of health plans, with 70% of respondents saying that they trust their health plans the most to administer their benefits. However, an alarming 40% of respondents blame health insurance companies for the high cost of healthcare today.

Download the full research report to learn what more than 2,800 healthcare consumers had to say, and if you missed the webinar, watch the full recording here.

References:

• Kaiser Family Foundation Medicare Advantage Spotlight CMS Fact Sheet, October 2023
• CMS Open Enrollment Report, January 2023
• CMS Fact Sheet, October 2022

Difficult care management implementations have led to the demise of many care management solution vendors. Sometimes success can be a vendor’s worst enemy. If they pick up too many customers and can’t implement them properly, word of that spreads quickly.

How We Help Our Customers Implement 

We’ve invested a lot in having a successful care management implementation team. We wanted to make sure that if we win new business, we implement the customers properly so they can stay focused on improving care for their members.

Every customer is assigned an executive sponsor for their implementation, someone on our senior leadership team responsible for the customer relationship and ensuring that we’re meeting their needs.

Each implementation also has a core team that includes a project manager, a business analyst, a clinical subject matter expert, and, most importantly, a solutions architect. The solutions architect looks at the health plan’s overall ecosystem and configures it in the best way for GuidingCare.

The role of the solutions architect is important because health plans today want to seamlessly connect their care management system to other entities in the ecosystem.

Take social determinants of health (SDOH), for example. Care managers need the ability to reach out to an SDOH vendor, such as Unite Us, Healthify or Aunt Bertha, make an appointment for the member on whatever it might be―housing, food, job― without leaving the care management system. Everything must be connected and documented so they can report against it. Or, during an appointment, a care manager may realize a member could benefit from receiving specific content related to their healthcare needs. Without leaving the system, the care manager should be able to reach out to a vendor like HealthWise through the care management platform, gather that information and send it to the member in their preferred format.

Our customers want more integrations, and we’re listening.

Today, we have a developer portal with hundreds of APIs and continue to make new ones every month.

Health plans want a care management platform that is brilliant at the basics and innovative for the future. From the beginning of the implementation, we want our customers to know we will always be there to run to any challenge, support their needs, and continually improve our product.

Empowering Change through Cross-Functional Synergy

For the HealthEdge Transformation Management Office, the primary objective is clear: to identify market needs, customer requests, and operational inefficiencies, and then design strategic solutions that drive growth and improvement. This involves the convergence of cross-functional teams, uniting departments that may have operated in silos in the past. An inspiring example of this approach is the Care-Payer initiative. This groundbreaking endeavor brings together claims processing and care management under the unified umbrella of One HealthEdge. It’s not just about technical integration; it’s about harmonizing product teams, consulting teams, and technical experts from different entities that were once separate.

The result? A more streamlined deployment process, enhanced training materials, and a simplified approach to understanding and mapping product hierarchies. This approach exemplifies how different components, once disjointed, can come together as a unified force to deliver a seamless experience. The key takeaway here is that while challenges exist, strategic collaboration can bridge gaps and pave the way for innovation.

Innovating for Customer-Centric Solutions

The commitment to innovation is not limited to internal processes. HealthEdge Professional Services is consistently expanding its range of offerings to cater to customer needs more comprehensively. An outstanding example of this is the EDGEcelerate solution that was launched earlier this year. Originally introduced to support health plans who use HealthRules^® Payer, EDGEcelerate has since evolved to embrace GuidingCare^® customers and more, exemplifying the adaptability and customer-centric mindset of the organization.

EDGEcelerate revolves around a master umbrella Statement of Work (MSOW) that provides a holistic view of services and features available to clients. This modular approach allows customers to choose and execute services as needed, providing flexibility and scalability. This approach is not about imposing predefined services; it’s about tailoring solutions to meet the unique needs and growth trajectories of each client. The underlying principle is clear: customers are not just clients; they are partners in growth and innovation.

Digital Transformation for Enhanced Visibility

Enhancing customer experience goes hand in hand with providing better tools for both customers and internal teams. HealthEdge Professional Services is harnessing the power of digital tools to elevate project management and visibility. The organization is piloting new tools that provide real-time insights into project progress, helping to identify deviations from the course and making timely adjustments. This is not just about keeping projects on track; it’s about facilitating transparent communication and informed decision-making.

From a governance perspective, the introduction of dashboards and stoplight indicators ensures that all stakeholders have a clear understanding of project health. This level of transparency extends to executive leadership teams, ensuring that they are well-informed and equipped to provide the necessary support. The goal is not just project success; it’s a collaborative effort to achieve excellence at every step.

A Powerful Partner in Digital Transformation

HealthEdge Professional Services’ journey is an inspiring tale of transformation fueled by collaboration, customer-centricity, and innovation. By embracing cross-functional cooperation, adapting offerings to customer needs, and leveraging digital tools, the organization is not only enhancing customer experiences but also fostering a culture of continuous improvement.

As the healthcare landscape continues to evolve, HealthEdge stands as a beacon of change, demonstrating that by aligning efforts and embracing change, remarkable accomplishments are achievable. The future promises more growth, more collaboration, and more innovation, as HealthEdge Professional Services continues to shape the healthcare landscape with a customer-centric mindset and a commitment to excellence.

To learn more about how HealthEdge Professional Services can lead your organization through a digital transformative change, visit www.healthedge.com.

The traditional methods of handling payment integrity are proving inadequate in the face of evolving requirements, resulting in recurrent inaccuracies, inefficiencies, and wasted resources. It’s time for a paradigm shift, and Source Platform Access is leading the way.

The Challenge

Traditionally, payers have resorted to layering multiple editing solutions to address payment integrity concerns. However, this approach brings its own set of complications. Each editing solution operates on its own update schedule and data sets, leading to fragmented processes and siloed information.

Plus, the inherent incentive for primary and secondary editing vendors to safeguard their own intellectual property has led to a lack of collaboration and sharing among stakeholders. This not only hampers the overall accuracy of the payment process but also perpetuates a cycle of continuous charging for the same issues month after month, without any issue-resolution in sight.

The Solution

There is a better way, and it’s called HealthEdge^® Source Platform Access. It challenges the status quo and creates a new path to payment integrity improvements by giving payers the power to identify the root causes of payment inaccuracy issues and correct the issues earlier in the process for greater efficiency gains and lower contingency fees.

Behind the innovative technology of Source Platform Access is a highly seasoned team of payment experts who work in partnership with Source clients. This collaborative approach ensures that the technology is not only implemented effectively, but it is also aligned with the long-term goals of the organization.

Today’s hectic healthcare environment requires an innovative approach to payment integrity, and Source Platform Access stands at the forefront of this evolution. With Source Platform Access, the path to transformative payment integrity is clear, and the possibilities are limitless.

Learn more about how Source Platform Access can help your organization challenge the status quo and dramatically improve the effectiveness of your payment integrity initiatives here.

In response, HealthEdge conducted an independent research study of more than 2,800 insured individuals in the United States to gain valuable insights into consumer preferences, perceptions, and expectations. The 2023 study reveals crucial findings that can help health plans adapt and thrive in today’s competitive landscape.

Snapshot of Key Findings

The study uncovered several significant findings that hold vital implications for health plans:

1. Member Satisfaction: Only 45% of healthcare consumers report being fully satisfied with their health insurance provider. Interestingly, member satisfaction levels increase to 56% among those with assigned care managers. The answer to closing this satisfaction gap lies in delivering personalized member experiences – which is no easy feat.
2. Social Determinants of Health (SDOH): While members who have a care manager report higher satisfaction levels, care managers still have significant opportunity to better leverage available SDOH data to deliver personalized, relevant services and address members’ individualized needs.
3. Communication Preferences: An overwhelming 82% of consumers report higher satisfaction when payers communicate with them in their preferred ways. Adopting omni-channel communication strategies is crucial for enhancing access, convenience, and engagement.
4. Improving Member Satisfaction: The survey identified two key actions for improving member satisfaction: enhancing customer service and increasing access to self-service tools. Equipping customer service representatives and care managers with data and tools for personalized care is essential, as is empowering members to take a more active role in their healthcare journeys.
5. Trust in Health Plans: Despite increasing competition from non-traditional players, health plans remain the most trusted source among 70% of respondents for administering health insurance. However, generational differences affect trust levels, highlighting the importance of accommodating each generation’s needs.
6. Transforming Perceptions: 40% of respondents blame health insurance companies for the high cost of healthcare. To change this perception, health plans must be perceived as partners in care rather than just payers of care.

Three Reasons Why Member Satisfaction Matters More Than Ever Before

1. Choice: Historically, healthcare consumers had limited choices. Many simply accepted their employer provided benefits without question, as most employers covered 100% of medical expenses. Millions of Americans did not have health insurance. Medicare was the primary health plan for the majority of seniors. Most benefit plans left little financial burden on the consumer, and as a result, the average healthcare consumer didn’t think twice about the high cost of healthcare. Today, healthcare consumers have more choices than ever before. There are nearly 4,000 Medicare Advantage plans from which seniors can choose, with the average beneficiary having more than 39 different options in their coverage area.
2. Competition: Market choice drives competition, and the competition among health plans has never been greater. Health plans that operate on outdated technology are unable to adapt to changing market conditions or deliver the innovative solutions today’s market requires. As more non-traditional players like Amazon, CVS, and Walmart enter the market and continue to raise the bar on consumer experience, health plans must match this new wave of tech-savvy competitors with modern care management and member engagement platforms.
3. Criteria: New and expanding government regulations continue to put pressure on health plans to improve transparency and the member experience. In fact, the Centers for Medicare & Medicaid Services (CMS) doubled the weight of member satisfaction scores for the 2023 rating year. The increase means member satisfaction has a larger impact on performance metrics that affect health plan bottom lines.

Practical Guidance for Health Plans

To address growing consumer expectations and remain competitive, health plans should focus on innovation backed by modern technology. Implementing modern platforms, deploying digital member engagement tools, and empowering care management teams can significantly enhance member satisfaction and improve the overall healthcare experience.

The 2023 HealthEdge consumer satisfaction survey report highlights the urgency for health plans to prioritize member satisfaction in today’s competitive landscape. By leveraging modern technology and adopting innovative strategies, health plans can meet consumer expectations, remain competitive, and prepare for the generations of members to come. As healthcare continues to evolve, empowering the future of healthcare lies in delivering personalized, transparent, and convenient experiences to consumers. The time to act is now.

Visit the HealthEdge website to access the full research report or watch a recording of the recent AHIP webinar where HealthEdge clinical and business leaders discuss the survey findings.

Recently, I had the privilege to catch Martin Makary, MD, a surgical oncologist, chief of the Johns Hopkins Islet Transplant Center, and author of The Price We Pay: What Broke American Health Care And How to Fix It, present at the THAP Texas Healthcare conference.

During his presentation, “The High Cost of Health Care and How People can get a Better Deal During and After COVID-19,” Dr. Makary started down a list of key aspects of care that are rising around value-based, such as the appropriateness of care and referral processing by quality. Additionally, Dr. Makary touched on the European public markets, like Italy, that are finding success with globally capitated value-based arrangements versus the broken fee-for-service revenue stream we see more commonplace in our commercial markets here in the states today.

The Importance of Value-Based Care for Health Plans

Continuing the value-based care theme at the same conference, Dr. William Shrank, Chief Medical Officer at Humana, discussed topics like de-adopting low-value care, reducing waste, and re-imagining prior authorization and utilization management.

Dr. Shrank reviewed a gold card approach to value-based care that would exempt physicians based on performance for authorizations or referrals. Focus on high-value, quality care, value-based reimbursements are driving Humana’s shift to shared risk models.

Humana is not alone. In September of 2020, CareFirst BlueCross BlueShield and MedStar Health announced a value-based care initiative they project could save $400 million. The concept of Total Care includes new value-based care reimbursement models that focus on outcome-based medicine utilizing coordinated care to reduce costs and improve quality.

As my colleague, Harry Merkin, previously wrote, “The COVID-19 pandemic has also highlighted the flaws of the fee-for-service model, with providers of all types experiencing the delay of preventative and elective medicine resulting in revenue disruption… leading to higher costs for both health plans and providers.” Janet Barros also has a great blog, Value-Based Care Requires Payer-Provider Collaboration, where she reviews how sharing data and analytics can help with Social Determinants of Health (SDoH) and understanding how it impacts high utilizing members. Sharing data and analytics can help with SDoH and understanding how it affects high-utilizing members. A couple of aspects to consider around value-based reimbursement and the many moving parts.

A core solution that can both integrate with best-in-class care management applications and providers via EDI transactions with near real-time insights into the business will be integral in this enablement. Above integration, however, how easily the core system and ancillary components can be configured to implement these emerging models will directly impact the costs of change. The automation and level of business user enablement to accommodate these (and many other similar) changes directly attribute to the overhead of implementing these market-driven needs. Modeling, projecting, i.e., the analysis of any claims testing transactions, including quality, all of these activities will need to come together, like any other implementation, in order to make these concepts reality. The payers that can execute these aspects the best will likely determine their success in the landscape of value-based reimbursement.

Corporate Compliance:

Corporate compliance encompasses a comprehensive framework of regulations, laws, and ethical guidelines that govern a company’s business operations, governance structure, and interactions with stakeholders. At HealthEdge, corporate compliance serves as a fundamental pillar for ensuring transparent and ethical conduct, mitigating legal risks, and upholding the company’s reputation. HealthEdge follows the seven (7) foundational elements established by the United States Federal Sentencing Commission:

• Policies, Procedures & Code of Conduct.
• Training & Education.
• Reporting.
• Monitoring & Auditing.
• Enforcement & Discipline.
• Response & Prevention.
• Compliance Officer & Compliance Committee.

By adhering to these elements, HealthEdge demonstrates its commitment to ethical conduct and builds trust with healthcare providers, patients, and investors.

Security Compliance:

Security compliance, is centered on safeguarding sensitive data, digital assets, and information systems from unauthorized access, breaches, and cyber threats. In the context of HealthEdge, security compliance is pivotal to protect sensitive data, and other confidential information from potential vulnerabilities.

Prominent security compliance frameworks, such as The Health Information Trust Alliance (HITRUST), and the National Institute of Standards and Technology (NIST) 800-53, provide guidelines for implementing cybersecurity controls. These controls encompass a spectrum of measures, including encryption, access controls, intrusion detection systems, data loss prevention, regular vulnerability assessments, and incident response plans. By adhering to security compliance standards, HealthEdge establishes a resilient defense against cyber threats and data breaches.

Security compliance goes beyond mere regulatory adherence—it fosters a culture of data protection and risk management. As healthcare companies increasingly become targets for cyberattacks, security compliance at HealthEdge ensures confidentiality, integrity, and instilling confidence in both clients and end-users.

Interaction and Collaboration:

While corporate compliance and security compliance have distinct focal points, their interaction and collaborative relationship are evident within the operations of HealthEdge. Effective security measures often align with corporate compliance objectives, particularly in safeguarding sensitive data and maintaining the company’s ethical standing.

For instance, secure data handling practices mandated by security compliance regulations contribute to maintaining privacy and fulfilling regulatory requirements including HIPAA. Establishing a strong security posture can prevent data breaches and legal penalties, thereby preserving the company’s reputation and financial stability.

Benefits of Integration:

Integrating corporate compliance and security compliance yields comprehensive benefits for HealthEdge. The alignment streamlines efforts, minimizes redundancies, and ensures that compliance requirements are addressed. This initiative-taking approach reduces the risk of overlooking critical regulatory and security obligations.

A unified compliance strategy enhances risk management capabilities. By identifying vulnerabilities from both corporate and security perspectives, the company can proactively mitigate potential risks and respond effectively to emerging threats. This approach fosters a culture of caution and accountability throughout the organization.

The integration of corporate and security compliance bolsters stakeholder trust. Our customers are more inclined to engage with a company that proves a commitment to ethical conduct and data protection. This trust translates into improved customer retention, client satisfaction, and competitive advantage.

Conclusion:

The cooperative relationship between corporate compliance and security compliance is essential for success. The fusion of ethical conduct, legal adherence, and data protection creates a foundation for sustainable growth and innovation. This integration not only safeguards sensitive data but also preserves the company’s reputation as well as reinforces stakeholder trust and competitive positioning.

Empowering Informed Decision-Making

At HealthEdge, we believe that informed decision-making is crucial in empowering health plans and their members. Price transparency serves as a powerful tool in this endeavor, enabling health plans to provide members with information about the cost of medical services, treatments, and medications. Our Price Comparison Tool, integrated into HealthRules Payer, equips health plans with easy-to-use resources to compare prices and deliver personalized estimates, allowing members to make well-informed decisions tailored to their unique healthcare needs and financial priorities and enabling payers to be compliant with key provisions of the No Surprises Act and the Transparency in Coverage Final Rule.

What is the No Surprises Act?

The No Surprises Act is a federal law enacted to protect patients from unexpected and excessive medical bills. The Act ensures that patients are only responsible for their in-network cost-sharing amounts, shielding them from surprise medical bills and providing greater financial security in healthcare transactions. The legislation passed in December 2020 as part of the Consolidated Appropriations Act, 2021.

What is the Transparency in Coverage final rule?

The Transparency in Coverage final rule, issued by the Centers for Medicare & Medicaid Services (CMS) with a phased implementation period that started in January 2021, promotes price transparency and empowers consumers to make informed healthcare decisions. The rule requires most health plans to disclose cost-sharing information and negotiated rates for specific healthcare services and items to their beneficiaries.

Enabling price transparency and compliance with the No Surprises Act with HealthRules Payer

The No Surprises Act and the TIC Final Rule place significant requirements on health plans to ensure price transparency and accessibility to pricing information. HealthEdge’s HealthRules® Payer is designed to support compliance with these regulations by providing health plans with the advanced Trial Claims functionality. Through Trial Claims, health plans can deliver required pricing information through various channels, including online, over the phone, and in paper form, as mandated by the legislation.

The tool leverages a capability called Trial Claims that has been used by health plans for many years, making it simple for health plans to meet these regulatory requirements. Here is how it works:

1. Members access the Member Portal and provide details that determine claim elements for their price comparison
2. Claim elements are passed to HealthRules Payer for Trial Claim Adjudication via API
3. Trial Claim adjudicates the claim in HealthRules Payer
4. Pricing and cost sharing information is returned to the Member Portal via API
5. The Member Portal presents the cost sharing information to the member

A similar process is followed when the member prefers to receive the information by phone or mail. The member just contacts a customer service representative who conducts the Trial Claim Adjudication and informs the member of the cost sharing information.

A Bonus: Increasing Member Trust

Delivering exceptional member experiences is at the core of every successful health plan. With the HealthEdge Price Comparison Tool functionality, health plans can improve member satisfaction by providing easy access to transparent pricing and cost-sharing information. The user-friendly tools enable members to access accurate and up-to-date cost-sharing details specific to their benefit plan and usage, promoting transparency and fostering trust between health plans and their members.

A Bright Future

At HealthEdge, we are committed to supporting health plans in their journey towards price transparency and regulatory compliance. By embracing the spirit of the No Surprises Act and the TIC Final Rule, health plans can build stronger partnerships with their members, foster trust, and deliver exceptional care that puts members’ needs first.

To learn more about how your organization can achieve compliance with the Transparency in Coverage and No Surprises Act while also empowering your members, visit www.healthedge.com.

Price Transparency

• Machine Readable Files: It has been one year (July 1, 2022) since the Transparency in Coverage Final Rule went into effect. This rule requires health plans to make pricing data available, free of charge, to the public in Machine Readable Files. According to an April 2023 American Hospital Association article, more than 200 payers have posted machine readable files, up from only 68 in July 2022. This data now represents all sites of service, and more than 95% of commercially insured lives in the United States.The HealthRules Payer product team made these capabilities available to its customers via APIs and continues to make enhancements to improve processing time for the creation of these mega files. Our professional services team ensures a smooth transition for HealthEdge clients.
• Price Comparison Tool: The first phase of this rule, which went into effect January 1, 2023, required health plans to make 500 shoppable items accessible to members. The final phase is scheduled to take effect on January 1, 2024, and will require health plans to make pricing available for all shoppable items covered.Again, the HealthRules Payer teams are making compliance easy with advanced API and specialized services. In addition, for customers who choose to use other solutions, the team is prepared to support customers’ compliance efforts.

Payer Interoperability

While interoperability is not a new topic within the healthcare industry, a wave of proposed rules focused on facilitating the exchange of health data between patients, providers, and payers are proving to be formidable challenges for payers dependent on legacy or outdated technology.

While the industry anxiously awaits the final rule on interoperability, health plans must prepare now to support more advanced interoperability goals.

• Electronic Prior Authorizations: According to the CMS announcement in December 2002, the proposed rule aims to improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services. It requires payers to implement an electronic prior authorization process, which will shorten the time payers can take to respond to prior authorization requests and establish policies to make the prior authorization process more efficient and transparent. The rule also supports the development of standards that payers will follow when exchanging data, making it easier to ensure complete patient records are available when transitioning between payers.The mechanism the rule uses to enforce the mandate will be APIs. More specifically, the proposed rule will require health plans to use a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorizations. By providing standards that all health plans must use, it is likely that in the long run, the rule will be more effective.
• Interoperability Standards: According to CMS, the proposed policies in this rule would also enable improved access to health data, supporting higher-quality care for patients with fewer disruptions. These policies include: expanding the current Patient Access API to include information about prior authorization decisions; allowing providers to access their patients’ data by requiring payers to build and maintain a Provider Access FHIR API, to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship; and creating longitudinal patient records by requiring payers to exchange patient data using a Payer-to-Payer FHIR API when a patient moves between payers or has concurrent payers.HealthRules Payer customers will be able to use the advanced set of APIs from HealthEdge to comply with the final rule.

Additional regulatory changes are coming to the Medicare Advantage Designated Special Needs Programs (D-SNP) that follow the same transparency and interoperability themes. These changes, including the collection of social determinants of health and health equity, are outlined more specifically in a recent blog post by HealthEdge’s Compliance team.

The Bottom Line

Transparency and higher levels of payer interoperability are front and center on the regulatory stage today. With the provider side having been through much of this transformation in the past 10-15 years with the adoption and use of electronic health record (EHR) systems, CMS and the regulators are turning their attention to the administrative side of healthcare claims, zeroing in on opportunities to improve transparency and interoperability.

To learn more about how HealthEdge is supporting its customers’ ability to meet current and future regulatory requirements, please visit www.healthedge.com.

Six things health plan leaders should expect from their modern payer solutions software:

Streamline administrative operations:

Payer solutions software should automate labor-intensive processes such as claims processing, enrollment management, and provider network management. Health plans should be able to consolidate and manage data from various sources, which enables payers to reallocate resources to more critical areas, ultimately leading to increased operational efficiency.

Improve payment accuracy:

Payer solutions software must be able to help health plans increase efficiencies within their claims payment operations to not only streamline processes, but also increase payment accuracy. This, in turn, helps reduce the downstream work staff members have to perform to reconcile inaccurate payments.

Enhance member engagement:

By using modern payer solutions software, health plans can more efficiently identify at-risk member populations and deploy more targeted member outreach, health plans are able to not only streamline care management workflows, but also increase the productivity and scale of care management teams. Plus, with more personalized engagement, members are more likely to adhere to their care plans and improve outcomes.

Optimize claims and configuration management:

Payer solutions software should support automated claims processing and contract configuration. As the industry evolves at a rapid pace, the system should enable business agility and speed to market. Additionally, the solution should provide advanced analytics help health plans identify cost-saving opportunities, such as identifying and preventing fraudulent claims, negotiating more favorable contracts with providers, and optimizing risk adjustment models.

Facilitate value-based care:

As the healthcare industry shifts towards value-based care models (paying for value and outcomes vs. paying for volume), modern payer solutions software must be able to accommodate for multiple, complex payment models. Strong data analytics and reporting capabilities are also important capabilities that help health plans assess provider performance, identify high-risk members, and implement targeted interventions, which in turn enables health plans to drive better health outcomes and cost savings.

Promote interoperability and integration:

Modern payer solutions software must be able to support interoperability and integration with third-party systems to not only comply with emerging regulatory requirements, but also to meet rapidly evolving market dynamics. A robust set of APIs should be available to support the exchange and use of third-party data, and in some cases, pre-packaged integrations should be available to help minimize the IT burden and accelerate time to market.

Health plans achieve extreme efficiencies with HealthEdge payer solutions software

In the face of an ever-changing healthcare landscape, health plans need modern payer solutions software like HealthEdge’s comprehensive suite of software solutions that can enable business agility and create extreme efficiencies.

• HealthEdge’s core administrative processing system (CAPS), HealthRules^® Payer, revolutionizes the way health plans handle administrative tasks, leading to significant time and cost savings.
• HealthEdge’s prospective payment integrity platform, Source, enables health plans to transform their operations at the reimbursement, payment integrity, and enterprise levels.
• HealthEdge’s complete Care Management workflow platform, GuidingCare®, offers both health plans and providers easy-to-use, next-generation data integration and workflow management tools that streamline workflows, facilitate coordination and collaboration, accelerate quality improvement, and promote provider and patient engagement.
• HealthEdge’s digital health management and engagement platform, Wellframe, helps organizations extend their reach across more critical touchpoints and deliver modern member services more efficiently. Members can access their health information, review claims, and even schedule appointments.

HealthEdge’s comprehensive suite of payer solutions software applications meet the above-mentioned requirements for modern payer solutions software, and more. To learn more about how HealthEdge can help your health plan drive extreme efficiencies, visit www.healthedge.com.

Of particular interest to attendees was the growing connection between regulatory compliance and the member experience – a topic that spurred thought-provoking conversation and discussion. Today, this topic continues to hold relevance for health plans as an increasing number of regulations emphasize the member experience.

Here, we summarize key learnings and takeaways from the session, “Quality Insights & Regulatory Update,” which covered evolving regulatory changes and the increasing influence of health equity and member experience as factors for achieving compliance. The session presenters, clinical experts from HealthEdge, also discussed how health plans can prepare and support compliance in the rapidly changing landscape.

Let’s dive into the key learnings and takeaways from this informative session.

The Importance of Member Engagement Reaches New Heights

While member engagement has long been recognized as crucial, it has now reached unprecedented importance. The COVID-19 pandemic highlighted existing health disparities and underscored the need for enhanced member engagement to address the challenge. Health disparities are preventable and new regulations aim to put better measures in place to improve engagement of priority populations and advance health outcomes where disparities exist today.

Changes in Regulatory Measures

The presenters discussed the Centers for Medicare & Medicaid Services’ (CMS) proposed changes set for December 2024 that target improvements in member engagement and health equity, which ties member satisfaction closely with outcomes. Proposed changes include:

• Reducing the weight of patient experience to better align with outcomes.
• Identifying and offering health education to improve digital health literacy.
• Improving language accessibility by delivering materials in all languages spoken by members.
• Delivering culturally competent care to better support diverse populations.
• Changing and enhancing calculations to better align with other programs.

The presenters also covered updates to HEDIS measures to better support diverse and underserved populations and improve their engagement.

A New Trend in Regulatory Changes: Member Engagement

The presenters pointed to an underlying theme across many new regulatory changes: increased focus on member engagement. As a result, optimizing the member experience and engagement is becoming even more of a top priority for health plans. To deliver on this priority, health plans should evaluate how they are supporting members needs in five key areas:

1. Multiple channels of communication: Health plans should work to understand how their members want to communicate and strive to offer those methods. Offering the right methods of communication is the first step to ensuring members receive the information they need to better manage their care.
2. Strategic outreach & follow-up: Intentional follow-up to build relationships or outreach after appointments and procedures can improve engagement.
3. Streamlined member service experience: Health plan leaders should know customer service call stats and hold times, listen to calls to understand if issues are truly being resolved, and find out how customer service teams are engaging with members. Deeper knowledge of the real customer experience allows health plan leaders to assess and make improvements as needed.
4. Identify unengaged members and activate campaigns to re-engage: Gather data to holistically understand the member experience and identify unengaged members. Using claims data, encounter data, failed outreach attempts, and more gives health plans the opportunity to assess whether members are taking steps needed to effectively manage their health.
5. Understand the impact of member experience on outcomes: Health plans should consider conducting surveys to understand the member experience and make improvements. Also, consider the value of annual wellness visits and regular appointments, as members who are getting next level care through mammograms, lab testing, colonoscopies, and more can take steps to manage their health concerns as needed – and have a significant impact on outcomes.

Partner Expectations: Using Technology to Advance Member Engagement

The right technology partner can support health plans in their journey toward improving member engagement and outcomes tied to regulatory compliance. Seek care management partners that deliver the following capabilities:

Robust reporting: Ensure reporting capabilities can facilitate quality improvement projects and demonstrate that the plan is improving member health. Effective reporting should allow health plans to identify unengaged members, get them engaged, and keep them engaged.

Member demographics: Ensure the system can capture key data points, report out, and stratify that data. Key demographics include geographic location, gender identify, race, ethnicity, and more.

Detailed HRAs that drive Plan of Care & Service Plan: Use technology with capabilities to enter surveys, get members responses, and capture data. The technology should allow care managers to use the data to ensure the care plan is specifically targeted based on information collected.

Real time referrals to Social Determinants of Health (SDoH) providers: Implement full integration with social care providers to enable care managers to better manage all individualized member needs.

Care gap monitoring and closure: Use technology that identifies care gaps and supports methods to intervene and drive closure.

Programs identification and management: Seek partners with capabilities that automatically identify members for complex and disease management programs through self-reported or automated data collection. Ensure the technology uses the data to assign members to the right care coordinator to ease the process of improving engagement for high-risk populations.

Integrated educational content: Implement technology with the ability to deliver clinically sound, evidence-based data through effective communication channels. This capability is critical to combat misinformation and improve care outcomes.

Interdisciplinary team management: Deliver tools, such a provider portal, to allow the full team to understand member needs, see their goals, talk to members about those goals and help work towards achieving them.

Take the Next Steps Toward Supporting Regulatory Compliance and Member Engagement

By promoting health literacy, addressing disparities, and prioritizing member engagement, health plans can navigate the shifting regulatory landscape. Collaborating with the right partners and leveraging modern technological capabilities allows health plans to deliver high-quality, equitable care and achieve positive health outcomes.

Learn how GuidingCare and Wellframe from HealthEdge can help health plans achieve these goals by visiting www.healthedge.com.

To effectively implement and manage value-based care contracts, modern software solutions have become essential. In this blog post, we will explore how value-based care software is transforming the health insurance landscape and optimizing outcomes for patients, providers, and payers.

Understanding Value-Based Care

Value-based care is a departure from the traditional fee-for-service model, where providers are reimbursed based on the volume of services rendered. Instead, value-based care focuses on aligning incentives between payers and providers to promote quality care, patient satisfaction, and cost-effectiveness. Contracts are structured around outcomes, quality metrics, and patient satisfaction.

The Challenges of Implementing Value-Based Care Contracts

While the concept of value-based care is promising, its implementation poses significant challenges for health plans. Tracking and analyzing vast amounts of data from multiple sources, calculating reimbursements based on outcomes, and ensuring accurate reporting require sophisticated software solutions that can handle complex computations and streamline processes.

Value-based care software solutions, like those from HealthEdge, play a pivotal role in successfully implementing and managing value-based care contracts. These modern solutions offer a range of features and functionalities that optimize the healthcare ecosystem:

Data Aggregation and Analysis

Value-based care software solutions facilitate the aggregation of data from various sources, such as electronic health records, claims data, and social service providers. Advanced analytics capabilities allow for the extraction of valuable insights, identifying patterns, and predicting member outcomes. These insights drive informed decision-making, enabling health plans to determine which members may be at risk for developing costly complications and need more personal, proactive care.

Care Coordination and Communication

Value-based care software can enable more seamless collaboration and communication among care teams, members, and payers. Real-time updates, shared care plans, and secure messaging platforms ensure effective coordination and enhanced member engagement. By fostering continuity of care and reducing duplication of services, value-based care software optimizes patient outcomes while minimizing costs.

Performance Monitoring and Reporting

To ensure accountability and adherence to quality standards, modern value-based care software solutions enable continuous performance monitoring and reporting. Payers can monitor network performance, measure the effectiveness of interventions, and drive network optimization strategies. Providers can track their performance against established quality metrics, identify areas for improvement, and proactively address gaps in care.

Benefits of Value-Based Care Software

Implementing value-based care software offers numerous benefits to all stakeholders involved:

1. Improved Member Outcomes: By leveraging real-time data and analytics, value-based care software empowers health plans to deliver personalized care plans, preventive interventions, and evidence-based treatments. Members receive more comprehensive, proactive, and coordinated care, resulting in improved health outcomes and enhanced member satisfaction.
2. Cost Savings and Efficiency: Value-based care software streamlines administrative processes, reduces paperwork, and automates tasks, enabling care managers to allocate more time and resources to at-risk and rising-risk members. By promoting preventive care and early intervention, costly complications can be minimized, leading to significant cost savings for payers and patients alike.
3. Enhanced Provider-Payer Collaboration: Value-based care software promotes collaboration between providers and payers, fostering a shared commitment to delivering quality care. Through transparent data sharing, real-time performance feedback, and aligned incentives, providers and payers can work together to optimize care delivery, drive population health management, and negotiate mutually beneficial contracts.

Driving Value Through Value-Based Care Software

As the health insurance industry continues to evolve, so will the ways in which health plans create and manage their value-based care contracts. Value-based care software empowers stakeholders to harness the power of data, streamline processes, and foster collaboration, ultimately revolutionizing the healthcare ecosystem. By embracing value-based care software, the health insurance industry can unlock the full potential of value-based care, leading to better patient outcomes, increased cost savings, and better member experiences in the future.

At HealthEdge, our full suite of software solutions supports our customers’ efforts to embrace value-based care contracts in many ways, including:

• GuidingCare^® care management solutions that help health plans coordinate and manage care for members more effectively. These solutions include care coordination tools, population health management tools, and analytics to identify high-risk members and deliver more personalized care plans for better health outcomes.
• HealthRules^® Payer, an advanced Core Administrative Processing System (CAPS), supports health plans’ ability to manage multiple, complex payment models with the efficiency, flexibility, insights, and agility necessary to control costs, embrace change, and move quickly to take advantage of new opportunities value-based care models afford.
• Source, HealthEdge’s prospective payment integrity platform, includes rich editing libraries with history-based capabilities and enables easy development of customized edits, improved transparency, and reduced downstream work from inaccurate payments, which leads to better provider and member relations.
• Member Engagement: HealthEdge’s Wellframe solution enhances member engagement and empowerment. This may involve mobile apps or member portals that enable patients to access their health information, schedule appointments, receive reminders, and communicate with their care team.
• Data Analytics: All HealthEdge solutions incorporate advanced data analytics’ capabilities that help health plans gain actionable insights from virtually any data source, identify cost-effective treatment options, assess provider performance, and optimize care delivery.
• Integration and Interoperability: Seamless data exchange and interoperability are critical in value-based care. HealthEdge solutions aim to integrate with various electronic health record (EHR) systems, health information exchanges (HIEs), and other healthcare applications to ensure smooth data flow and better care coordination.

To learn more about how HealthEdge value-based care software solutions can help your organization thrive in a value-based care world, visit www.healthedge.com.

However, recent developments in the Star ratings program are set to bring about significant challenges for many payers.

One of the most notable changes is the introduction of a health equity index in 2027. Social risk factors, such as income, education, housing, and access to transportation, can significantly impact individuals’ health outcomes. The health equity index aims to evaluate how well health plans are addressing these factors and working towards reducing health disparities among their beneficiaries. However, this presents signification challenges for payers:

• Data Collection and Standardization: Assessing social risk factors requires reliable and comprehensive data. Payers will need to collect and analyze data from various sources to accurately evaluate their performance. Standardizing the data collection process across different plans and regions may also prove to be a complex task.
• Resource Allocation: Addressing social risk factors often involves implementing community-based programs, outreach initiatives, and partnerships with social service organizations. Payers will need to allocate resources effectively to support these efforts while balancing their financial viability and sustainability.
• Collaborative Approach: Tackling social determinants of health (SDoH) requires collaboration among multiple stakeholders, including healthcare providers, community organizations, and government agencies. Payers must foster partnerships and cooperation to drive meaningful change in social risk factors, which may require navigating complex networks and overcoming potential resistance.
• Long-Term Impact Measurement: Evaluating the impact of interventions targeting social risk factors requires a long-term perspective. Changes in health outcomes may not be immediately evident, requiring payers to invest in ongoing monitoring and assessment to accurately gauge the effectiveness of their efforts.
• Addressing Inequities: The health equity index aims to reduce disparities in health outcomes among beneficiaries. However, payers may encounter challenges in identifying and addressing specific inequities within their member populations, as these disparities are influenced by a range of complex and interconnected factors.

Other proposed changes to Star ratings:

• Limited Application of the “Better of” Methodology: In response to the COVID-19 pandemic, CMS allowed all contracts to use the existing disaster provision in 2022. This provision enabled contracts to choose the “better of” current or historical performance for most measures. However, in 2023, this methodology will no longer apply universally.
• Implementation of Upper and Lower Limits (Guardrails): Starting in 2023, CMS will implement annual guardrails on changes in cut points for non-CAHPS measures. Cut points define the ranges within which a contract’s score on a specific measure needs to fall to achieve each Star value. These guardrails will introduce more challenging cut points, potentially impacting the ratings of MA plans.
• Removal of Performance Outliers: In 2024, CMS will use the Tukey outlier deletion method to remove performance outliers from the calculation of non-CAHPS measure rating cut points. This change aims to enhance the accuracy of the ratings but may pose additional challenges for MA plans.

To mitigate negative impacts, Medicare Advantage plans must turn to modern care management systems that support the growing complexities of performance measurement programs. Payers should embrace these challenges and use them as opportunities for growth and improvement. The journey towards achieving higher Star ratings and ensuring equitable healthcare requires dedication, innovation, and a deep understanding of the diverse needs of the communities they serve.

To learn more about how HealthEdge’s GuidingCare care management solution suite can help your organization address the growing challenges associated with Star ratings, visit www.healthedge.com.

Processing data and protecting data are fundamental components of today’s digital economy, generating extraordinary value and catastrophic risk across the globe. Fueled by the increasing number of large-scale and well-publicized data breaches and a growing privacy awareness, individuals and businesses are becoming more discerning about the parties with whom they choose to do business. In addition to the quality of a business’s products or services, individuals want to know how companies incorporate privacy into their operations and want assurances that their personal information will be treated with the utmost care and respect. Individuals are more likely to share their information with companies they know will keep their data safe, making trust an essential component of the information exchange between individuals and the companies with whom they choose to do business.

The risk of harm to an individual from the loss or exposure of personal information is particularly apparent in healthcare due to the sensitive nature of the information involved. Medical records, test results, and other types of protected health information (PHI) hold an incredible amount of private data that could cause extraordinary harm or embarrassment if exposed or stolen. Protecting the privacy of high-risk information requires a proactive and multi-faceted approach and companies must implement strong privacy and security measures to safeguard PHI from unauthorized access, use, or disclosure.  The sprawl of digital data compounds the innate challenges that come with the responsibility of safeguarding personal information. Privacy regulations, like the Health Insurance Portability and Accountability Act (HIPAA), have requirements that can be time-consuming and complex. Administrative safeguards, such as access controls, can hinder operational ease due to limitations on employees who can access PHI. However, in the digitized healthcare industry, the preservation of privacy is paramount.

At HealthEdge, we value privacy and utilize an integrated approach to ensure that the information entrusted to us remains protected and secure.

Privacy + Security

While privacy focuses on the appropriate and permissible handling of data, security is responsible for implementing technological measures and safeguards that actively protect data from unauthorized access, loss, or exposure. At HealthEdge, the Privacy and Security teams work together in a dynamic and collaborative partnership to instill good privacy practices and security safeguards throughout the enterprise.  Implementing robust security measures that align with broader privacy principles like data integrity provides a layered data protection approach that effectively mitigates areas of increased risk.

Comprehensive Risk Assessments

Comprehensive risk management should incorporate privacy assessments to properly identify and mitigate risks to an enterprise. Risk assessments are a commonly used risk management process for identifying and evaluating the likelihood, vulnerability, threat, and impact of identified risks throughout a company’s operations. Enterprise-wide privacy risk assessments can help businesses identify overlooked vulnerabilities, encourage opportunities for collaborative decision-making, spur creative innovation in the development of new data protection solutions, and increase employees’ privacy awareness.

Minimum Necessary Standard

Companies with strong privacy programs recognize the heightened risks that sensitive data carries and implement a variety of safeguards to ensure their data is adequately protected. By prioritizing privacy, businesses can demonstrate their commitment to protecting personal information while also mitigating the risk of security incidents and data breaches.  At HealthEdge, we enforce the minimum necessary standard for our data processing activities. The minimum necessary standard is a data minimization requirement under HIPAA and a fundamental privacy principle meaning only the minimum necessary data should be used to accomplish the intended business purpose. By minimizing the collection and use of personal information, companies can demonstrate their commitment to protecting personal information and reduce the risk of processing a surplus of information.

The Value of Good Privacy

Companies should have a firm understanding of these fundamental privacy practices, a cross-functional approach to data protection efforts, and the ability to recognize and adapt to the evolving (and expanding) privacy preferences of customers who are looking for businesses they can trust. The successful evolution of a company’s privacy program into a full Privacy by Design (PbD) framework is largely dependent on receiving intradepartmental and leadership support, but support for driving privacy initiatives forward can be a challenge. Stakeholders should know the necessity of privacy in today’s environment and understand how it can be leveraged as a competitive differentiator that builds trust. Aligning privacy goals with core business objectives can influence business decisions and help ensure that privacy is prioritized and supported. A trustworthy reputation is an asset that can generate economic value, attract new customers, and fortify a company’s ability to withstand challenging incidents.

At HealthEdge, we understand the vital role that privacy plays in securing customer trust and embodying good data stewardship. By prioritizing privacy, the data that is shared with us is kept confidential and secure.

At HealthEdge, we have been committed to our employees for years. Years before the pandemic, we focused on employee engagement. Through annual surveys, we would tap into the employee voice and digest the results collectively focusing on how we can learn and grow and ultimately improve together. This has become the foundation of our approach to employee experience.   Since the pandemic, many forces have changed our approach to achieving the same end state. Internally, HealthEdge has grown organically and inorganically, we have acquired and welcomed new products into our product suite and constantly seek ways to fulfill our vision of innovating a world where healthcare can focus on people. Externally, we lived through drastic shifts that have left many lasting effects on the way we live and work. To continue to approach employee engagement the same way we had through all that change felt shortsighted and I am proud of how we stayed curious and flexible. This work is never done but with employee experience as our north star, creating something intentional with our company culture has renewed vigor.

If you are interested in doing this too, we recommend building your employee experience model around the following:

1. Purpose

Employees want to know about your purpose. They want to feel like they’re a part of something bigger than themselves. A powerful, compelling purpose and why is critical to employee engagement in their work and connection to those around them. We want our employees to be excited about how we’re shaping the future of healthcare. Therefore, it is our responsibility to tell that story, over and over.  You know the story and principles have sunk in when they begin telling others.  Find your company’s purpose and make sure it is persuasive and inspiring, then tell everyone, and then tell them again.

2. Enablement

Enablement is a reflection of whether an employee has what they believe they need to do their job well. Fundamentally, this is highly subjective territory. I am not advising you to please everyone, but asking staff about their perspectives equips you with insights into their expectations.  This is about recognizing themes and solving for the collective. More than anything it is about listening to your staff and ensuring they feel heard.  Enablement goes beyond tools and resources used to do the mechanics of the job. It encompasses collaboration, community, and camaraderie as well. At HealthEdge, among other things, this dialogue and feedback has led us to streamline our digital collaboration tools as well as how we collaborate in person within our hybrid work environment.  We are always working to improve how we purposely gather during our monthly collaboration weeks. Talk to your employees about enablement, community, and collaboration topics because these are unspoken pillars that are critical to keeping employees engaged.

3. Autonomy

Autonomy means setting the vision and empowering your employees to make it happen. It means trusting your employees and enabling them to make decisions. For years, we have been inspired by the work of Daniel Pink who coined “autonomy, mastery, and purpose” as the fundamental factors that DRIVE employees. Granting autonomy can manifest in many ways. It can be finding ways to support remote or hybrid work based on the asynchronous workflows. It can be evaluating how much oversight managers and leaders provide vs allowing your teams space to exercise new skills. With autonomy, employees can harness the power of maximizing their personal productivity, creativity, and flow. Autonomy is highly reflective work and leads to greater ownership over the work. As you get started, talk to your teams about small ways that would have big impacts.

4. Rewards & Recognition

Rewarding and recognizing talent are paramount to employee experience. Rewards are tangible and transactional in nature: salary, benefits, PTO, holidays, etc. Regardless of the offerings you have available, it is paramount that your process for rewarding is consistent, fair, and equitable. Our approach to rewards at HealthEdge is merit based, meaning they are intrinsically connected to recognition of a job well done. In 2022, we added 4 extra company holidays in the summer – this created four 4-day weekends in the US, putting our values of encouraging our employees to take time to relax and recharge into action. Where rewards are transactional, recognition is motivational. Recognition is what drives behavior, builds connection, and breeds a self-sustaining culture.  Non-monetary recognition can take the form of saying thank you, publicly shouting out your appreciation of a job well done, providing new opportunities, mentoring/coaching, etc. People want to be seen and heard and recognized for the contributions they make. At HealthEdge we have an organic culture of appreciation best exhibited by our public and global “rockstars channel”. On this channel anyone can thank or give a shoutout to a person or team that made a difference, while the initial shoutout is amazing the best part is watching the shared celebration happen in supportive comments. Celebrate and recognize big and small efforts and be fair, consistent and equitable in rewards.

5. Leadership

Finally, the last element critical to strong employee experiences is strong leadership. Leaders and managers are the lynchpin – from the behaviors they model, the vision they set, and the experiences they create with their teams. Leaders/managers bring the above elements to life and into everyday actions. Employees work for managers first, companies second. At HealthEdge we have focused on supporting, empowering, and equipping our manager and leader population to be brilliant at the basics: from how to host great 1:1s, to engaging in feedback, navigating potentially difficult situations, and strengthening their emotional intelligence (EQ). Assess how you are supporting the employee experience from this lens? Don’t lose site that manager relationships are the grassroots level of this work. 

The Dividends of Employee Experience

Employee experiences are an amalgamation of everything the employee interacts with beyond their day to day job tasks: people, process, tools, physical or virtual workspaces, etc. Most experiences are not under management’s control because true culture is what happens when no one is looking. The trick is focusing on what you can influence, facilitate, and improve. Remember to keep the end in mind as you embark on this work. Remember the interconnectedness of how employee experience, engagement, and satisfaction lead to improved business outcomes.  Happy, satisfied, engaged, empowered, connected employees expend discretionary effort. It is that effort of going the extra mile to; deliver better products and services, provide enhanced customer service, become brand ambassadors who speak highly about the company, that builds connection and loyalty resulting in people who are more likely to stay and refer others. You will know it is working when the virtuous cycle begins – when without intervention you notice these efforts in action organically.  There is so much you can start doing today to yield better employee experiences- let’s make work better!

Learn more about working at HealthEdge here.

During the recent webinar, Understanding Your Medicaid and Dual-Eligible Members as Consumers: What Matters Most Today, HealthEdge released the findings from its nationwide survey that gathered the opinions and perspectives of more than 2,800 healthcare consumers. Presenting exclusively to Association for Community Affiliated Plans (ACAP) members, the speakers focused their interactive discussion on the survey findings from the nearly 500 Medicaid and Dual-eligible plan members who responded.

The results shed light on member satisfaction, communication preferences, the role of social determinants of health (SDoH), and the trust today’s consumers have in health plans. Understanding these aspects is crucial for health plans to meet the evolving needs and expectations of their members. Here, we summarize the discussion.

Member Satisfaction: A Top Priority for Health Plans

Member satisfaction has become increasingly important, driving health plans to seek modern, digital transformation that facilitates a more connected, consumer-centric healthcare marketplace. Factors influencing the growing importance of member satisfaction include:

• Consumer buying behaviors being shaped by retail experiences,
• New market entrants setting standards for consumer-friendly experiences and driving the need for increased health plan agility,
• Increasing availability of data sources and maturing interoperability standards,
• Growing participation in Medicare Advantage, Medicaid, and individual marketplaces.

By keeping a pulse on what matters most to consumers, health plans cans can more effectively adapt, prepare for the next generation, and remain competitive in the evolving market.

Consumer Preferences and Expectations: Summary of Survey Results

The study revealed meaningful insights about Medicaid and Dual-eligible members:

• Medicaid and Dual-eligible members tend to be more satisfied than their counterparts in Medicare and employer-funded health plans, but significant gaps remain.
• Good customer service has emerged as a top priority for members.
• Adhering to members’ communication preferences significantly impacts overall member satisfaction.
• Consumers expect health plans to leverage SDoH data to deliver more personalized and relevant services.
• While most consumers trust health plans to manage their insurance, they also hold health plans most responsible for high healthcare costs.

Now, let’s dive into the details.

The survey indicated that Medicaid and Dual-eligible populations show higher levels of satisfaction with 44% and 52% fully satisfied, respectively, compared to other groups. Conversely, the study revealed 44% of Medicare-only members were fully satisfied and 38% of members in employee-sponsored programs. Given this data, there is still ample room for improvement.

The study reveals the vital role care management plays in enhancing member satisfaction, providing a more personalized experience, and improving outcomes. The speakers explained that to scale care management efforts and achieve higher member satisfaction, health plans need modern technology in place. Technology can automate manual, mundane processes and empower care managers to be more productive, reach more members, and provide personalized engagement.

“We need to find ways to reach more members without taxing our nurses. When the right technology is present, payers are able to put the care manager in the center and empower them to be more productive to meet member needs at scale,” explained Jennie Giuliany, RN, Lead Clinician, Client Management, HealthEdge, GuidingCare.

Christine Davis, Senior Vice President, Marketing at HealthEdge also added, “Technology can help plans understand members holistically – medically, behaviorally, environmentally – and allocate the right resources based on populations. The right tools can help care managers scale so more members can receive the personalized engagement that previously could only be given by a care manager. For example, by improving care managers’ access to more real-time data, they have better insights immediately available. Technology can also automate manual tasks that take time away from care managers connecting with more members.”

Connecting with Members: Using Preferred Methods of Communication Improves Satisfaction and Outcomes

Medicaid and Dual-eligible members tend to prefer communication via phone, email and text or mobile app. Technology can equip health plans with the right tools to engage these hard-to-reach members. In addition, the study found that being able to communicate with members through multiple channels – and specifically their preferred channels – has a positive impact on overall satisfaction scores. Adopting an omni-channel communication approach allows health plans to connect with members through their preferred channels, which ultimately helps improve engagement and care plan adherence.

Holistic Inights and Actions: Using SDoH Data to Improve Member Satisfaction

A growing number of state policies now include SDoH. As SDoH data becomes more available, health plans can use this information to address health equity challenges. However, study participants demonstrated they are less than fully satisfied when it comes to their care manager’s ability to provide personalized care based on their personal traits, current economic conditions, and location or community. For example, results indicated:

• 50% are less than fully satisfied with their care manager’s ability to provide individualized services based on their personal traits, such as race, ethnicity, gender, or religion.
• 60% are less than fully satisfied with their care manager’s ability to provide access to essentials such as housing, food, utilities, or transportation.
• 64% are less than fully satisfied with their care manager’s ability to provide services based on the location and/or community in which they live.
• 69% are less than fully satisfied with their care manager’s ability to provide individualized services based on their current economic conditions such as education, employment, or income level.

To close these gaps in satisfaction, payers can turn to technology to easily identify at-risk populations and build more whole-person care strategies that can make meaningful differences in member outcomes and costs.

Using the right data and workflow tools, health plans can align individuals who have specific needs with more tailored services, such as access to housing, food, utilities, and transportation. Leveraging a care management platform that integrates with SDoH vendors can help accomplish this.

Understanding Member Needs and Gaps

When selecting a health plan, Medicaid and Dual-eligible members prioritize factors such having more services covered; offering benefits that align with service and medication needs; the ability to keep current providers; and in-network providers close to home or work.

However, the survey revealed that gaps exist in health plans’ abilities to address key member needs. Consumers identified the biggest gaps as:

• Good customers service
• Easy access to my health records
• Incentives and rewards for health behaviors
• Regular communication through preferred channels

Perceptions and Trust in the Health Plan Ecosystem

Medicaid and Dual-Eligible members generally trust health plans over other entities like the government to administer their health insurance. However, the research shows important trends emerging from different generations, such as younger members placing more trust in retail companies and being more likely to assign assigning blame for high healthcare costs to health plans. Understanding individual experiences and touchpoints within the healthcare ecosystem is essential for shaping perceptions and trust.

Actions for Health Plans to Improve Member Satisfaction

To enable care managers to be more efficient and effective, and to enhance current and future member satisfaction, payers can leverage modern care management solutions, like GuidingCare^® and Wellframe from HealthEdge. The right solutions to support member experience should include key capabilities that allow health plans to:

• Remain agile and adaptable to support regulatory changes
• Automate multiple redundant and inefficient workflows
• Expand into new markets and business models
• Manage and support value-based care
• Personalize member engagement at scale

Following consumer trends and needs allows health plans to improve member satisfaction and health outcomes at a time when the stakes have never been as high. To watch the full webinar, visit the HealthEdge website here.

Even though payers possess a wealth of data that can provide valuable insights into healthcare outcomes and costs, the sheer volume of data can be overwhelming. Payers often struggle to extract meaningful insights due to the terabytes of siloed data they collect across their enterprise and outdated analytics solutions that cannot handle the complexities of performance-based arrangements.

Bridging the Data Gap

While the management and reporting of data for traditional measures have made progress, value-based contracting presents unique challenges. Value-based contracts are often complex and vary in nature, requiring customized infrastructure and data management systems.

Modern technology solutions, like those provided by HealthEdge, are designed to handle diverse data types, such as fee-for-service and value-based data, and they can help payers more effectively evaluate their performance across measures such as Healthcare Effectiveness Data and Information Set (HEDIS) and STAR ratings. HealthEdge solutions enable accurate pricing, continuous performance comparison between providers, and transparent reporting to establish a balanced and collaborative relationship between payers and providers.

One of the significant barriers to effective value-based care is the asymmetry of information between payers and providers. Payers often have access to extensive data that providers lack, which can create a sense of uncertainty and fear among providers during contract negotiations.

To foster trust and encourage provider participation in value-based contracts, the flow of information must be balanced. Miscommunication and roadblocks can hinder effective collaboration and limit the progress of value-based care initiatives. Providers may view value-based care as a potential financial risk, which creates resistance and a perception of being taken advantage of. The accurate and timely flow of data supports the development of mutually beneficial relationships and an open dialog.

Payers need to provide transparent insights to providers regarding their performance, patient gaps in care, and financial implications. By doing so, providers can make informed decisions and actively engage in collaborative efforts to improve patient outcomes and confidently pursue value-based care reimbursement plans.

Creating Transparent and Sustainable Arrangements

To overcome the challenges and facilitate the advancement of value-based care, payers and providers must come together to create transparent and sustainable arrangements. This involves fostering an environment of trust, open communication, and shared goals that come by leveraging accurate and timely data.

By embracing accurate and timely data, payers and providers can work together to improve health outcomes, enhance cost containment, and deliver positive member experiences – all common goals of the healthcare industry’s push towards a value-driven future.

To learn more about how your organization can better leverage data to advance value-based care arrangements with providers, visit www.healthedge.com.

While the term “value-based care” has gained popularity, its widespread adoption has been slower than anticipated. It essentially represents different contracting models beyond traditional fee-for-service reimbursement that aim to reduce costs and improve health outcomes.

The main challenge in expanding value-based care is getting both payers and providers comfortable with the uncertainty of reimbursements under these arrangements. Providers often struggle to shift from their fee-for-service mindset and adapt their business operations to take on financial risk. Payers are often unsure about how to best build and manage their care networks to achieve their value-based care goals while also meeting the needs of the populations they serve.

Building a partnership between payers and providers, based on transparency and information symmetry, is crucial for successful value-based care implementation.

The Role of Technology in Value-Based Care

Complex workflows, analytics for identifying gaps in care, and member risk stratification can be facilitated by modern care management systems. Digital tools and mobile infrastructure can empower members to be more engaged in their care, especially when they are outside of their traditional healthcare setting.

Technology can also help health plans tap into the vast amount of data they possess to evaluate performance across various measures, such as HEDIS and STAR ratings. It can also be used in predictive modeling for gaps-in-care analysis, which can help identify members at risk before they experience an adverse event.

Many health plans face challenges in consolidating data, analyzing it effectively, and presenting actionable insights from it. Modern technology platforms are needed to support value-based contracting, enabling accurate comparisons between providers on different payment models, and fostering transparency in the provider-payer relationship.

HealthEdge’s Contribution to Value-Based Care Success

HealthEdge offers modern technology solutions that support payers’ efforts to manage value-based care arrangements. HealthEdge products, such as HealthRules^® Payer, GuidingCare^®, and Source streamline claims management, adjudicate capitation arrangements, facilitate care management workflows, and improve payment integrity. The company’s Wellframe^® product enables digital care management, enhancing patient engagement and improving health outcomes. HealthEdge’s technologies aim to simplify healthcare processes, deliver real-time information, and improve overall member experiences.

At HealthEdge, we believe value-based care holds the potential to transform healthcare delivery and reduce costs. That’s why we are focused on helping the healthcare industry make progress against their value-based care goals by leveraging technology to provide real-time cost and benefit information to members and providers, resulting in greater transparency and better healthcare experiences.

To learn more about how HealthEdge solutions can help your better manage risk, streamline operations, and enhance member experiences, and pursue value-based care arrangements, visit www.healthedge.com.

Based on the data, it appears that health plans should consider a fresh approach to payment integrity across their enterprise to help tackle some of their long-standing and most frustrating challenges. The highly interactive webinar featured Ryan Mooney, EVP and GM, HealthEdge Source and Carl Anderson, Carl Anderson, Senior Product Manager HealthEdge Source sharing their perspectives on the data.

To watch the full webinar, click here: New Research In Payment Integrity Reveals a Paradigm Shift is Underway.

We’ve summarized the five key findings in this post.

5 Take-Aways From the New Research

1. Workforce Shortages and Limited Resources: A significant challenge faced by payer organizations is the limited availability of qualified resources to ensure accurate claims payment. The webinar revealed that 64% of respondents ranked limited resources as one of their top issues, preventing them from keeping up with changing fee schedules and policy updates. Additionally, 58% expressed difficulty in hiring and retaining qualified professionals for this complex work. These challenges may arise due to the manual labor involved in ensuring accurate claim payments.
2. Limited Visibility and Root Cause Issues: Another prominent challenge identified by payers is the limited visibility into third-party vendors and root cause issues. Without comprehensive visibility, payers struggle to identify the underlying causes of payment errors and address them effectively. This lack of insight leads to a cascade of problems, such as increasing workload and growing financial losses. Achieving transparency and identifying root causes are crucial for building effective payment integrity programs.
3. Manual Rework and Costly Errors: More than half of the respondents revealed that over 20% of their claims required rework, which incurs significant costs ranging from $25 to $181 per claim. The financial burden resulting from these errors extends beyond rework expenses and includes factors like provider dissatisfaction and member dissatisfaction. To address this issue, payers need to focus on getting claims right on the first attempt.
4. Misaligned Initiatives: While payment integrity initiatives involve multiple departments within an organization, misalignment often hinders their effectiveness. The webinar findings indicated that over half of the respondents felt that their organization’s payment integrity initiatives were at odds with other initiatives. This misalignment can be attributed to a lack of a common goal across departments, competing priorities, and stretched resources. Achieving a more holistic enterprise approach is vital for overcoming these challenges and ensuring a unified payment integrity program.
5. Misaligned Vendor Incentives: Many payers struggle with the burden of multiple third-party vendors, resulting in increased costs and complexities. In the webinar, the speakers highlighted the challenges faced by payers when using several editing tools stacked on top of each other. These challenges include maintaining multiple IT systems, managing conflicting content, and navigating fragmented workflows. Consolidating vendor relationships and adopting a single, unified platform can help reduce costs, streamline operations, and enhance efficiency.

The Path Forward: Technology as a Solution

Historically, technology has taken a backseat to content when it comes to selecting payment integrity vendors. However, the webinar highlighted a shift in focus, with technology emerging as a critical component in overcoming payment integrity challenges. Payers are realizing that technology can provide solutions and streamline processes that manual labor alone cannot achieve. By leveraging modern and flexible technology, payers can effectively tackle rising complexities and improve their payment integrity initiatives.

To address the challenges identified in the webinar, HealthEdge Source delivers a modern technology platform that gives payers the ability to access pricing and policy changes from a single place, thereby improving transparency and streamlining operations. By leveraging technology, payers can achieve greater control, visibility, and interoperability within their payment integrity initiatives. Additionally, technology empowers payers to reduce dependency on contingency vendors and address root cause issues, resulting in improved accuracy and savings.

To learn more about how Source can help your organization achieve its payment integrity goals, visit Prospective Payment Integrity – HealthEdge.

A Bit of Background

Historically, HealthEdge’s software solutions have relied on VPN connections to connect with customer data centers. While VPNs have been effective for many customers, they do pose constraints when it comes to transferring large amounts of data quickly. HealthEdge now offers high-speed connectivity options to cater to the specific needs of customers with demanding data transfer requirements. By providing dedicated point-to-point circuits, HealthEdge ensures that customers can transfer data swiftly, enhancing operational efficiency and minimizing any bottlenecks that may arise from slower connections.

Top 5 Value Points of High-Speed Connectivity

HealthEdge’s high-speed connectivity options come with several significant benefits that set them apart from traditional VPN connections. Let’s explore some of these benefits:

1. Secure User Authentication: HealthEdge employs OpenID Connect and/or SAML2.0 protocols for user authentication. These protocols are industry-standard and provide a secure and open authentication framework. By leveraging SAML and OpenID Connect, HealthEdge enables customers to authenticate users via a secure Identity Provider (IdP) managed by the customers themselves. This approach ensures that sensitive credentials are only sent directly to the customer’s IdP, enhancing privacy and minimizing the risk of storing data within the application.
2. Payer Authentication Delegated to Customer’s IdP: HealthEdge’s high-speed connectivity options allow customers to apply their own password policies independently, without HealthEdge’s involvement. Additionally, by relying on the customer’s chosen IdP, which specializes in secure industry-standard authentication, the burden of implementing and maintaining advanced security methods rests with the IdP. This arrangement ensures that customer data remains safeguarded while benefiting from the economies of scale and expertise provided by the IdP.
3. Multifactor Authentication (MFA): HealthEdge supports the use of Multifactor Authentication as an optional layer of security. MFA requires users to provide two or more categories of authentication to verify their identity. This can include something the user possesses (e.g., a unique token from a third-party application) or something they are (e.g., a fingerprint or retinal scan) along with a standard user ID and password. By implementing MFA, HealthEdge adds an extra layer of security, ensuring that access to sensitive data, such as ePHI (electronic Protected Health Information), is limited to authorized personnel only. This aligns with regulatory requirements such as HIPAA compliance.
4. Just-in-Time (JIT) User Provisioning: HealthEdge’s high-speed connectivity options streamline user access management and identity governance. JIT user provisioning automates the process of managing users in the health plan’s system, saving time and reducing the workload for administrators. This efficient approach frees up valuable resources for other critical tasks.
5. One-Time Single Sign-On (SSO) Configuration: HealthEdge’s SSO configuration is a one-time activity. Once implemented, the same configuration works seamlessly across all of the health plan’s environments, including Production, Pre-Prod, UAT, Dev, and Test. This externalized configuration approach accelerates deployments and upgrades and reduces operational costs.

How it Works

To initiate the process, HealthEdge first assesses the best carrier option available in the geographic area. Based on this evaluation, HealthEdge will order a dedicated circuit from the chosen carrier. The dedicated circuit serves as the primary connection, enabling high-speed data transfer between HealthEdge and customer networks.

Once the carrier is selected and the circuit is ordered, HealthEdge provides the customer with connection details, including addresses and routing information. The customer is responsible for setting up a Layer 3 connection point within their data center. This connection point serves as the entry point for the dedicated circuit and facilitates the transfer of data between HealthEdge and the customer’s infrastructure.

In addition to the connection point, a Network Address Translation (NAT) IP address is required as an endpoint for routing traffic. The NAT IP address ensures that data is directed correctly between HealthEdge and the customer’s networks, enhancing the efficiency of data transfer.

The dedicated circuit serves as the primary connection between HealthEdge and the customer networks. This dedicated circuit offers superior performance and reliability, ensuring fast and uninterrupted data transfer. However, to further enhance resilience, HealthEdge also establishes an IPsec VPN tunnel as a passive redundant connection. In the event of the dedicated circuit becoming unavailable, the IPsec VPN tunnel acts as a backup, enabling continued data transfer.

Moreover, HealthEdge maintains a secondary IPsec VPN tunnel. This secondary tunnel remains disabled under normal circumstances. However, it can be enabled if the primary data center experiences an outage or during disaster recovery testing. By leveraging this setup, HealthEdge ensures continuous connectivity and data transfer, even in the face of unexpected disruptions.

To learn more about how HealthEdge’s new high-speed connectivity offering, visit www.healthedge.com or email us at info@healthedge.com.

The webinar kicked off with Jeff highlighting the advancements payers have made in recent years in value-based care. Payers are transitioning from being merely transactional entities to becoming active partners in care. With the advent of exchanges and marketplaces, payers have focused on improving the shopping experience for enrollment as well as the overall patient satisfaction and engagement. The rise of convenience as a leading factor in healthcare decision-making has led to the emergence of models such as retail health, telehealth, hospital at home, and care anywhere, all aimed at providing accessible and patient-centric care. Additionally, payers have been actively engaging in interoperability, striving to establish an open and seamless system where data can flow between payers, providers, and patients. Artificial intelligence and data analysis have played a crucial role in leveraging payer data to identify care gaps and predict patient needs.

The Role of Technology in Value-Based Care

According to Dr. Gardner, technology plays a pivotal role in facilitating the transition to value-based care by automating manual workflows and leveraging data. Technology can support the efficient delivery of care and improve patient outcomes, while also improving the reach of care management teams by identifying and stratifying at-risk populations. Modern care management solutions offer configurable algorithms to rank member risk based on multiple data sources, including clinical diagnoses, pharmacy claims, and health risk assessments. Digitalizing the intake process and automating care plans can further streamline care management workflows, making them more efficient and increasing member engagement and satisfaction.

Harnessing the Power of Data

Health plans have access to vast amounts of data, ranging from patient experience surveys to medical and pharmacy claims. The challenge lies in sifting through this data to identify relevant and actionable insights. In the webinar, Dr. Gardner emphasized the importance of leveraging data to drive quality improvement rather than merely focusing on compliance. She highlighted the need to surface the right data to the right stakeholders at the right time, enabling health plans to improve performance and outcomes across populations. For instance, data capture can aid in identifying gaps in care and leveraging technology to close those gaps. HealthEdge’s solutions provide configurable assessments and gap closure functionalities, empowering health plans to enhance quality and performance scores while improving patient outcomes.

Adapting to Regulatory Changes

The speakers discussed how technology can assist health plans in adapting to value-based regulatory changes. Examples included incorporating health equity stratification data into assessments to address disparities in care quality across different racial and ethnic groups. Furthermore, modern technology can help health plans meet the requirements of Medicare Advantage and ACA 2023 regulations, particularly in collecting social determinants of health data through health risk assessments (HRAs). Another critical aspect is provider data management and directory requirements, under the No Surprises Act, where HealthEdge’s upcoming provider data management solution can help health plans ensure accurate and up-to-date provider network information.

Accelerating the Journey Toward Value-Based Care Success

This webinar shed light on the progress health plans have made and the opportunities they have in front of them as they pursue their value-based care strategies moving forward. As payers continue to evolve toward become active care partners, embracing convenience and interoperability to enhance patient satisfaction and engagement is critical. Technology solutions have enabled the automation of manual workflows, streamlined care management, and facilitated data-driven decision-making. By harnessing the power of data and leveraging advanced technology, health plans can improve quality, outcomes, and member experiences in the value-based care landscape.

To access the full webinar on-demand, watch the recording here. If you’d like to learn more about how HealthEdge can support payers with value-based care, visit www.healthedge.com.

To achieve seamless care coordination, reduce costs, and increase efficiencies, care management platforms must integrate effectively within care management functions as well as across the entire healthcare ecosystem. However, identifying and prioritizing the right integrations can prove challenging for health plans. To get the most out of an interoperability strategy, health plans should understand market drivers and establish goals for what should be accomplished through enhanced integration.

After working with many health plans on developing and executing their interoperability strategies, we have a thorough understanding of how the most successful plans view interoperability.

With the right integrations in place, health plans can break down siloes, support new regulations and payment models, and improve the member experience.

The Race is On: Market Dynamics and Priorities Driving Urgency for Interoperable Care Management Systems

New regulations, evolving payment models, and shifting member expectations are driving urgency for health plans to advance interoperability across multiple systems. For example, the recently proposed CMS rule, “Advancing Interoperability and Improving Prior Authorization Processes,” will prompt health plans to address integration gaps in their prior authorization and utilization management processes. In addition, the transition to value-based care demands more advanced interoperability to allow for better collaboration and outcomes.

Meanwhile, payers are also investing in strategies that improve health outcomes and member experience to advance ratings in the CMS Star Ratings program. Star Ratings can have a significant financial impact for health plans, as moving up from a 3.5- to 4-star rating is worth an additional $400 per member per year on average for Medicare Advantage plans. With member satisfaction and care outcomes being key drivers of the health plan rating, many are finding interoperability to be a critical investment for advancement in these core areas.

Finally, innovation in digital experiences and rising consumerism in the industry continue to shift to member expectations of access to health data and information from across the broader healthcare ecosystem. Members are seeking ease of access to their health and claims data, making efficient exchange of information a top priority.

Integrating the Care Management Function

When building a successful integration strategy to address these needs, health plans should first consider several key integrations within the care management function. These integrations facilitate better care coordination, improve communication, and ultimately optimize health outcomes. To begin, payers should consider how their core care management platform will integrate with solutions housing these types of data:

Social Determinants of Health (SDOH): According to the National Academy of Medicine, new payment models are prompting health plans to prioritize strategies to improve the social wellbeing of their members. SDOH account for approximately 80-90% of a member’s overall health, with medical care accounting for only 10-20%. As a result, many health plans are elevating the importance of investing in ways to enable members to manage aspects of their environment that contribute to overall health.

By systematically integrating care management with SDOH data,  care coordinators can deliver more whole-person care and services by supporting social and economic needs that contribute to a member’s health status. By quickly and easily connecting members with social services, enabling seamless data exchange, and tracking and measuring progress, care coordinators can support overall health needs of their members.

Clinical Criteria: Integrating care management with clinical criteria platforms enables health plans to streamline utilization management (UM) workflows, while informing care strategies that improve outcomes for members and reduce costs for health plans. The integration has become more critical for health plans as costs continue to rise and health plans seek new strategies for improving efficiencies.

Lettering & Correspondence: Timely, clear, and effective communication can advance member engagement, a key factor when it comes to improving overall health outcomes. Integrating care management with lettering and correspondence solutions allows efficient creation of personalized member mailings. Streamlining the process of delivering real-time correspondence for denials, appeals and grievances, and other member communications strengthens member engagement and saves time for health plan administrators.

Business Rules: When business rules are seamlessly integrated with a care management platform, health plans can more effectively manage complex care, automate best practices, and streamline the prior authorization process. Improving efficiencies through this level of integration enables health plans to make strides in preparation for new CMS guidelines to improve processes and efficiencies related to prior authorizations.

Business Intelligence: Health plans are managing more data than ever before. To unlock insights and intelligence behind the data, health plans require use of advanced tools. Integrating reporting and business intelligence allows health plans and care managers to easily access and use the real-time data to improve care management strategy and workflows.

Prioritizing Integrations Across Healthcare Ecosystem

In addition to interoperability within the function, care management solutions should integrate with platforms across the healthcare ecosystem to improve efficiencies and reduce costs. As health plans build their interoperability strategies, health plans should prioritize integrations with other functional systems, including:

Core administrative processing system (CAPS): Integrating claims data into care management workflows allows care managers to incorporate indicators such as repeat provider visits, lack of medication adherence, and missed encounters to create the most effective care plans. With access to the complete view of member history and claims data, care managers can make more informed decisions. Efficient exchange of this type of information is integral to the success of value-based care.

Payment integrity platforms: Interoperability between care management and payment integrity platforms ensures payment teams can access real-time clinical data. As a result, they can improve the accuracy of the claim, configure more effective benefit packages, and reduce provider and member abrasion. The integration also improves efficiencies and reduces costs by eliminating manual data entry.

Digital health management tools: The availability of digital tools and remote monitoring devices for connectivity to patients continues to grow exponentially. With better access to patient data from multiple sources, care managers can more effectively care for members and improve outcomes. According to HIT Consultant, “Creating and utilizing clinical-grade digital health innovations increases adherence and provides members with more accessibility. By utilizing things consumers already have – such as smartphones and videoconferencing platforms – these innovations can create new pathways to care.” Integrating care management platforms with innovative digital health tools not only improves member satisfaction, but also promotes better health outcomes and care quality. By delivering results in these areas, health plans can support value-based care and boost Star Ratings.

Delivering Interoperability Strategy with GuidingCare®

GuidingCare takes a multi-faceted approach to interoperability that includes both integrations within the care management function, as well as those across the entire healthcare ecosystem. With more than 75 unique vendor integrations and 12 productized integrations, and 75 API endpoints to integrate content into native workflows, GuidingCare provides the tools and resources health plans need to successfully execute their care management interoperability strategies.

To learn more about how about how GuidingCare’s highly interoperable platform can accelerate your organization’s care management strategies, visit the GuidingCare page on the HealthEdge website.

What is Legal Compliance at HealthEdge?

Legal compliance is the ongoing process of ensuring that a company, business, or other organization is adhering to the applicable laws, regulations, and industry standards. This can include complying with financial reporting requirements, implementing privacy and security safeguards, training workforce members, and conducting operations in accordance with the numerous laws that govern businesses, such as employment, tax, and insurance laws.

The purpose of having a strong compliance program is to help organizations operate at a high level and to avoid the penalties, financial losses, and reputational damage that can result from violations caused by non-compliance. The financial penalties for violations can be significant and have the potential to cause additional harm that can be devastating to the success of a business.

A quality compliance program provides assurance to prospects and customers that a business is well-managed, trustworthy, and reputable. A compliance program can be tailored to support an organization maintain its ethical standards (like transparency, honesty, and respect) which also helps build trust with stakeholders, customers, workforce members, and shareholders.

HealthEdge prioritizes compliance throughout the company so that all workforce members are aware of and involved with its success. The compliance group takes a cross-functional approach to engage company-wide support and increase the efficiency of compliance efforts. By working with multiple departments, HealthEdge ensures that the compliance requirements are met, and regular work is unaffected so business can continue as usual.

HealthEdge is committed to working for the best interests of its customers, and the strength of its compliance program helps demonstrate that commitment.

How does HealthEdge achieve Compliance?

Implementing company-wide compliance is a complex process that requires knowledge and awareness of the many laws, regulations, rules, and standards that require strict adherence. HealthEdge takes a detailed approach to ensure the compliance program is performing at a high level, and that the compliance program is working as intended. The program is designed around the seven foundational elements of a compliance program outlined by the United States Sentencing Commission, incorporating an additional element from the Department of Health and Human Services (HHS) Officer of Inspector General (OIG) Compliance Guidelines:

1. Governing Authority: HealthEdge has a Compliance Officer (CO) and the Risk Compliance and Governance Committee, that is comprised of members of the executive leadership team is responsible for the execution, correction, and oversight of all aspects of the compliance program.
2. Policies and Procedures, and Code of Conduct: HealthEdge commits to complying with all applicable federal and state regulations and standards–this includes providing guidance to workforce members on compliance-related matters. HealthEdge also provides procedures that assist in the identification and correction of non-compliance. These policies and procedures are reviewed on a regular basis and updated as needed based on requirement changes or regulations.
3. Training and Education: HealthEdge provides various training to its workforce members, including new hire, annual refresher, and role or product-specific training.
4. Reporting: HealthEdge is committed to fostering a culture of compliance, good corporate governance, and ethical behavior and encourages the reporting of improper, unlawful, or unethical behavior. Workforce members are encouraged to discuss any suspected violations with appropriate individuals within HealthEdge. HealthEdge has a strict non-retaliation policy–there can be no retaliation, penalty, or retribution for good faith reporting of any suspected compliance issue.
5. Monitoring & Auditing: Proactive auditing and monitoring of routine business practices is vital for the identification of potential compliance issues. HealthEdge routinely conducts audits and monitors business processes to identify risks. These processes help:

• Ensure compliance with policies and procedures, laws, and regulations.
• Confirm that corrective actions have been implemented.
• Evaluate the overall effectiveness of the compliance program.

6. Enforcement & Discipline: HealthEdge does not tolerate non-compliance with company policies or applicable laws. Any non-compliance could compromise HealthEdge’s operations, the services provided to customers, or its Violations of the HealthEdge Code of Conduct and other policies and procedures require a corrective action and reporting to the appropriate regulatory or law enforcement agency when applicable. HealthEdge has well-publicized disciplinary standards that:

• Prohibit authorization or participation in activities that violate HealthEdge policy.
• Articulate expectations for reporting compliance issues and assists in their resolution of issues.
• Provide timely, consistent, and effective enforcement of the standards when non-compliance or unethical behavior is detected.
• Encourage good-faith participation in the compliance program.

7. Response & Prevention: HealthEdge has a well-developed compliance program, with established procedures, processes, and system implementation for promptly responding to compliance issues. The HealthEdge compliance program ensures that:

• Issues are acknowledged as they arise.
• Potential compliance problems are investigated.
• Concerns are proactively identified through rigorous auditing and monitoring.
• Problems are corrected promptly and thoroughly to reduce the potential for recurrences.

8. Background Checks: In addition to the seven foundational elements of a compliance program outlined above, HealthEdge also incorporates Background Checks that include an investigation of criminal history, exclusions, and reference checks. HealthEdge makes reasonable efforts to ensure personnel and business partners are not engaged in illegal activities or conduct that is inconsistent with an effective compliance program.

Conclusion

Achieving compliance requires a thorough understanding of all applicable laws and regulations, the development of policies and procedures to ensure compliance, the implementation of controls and monitoring systems, and ongoing maintenance and updates to ensure compliance with changing requirements. HealthEdge’s compliance program ensures the company meets established standards, upholds its commitments, protects its business reputation, and avoids financial penalties. By prioritizing compliance, HealthEdge mitigates legal and financial risks, operates ethically, and serves the best interest of its customers.

Interoperability has transformed every facet of the healthcare delivery system, creating new opportunities to improve outcomes, reduce costs, and improve efficiencies. It has also been the key to enabling healthcare technology solutions to achieve their full potential.

By gaining a deeper understanding of the origins, current status, and future potential of interoperability, health plans can seize the opportunity to implement modern and innovative care management integration capabilities that deliver results for digital payers.

Defining Interoperability

Interoperability in healthcare refers to the ability of various information systems, devices, and applications to access, exchange, integrate, and cooperatively use data in a coordinated manner, in order to provide timely and seamless portability of information and improve the health of people and populations around the world.

Interoperability is the basis on which healthcare providers are able to deliver coordinated and comprehensive care to patients by accessing and sharing critical patient data in real-time. It also enables health plans to streamline administrative processes and reduce costs. As the healthcare industry continues to evolve and adopt new technologies, interoperability will also become an increasingly vital aspect of healthcare delivery and management.

Why Interoperability Matters

Interoperability can have significant positive implications across the healthcare ecosystem. Key goals of seamless integration include:

1. Advancing care coordination: Interoperability facilitates the sharing of member health information between payers, providers and systems, enabling better coordination and collaboration among organizations and teams.
2. Improving outcomes: By providing care managers and healthcare providers with access to comprehensive and up-to-date patient information, interoperability can help care managers create effective care plans and improve patient outcomes.
3. Streamlining administrative processes: Interoperability can reduce administrative burden, support new payment models, and ease claims processing.
4. Reducing costs: Interoperability can help reduce errors, streamline processes, and save time, leading to overall cost savings for payers, healthcare organizations, and members.
5. Improve member satisfaction: By improving data exchange, members have greater access to health and claims information, improving satisfaction and engagement.

The Beginning: Unlock the Power of Health Data through Interoperability

The need for interoperability originated as healthcare providers embraced widespread adoption of electronic health records (EHRs). EHRs were intended to revolutionize the way healthcare was delivered, enabling better coordination of care, reducing medical errors, and improving patient outcomes. However, in practice, EHRs created silos of health data that were not easily shared between providers or patients. This lack of interoperability led to fragmentation of care, duplication of tests, and unnecessary healthcare costs.

Recognizing the need to address these issues, the 21st Century Cures Act mandated that healthcare providers make patient health information available to patients and other providers in a standardized format through open, secure, and standardized application programming interfaces (APIs). The Act also created new provisions for healthcare data privacy and security, ensuring that patient data is protected when it is shared between providers.

These interoperability standards were important for several reasons. First, they empowered patients to take control of their health information and share it with any provider they choose. This increases patient engagement and allows for more comprehensive and coordinated care. Second, the rules helped to break down the silos of health data that had developed, enabling providers to access complete patient records, reducing the risk of medical errors, and improving the quality of care.

Finally, the interoperability rules promoted innovation in healthcare by encouraging the development of new applications and tools that can use healthcare data to improve patient outcomes, reduce costs, and improve efficiencies. Interoperability continues to be a priority for health plans and organizations across the healthcare ecosystem.

New Regulation and Innovation: Key Drivers Influencing Interoperability Today

Today, new regulations and continued innovation are driving urgency for greater interoperability. For example, the CMS Proposed Rule: Advancing Interoperability and Improving Prior Authorization Processes will directly influence integration priorities for many health plans. The proposed rule updates some of the policies included in the Interoperability and Patient Access Final Rule of 2020 and officially withdraws the December 2020 CMS Interoperability proposed rule. The objectives of the policy are to reduce the burden on both payers and providers, improve efficiencies, and advance patient access to health information. Some of the conditions take effect immediately, while others require implementation by 2026. Given the scope, it is important health plans to take action now and prepare their infrastructures for full implementation.

The proposed rule includes multiple requirements for payers that will directly influence their interoperability strategies:

Patient Access API: The rule proposes to require regulated payers to include information about patients’ prior authorization decisions to help patients better understand the process and contribution to their care. The proposed provision would also require impacted payers to report annual metrics to CMS about patient use of the Patient Access API.

Provider Access API: The rule proposes impacted payers build and maintain an API to share patient data with in-network providers where a treatment relationships exists with the patient.

Payer-to-Payer Data Exchange on FHIR: The rule proposes to require payers to exchange member data when a member changes health plans, with the member’s permission. The data elements include claims and encounter data, those identified in the USCDI version 1, and prior authorization requests and decisions – only if the patient opts in to data sharing.

Improving Prior Authorization Processes: The rule proposes a series of policies in an effort to improve the prior authorization process through greater efficiency and transparency.

The rule also outlines CMS’s recommended use of certain implementation guides for the APIs listed in the rule, but does not propose requiring their use.

The provisions outlined in the CMS proposed rule facilitate moving the industry toward more streamlined communication and better information exchange that can benefit members, payers, and providers. As organizations await the final ruling, there are steps that can be taken now to prepare:

1. Understand how the ruling will impact your health plan. Assess guidelines and determine which provisions will apply to your organization.
2. Evaluate your current data management processes. Is all member information available in a single source in order to create the full record required? If not, what changes need to be made to maintain a record for each member?
3. Evaluate your current interoperability strategy. How is member information exchanged between payers, providers, and patients today? How is prior authorization information managed and exchanged today? In what format are the data points being requested and can they easily be delivered via a Patient API or Provider API?
4. Assess resource availability. Who will be responsible for implementing the new standards? Who will be responsible for ensuring data is available to patients and providers within defined timeframes? What processes will need to change in order to accommodate the new standards?

Future State: Interoperability Considerations for Digital Payers

The proposed rule could be considered just the beginning for innovation in interoperability that will impact health plans moving forward. Rapidly evolving regulatory requirements, new payment models, rising consumer expectations, and new market opportunities will continue to drive payers to advance interoperability. The results promised by continual digital advancements across the healthcare ecosystem rely on seamless data exchange. In fact, interoperability can be considered a prerequisite for many health innovations.

Digital payers should consider their care management system’s ability to meet key requirements for modern and evolving integration criteria:

1. Exchange a variety of data types: Health plans should ensure their care management system can access, ingest, and exchange various data types across other systems with industry interoperability standards.
2. Support real-time data exchange: Informing decisions in a timely manner is critical when it comes to effective care management. Health plans should ensure care managers have real-time access to member information.
3. Work seamlessly with other systems and data sources: Care management systems function as the core orchestrator of member care. But the most effective care plans rely heavily on data from multiple sources to inform optimal care plans. In addition, care management systems must work in tandem with claims, payment integrity, and other administrative systems to streamline processes and reduce costs.

GuidingCare® enables digital payers to meet these modern interoperability needs, plan for future requirements, and support continued innovation. To learn more about how about creating a successful interoperability strategy with GuidingCare, visit the GuidingCare page on the HealthEdge website.

However, the growing complexity of the multiple configurations led to the need for a more efficient way to manage the HealthRules Payer infrastructure, and Medica turned to the experts within the HealthEdge team for guidance.

Medica faced two main challenges: Firstly, the company needed to create new efficiencies to help reduce complexities and administrative burdens associated with maintaining multiple HealthRules Payer environments, reducing the time spent on issue research and resolution, enabling faster system audits, and improving tracking of configuration changes to support more seamless configuration changes. Secondly, the company needed to maintain quality, reducing occurrences of early promotion of another user’s work related to multi-user risks of promoting someone else’s work and eliminating the risk of wiping out another user’s changes.

The outcome of this collaboration was the creation of HealthRules Promote, a web-based application that all HealthRules Payer customers can now use to manage complex configurations and multiple instances of the solution. Medica noted that the collaborative effort between the two teams resulted in a powerful solution that helped the company support more than 400 configuration projects in the past year.

HealthRules Promote provides insight into the complexities of HealthRules Payer configuration and ensures that all unique dependencies are considered prior to promoting the configuration to production. It also allows multiple users across multiple lines of business to control and understand which users’ configurations are ready for promotion and which ones have conflicting dependencies.

For Medica, HealthRules Promote provides delivers several meaningful benefits:

1. The solution saves time through configuration artifacts by removing the need to create and maintain exports, eliminating separate spreadsheets for tracking, and easily importing configuration sets to new environments in just a few clicks.
2. The solution allows the company to confidently migrate configurations without errors that ultimately cause problems in production.
3. The dependency-and-compare features of HealthRules Promote allow Medica to easily audit builds across environments and identify development changes over time that may be causing product issues.

To explore how HealthRules Promote can empower your organization with actionable insights into the complexities of your multiple HealthRules Payer configurations, visit the HealthRules Promote page on the HealthEdge website or email info@healthedge.com.

Prior to July 1,2022, most consumers of health care services were unaware of how much they cost, including myself.  My primary concern was whether it was a covered service and how much the copay or coinsurance was going to be after the insurance company processed the claim.  It never occurred to me that some providers may be charging vastly different prices for the same services.  The reality is that providers do have different rates for the same services.  The Transparency in Coverage (sometimes referred to as TiC) rule allows consumers to know the cost of a covered item or service before receiving them.

Beginning 1/1/2023, the Transparency in Coverage rule required that health insurance companies provide their members with an online tool that allows them to compare pricing data between different providers for several hundred covered services.  According to the rule, consumers should have the ability to access all their covered services using this same tool to make price comparisons no later than 1/1/2024.

How has this rule impacted the way consumers access healthcare services?

For me, the availability of price comparison data for my healthcare services is used to help me understand my potential out-of-pocket costs before I schedule services.  Even more importantly, this new ruling enables me to know how much of the cost is my responsibility before receiving the Explanation of Benefits (EOB) from the health plan.  Gone are the days when I would receive a bill from a provider indicating that I was responsible for tens of thousands of dollars for services rendered.  And yes, this did happen to me several years ago.

Providing consumers with this level of detail about their healthcare costs allows us all to engage in a more consumer-driven experience.  We now have tools to help us decide which providers we want to use, and this empowers each of us to play an important role in controlling the cost of our healthcare services.  As the saying goes ‘Knowledge is Power’ and it most certainly applies in this case.

Compliance with the Transparency in Coverage Rule

The good news is that health plans are complying with the Transparency in Coverage (TiC) rule and successfully implementing data processes and software applications to support this rule. Of course, this rule will continue to be refined and the processes in the background within health plans will continue to improve and evolve.  In the end, we will all benefit from the Transparency in Coverage (TiC) ruling by better understanding what is covered by our health insurance as well as managing the expected financial responsibility of our health care services.

Operationalizing Transparency in Coverage (TiC)

Making provider price comparison data available for use in an online tool for consumers is a massive undertaking for any health plan.  The data needs to include rates used for all covered items and services by in-network providers.  In addition, the allowed amounts, and billed charges from their out of-of-network providers are required.  Typically, this data is spread over multiple systems within a health plan, and consolidating the data is no easy task.

HealthEdge offers a suite of products to enable health plans to consume and transform the data needed to comply with this regulation.  Specifically, we can support health plans in the following ways:

• Adhere to the CMS mandate by understanding the health plans needs and system customizations
• Provide data in the required format that includes data dictionary updates
• Allows on-demand and monthly rate updates per contract configurations
• Enables data files access via SFTP line so they can be used to generate comprehensive rate lists

Learn more about HealthEdge’s suite of products here.

In the CY 2023 Final Rule, CMS made several changes that directly impact plans offering Dual Eligible Special Needs Plan (D-SNP) programs, which are a type of Medicare Advantage (MA) plan that are designed specifically for individuals who are eligible for both Medicare and Medicaid.

In general, the 2023 changes are intended to make the D-SNP population more attractive for providers, and therefore increase access to care for these beneficiaries. For payers, these changes are intended to increase clarification regarding different D-SNP programs and reduce the administrative burden of offering separate MA and D-SNP programs. However, many payers are concerned about the impact these changes will have on their bottom lines.

Here are four changes from the 2023 Final Rule that we believe deserve additional consideration.

1. Capturing Social Determinants of Health (SDOH) Data

The Final Rule requires D-SNPs to incorporate one or more questions in their standard health risk assessments (HRA) addressing beneficiary housing, food insecurities, and transportation. Acknowledging that many factors other than physical health go into a person’s ability to maintain their health, many physicians have already started collecting this type of information, which is commonly referred to as social determinants of health (SDoH). The goal of taking a more holistic view of a patient’s life, including psychological, functional, and environmental factors, is to increase the likelihood of better health outcomes and lower the total cost of care. Care management teams within many health plans are also on board with collecting SDoH data and are already using this data to tailor services beyond medical benefits to achieve optimal health outcomes. Some care management platforms, like GuidingCare^®, have already released capabilities within their platform that help health plans more systematically integrate SDOH into their care management programs.

2. Recalculation of the Maximum Out of Pocket (MOOP)

CMS also finalized changes to the way Medicare Advantage plans calculate MOOP, requiring plans to include all cost-sharing, including those paid by secondary payers, in the calculation of the beneficiary’s MOOP. Previously, MOOP was calculated only by the amount the enrollee had to contribute. The result? Beneficiaries are likely to reach MOOP faster, and health plans will have to pay 100% of the service costs sooner. Some industry experts believe this change will result in an additional $4B in costs to health plans, but the improvement in health outcomes and improved access to medical and non-medical care is projected to save $3B. Despite the pushback from health plans on this change, CMS proceeded with the implementation of this and made it effective June 1, 2023. The complexities and urgency of the implementation of this change is a perfect example of why health plans need a modern, highly flexible core administrative processing system (CAPS) like HealthRules^® Payer.

3. Enrollee Participation in Plan Governance

Medicare Advantage organizations offering a D-SNP must establish one or more enrollee advisory committees in each state to solicit direct input from beneficiaries on their experiences with the plan. Plans that operate D-SNPs in multiple states had to establish multiple committees, one for each state. Although these committees must have a representative sample of the population enrolled in this plan, very little direction was given about the committee meeting frequency, location, format and training.

4. Bringing Greater Definition to multiple Types of D-SNPs

Historically, the fully integrated dual eligible (FIDE) and highly integrated dual eligible (HIDE) SNP definitions have been confusing and inconsistent. Through this final rule, CMS is making changes to the definitions, which will support a greater understanding of the different types of D-SNPs, clarify beneficiary options, and improve integration. According to a National Law Review article, this means all FIDE SNPs, with the same legal entity holding the MA and Medicaid contract: 1) be capitated (with certain exceptions) for all Medicaid services, and 2) operate unified grievance and appeal processes. CMS also clarified the definition of HIDE SNPs requiring the plan to cover long-term services and supports, including i) community-based long-term services and supports and some days of coverage of nursing facility services during the plan year; or (ii) behavioral health services. For plan year 2025 and subsequent years, the FIDE and HIDE SNP must cover the entire service area for the dual eligible special needs plan. By helping health plans enroll the appropriate beneficiaries into the right categories and having the ability to create tiered or dual networks, HealthRules Payer enables health plans to quickly spin up whichever type of D-SNP program they believe would be most valuable for the communities they serve.

Turning Mandates into Advantages

While the only constant in government health plans, including D-SNP programs, is change, health plans with a highly configurable CAPS can turn mandates into competitive advantages. For example, health plans using HealthRules Payer now have the opportunity to pursue D-SNP populations with less IT and administrative burdens because the system can be configured to address the unique D-SNP requirements. Health plans don’t have to implement an entirely new system. Things like dual networks and tiered networks are completely configurable in HealthRules Payer. The business flexibility HealthRules Payer gives health plans is unmatched and dramatically lowers the cost of entry into new lines of business.

In addition, the requirement to capture additional data, such as SDoH, is another opportunity for health plans to convert mandates into competitive advantages. With modern data analytics and reporting solutions from HealthEdge, plans can easily turn data into actionable insights that can help drive improved member outcomes, higher HEDIS scores, and better Star ratings. For example, SDoH insights can help care management teams configure new non-medical services, like transportation or meal support, for certain populations. Utilization management data collected can be folded into benefit plan development, and even fed into payment integrity initiatives to minimize provider and member abrasion with more accurate payments.

Looking at the Whole Picture

When regulatory changes such as those mentioned above are put in place, health plans often make the mistake of just looking at the one part of their business that is directly impacted instead of taking an end-to-end approach to implementing the changes across their enterprise. That’s where the professional services team at HealthEdge can be a health plan’s biggest asset. With years of experience in helping government-related health plans properly configure their systems to support regulatory changes, the team knows how to guide health plans through all aspects of the business that may be impacted so that everything from enrollment to claims coming in and payment going out are aligned.

To learn more about how HealthEdge solutions help health plans turn mandates into advantages, visit www.healthedge.com or email info@healthedge.com.

Join us for a 4-part series that explores developing your company culture and taking your organization to the next level.

1. A Culture of Impactful Leadership
2. Continuous Development – The Path to Employee Engagement & Retention
3. 5 Simple Steps to Foster Inclusion & Diversity
4. 6 Secrets to Purposeful Collaboration & Equitable Experiences

Part 4: Hybrid Work – 6 Secrets to Purposeful Collaboration & Equitable Experiences

With some employees at home, some at the office, and some a hybrid of the two – creating and fostering a company culture that feels genuine can be elusive. And in the aftermath of the pandemic, and several years into widespread remote work, this hybrid lifestyle is a reality that’s here to stay.

There are many positives to the hybrid work environment. Employees have embraced the flexibility of working remotely and leaning into a schedule that allows them to maximize their personal schedule, productivity, and energy. But there are also challenges: Zoom fatigue, the mental exhaustion from back-to-back meetings on screens all day, and the dissipation of company culture are a few of the big concerns. Working from home makes it hard for employees to feel connected to the bigger picture, team, and company.

With hybrid work being the new normal, how do we maximize the effectiveness of this model & use it to our advantage?

1. Make the Office a Magnet, Not a Mandate

Fear has driven some companies to mandate employees’ return to the office. But why make your employees pay for the cost and time of a commute if they’re going to be doing the same work from the office as their house?

What could your company offer that makes the office a magnet? It could be offering free lunches, opportunities for collaboration, or a welcoming, comfortable work environment.

The key is to make returning to the office – even for a few days a week – enticing to your employees.

2. Foster Purposeful Collaboration

At HealthEdge, we are consciously fostering a culture of purposeful collaboration – where if employees are invited to come to the office, we provide a solid WHY behind that request. This could be creating connections, brainstorming/solving problems, celebrating, socializing, and/or building relationships. We want to encourage employes to get together when it makes sense – to solve a business need or to gather to form stronger bonds & relationships.

We also host ‘Collaboration Weeks.’ These purposeful weeks are designed to bring people local to the office together. The week includes community service, social activities, panel discussions, and more. They’re designed to get our people together to interact through different events. However, it’s critical to make remote employees feel included as well. We offer all the sessions virtually so any employee can join. The experiences of on-site, hybrid, and remote employees must be equitable.

3. Educate & Empower your Managers

Senior leaders are in the best position to both define and role model the desired company culture and connect employees to that culture. However, managers are in the best position to help connect their teams to the work and to why what they’re doing is important – linking back to the purpose of the company.

Educate your managers on:

• How to have successful remote meetings
• How to have successful 1:1 meetings
• How to assess performance in the hybrid world

Empower your managers to develop the right schedule & collaboration strategy for their teams. Rather than an Executive leader making a bold statement like, everyone must be at the office 3 days a week! Empower your managers, who know the composition of their teams & the individual members, to determine what the hybrid work model looks like to make the strongest connections and reap the highest levels of productivity.

4. Minimize Remote Meeting Fatigue

Staring at a screen all day, switching from meeting to meeting, is draining and has proven to be mentally exhausting for employees. Encourage your employees to turn their screens off and walk around during meetings where they just need to listen. Make it a norm for employees to block time off on their calendar for lunch and breaks in the morning/afternoon. With remote work, it’s easy to spend a whole day glued to your screen and desk chair – a surefire recipe for burnout and disengagement. Actively tell your employees to take breaks and get away from their screens. Without this active encouragement, it’s easy for remote employees to fall into the trap of feeling guilty when they aren’t immediately available via Slack/email. Managers can play a huge role here by role modeling this behavior.

Companies can also provide equipment/stipends that encourage movement throughout the day. This could include things like standing desks or under-desk walking pads. Companies can also encourage walking challenges with fun prizes to get employees moving.

5. Establish Meeting/Deep Work Norms

When you work in an office next to your neighbor, you can see when they have their headphones on and are deep in work. However, when you’re working remotely, you can’t see that – all you can experience is an unanswered Slack and wondering why your coworker isn’t responding.

Furthermore, when you work in an office, you get up from your desk and go to a meeting room. Then you get up and walk around after the meeting. When you work remotely, it’s easy to go from back-to-back meetings and never get up from your desk.

This is why it’s critical for managers to establish deep work, response, and meeting norms for their team. For example:

• Deep work: managers can actively support their employees to set the time and space for deep work each day/week. This can be as simple as encouraging employees to set their status as away so they have the time and space to focus. Managers could also establish deep work blocks of time – such as a 3-hour window on Wednesday mornings with no meetings.
• Response times: Managers can support their employees by setting expectations for response times for email and Slack/teams messages.
• Meeting norms: Managers can mandate that meetings be a maximum of 25 or 55 minutes, so employees have a chance to get up and move around throughout the day.

6. Lean into Synchronous/Asynchronous Work

Synchronous work is normal – we talk, we meet, we Slack – all in real time. But with remote work, there’s the opportunity for asynchronous work, which enables team members to work when and how they’re most productive.

For this to be successful, managers need to be empowered to establish the cultural norms for their team. These cultural “rules” can include how the team can expect to work together in an asynchronous fashion. For example, Slack response time expectations. The “rules” could include:

• When to use Slack versus email
• When Slack is to be checked (every time it dings or at set times like morning, noon, and end of day)
• What to put in Slack versus email

The Future of Hybrid Work

With remote and hybrid work, employees, especially highly performing ones, have more choice of employers than ever. Creating a hybrid culture of purposeful collaboration, equitable experiences, and flexibility is critical to engaging and retaining employees long term.

Learn more about life at HealthEdge here.

Join us for a 4-part series that explores developing your company culture and taking your organization to the next level.

1. A Culture of Impactful Leadership
2. Continuous Development – The Path to Employee Engagement & Retention
3. 5 Simple Steps to Foster Inclusion & Diversity
4. 6 Secrets to Purposeful Collaboration & Equitable Experiences – Coming soon!

Part 3: 5 Simple Steps to Foster Inclusion & Diversity

The business case for committing to diversity & inclusion is compelling. It has been shown that companies with above-average diversity produced a greater proportion of revenue from innovation (45% of total) than from companies with below average diversity (26%). This innovation-related advantage also translates into overall better financial performance. It follows that with the workforce becoming increasingly diverse across all categories, 57% of workers believe that employers should be doing more to increase workplace diversity. A study by McKinsey demonstrated that gender and ethnic diversity are clearly correlated with profitability.

Furthermore, when you bring people with diverse backgrounds together, it drives innovation. Instead of collaborating with a team of homogenous people – all with the same education, thinking, and background – the diversity of circumstances, ideas, and perspectives leads to enhanced problem solving and advancements in innovation.

When you diversify your employee base, your company culture benefits from the wealth of those perspectives, experiences, and approaches to problem solving. Diverse backgrounds include gender and ethnicity, but also age & generation, gender & gender identity, sexual orientation, religion & spiritual beliefs, disability, education, and socioeconomic status & background.

Diversity is a powerful force to drive revenue and profitability. Here’s how you can foster diversity in your organization.

Simple Solutions to Foster Diversity

1. Offer Diverse Benefits

Organizations can foster a welcoming environment to diversity by offering benefits that are inclusive. Employers should address the gaps and disparities in benefit plan offerings to optimize the health, productivity, well-being, and financial protection of underrepresented groups. This might mean providing benefits that don’t just cater to a heterosexual married couple with two kids. Building an inclusive benefits package shows employees, and prospective employees, that the company isn’t just talking about DEI – it’s taking action, making investments, and enacting changes.

The Diversity, Equity, and Inclusion efforts at HealthEdge have led to a conscious decision this year to enhance our US benefits package with more inclusive offerings. This includes things like infertility services, gender affirming services, travel & lodging reimbursement to ensure employees have access to covered women’s health services, and an increased parental bonding leave policy from 4 weeks to 14 weeks for birth and adoptive parents.

2. Seek talent with diverse backgrounds

Understand the current composition of your workforce – look at it by type, role, and function. Determine how you can diversify, and how you can attract/appeal to different candidate pools. Make it a goal to have a diverse pool of candidates to pull from. A hybrid/virtual workforce can help with this – when you expand your geographic boundary for hiring you get a broader pool of diverse candidates.

3. Educate your hiring managers

Hiring diverse candidates can take a little longer – which is why it’s crucial to educate your hiring managers on why diverse candidates are so important. Help them understand the business case for hiring diverse candidates and why it’s worth the investment in time and effort.

4. Foster an Environment of Inclusion & Belonging

It’s critical to create a work environment where people feel like they can bring their most authentic self and highest potential to work. What good is it to hire for diversity if your employees don’t feel like they can be themselves – where the work environment doesn’t support diversity. This is where inclusion and belonging come into play. Create an environment that fosters and welcomes diversity.

5. Internal Inclusion Best Practices

There are many ways to make diverse employees feel included in the organization:

• Create a community for them to be a part of. At HealthEdge, we have an iBelong group that seeks to include employees throughout the organization with ongoing virtual chats and a monthly event. Events serve to provide awareness and education in an interesting and engaging way.  The community also offers a safe space to seek support and discuss challenging topics.
• Educate managers on how to make employees feel welcome within their group. For example, recognize there are introverts and extroverts in our Zoom meetings. A simple technique during meetings is to present a topic and give everyone a minute to think about it before soliciting a response. Another is to go around the table during a discussion and give everyone a chance to contribute – not just the most loquacious extroverts.
• Encourage managers to build 1:1 relationship with their team members to build trust and provide support throughout their career journey.

Diversity & inclusion is a powerful way to increase revenue, profitability, and innovation. Learn more about HealthEdge’s culture of belonging here.

Join us for a 4-part series that explores developing your company culture and taking your organization to the next level.

1. A Culture of Impactful Leadership
2. Continuous Development – The Path to Employee Engagement & Retention
3. 5 Simple Steps to Foster Inclusion & Diversity
4. 6 Secrets to Purposeful Collaboration & Equitable Experiences – Coming soon!

Part 2: Continuous Development – The Path to Employee Engagement & Retention

At HealthEdge, our vision is innovating a world where healthcare can focus on people. With this vision in mind, we hire the best and brightest from around the world – as our ability to achieve this vision hinges on our employees’ skills, creativity, capabilities, and leadership from within.

Continuous development is becoming a critical pillar of our company culture – as keeping and engaging top talent requires an intentional approach to their short- and long-term development.

Since “development” can mean different things, these are our top 4 continuous development tenets:

1. Embrace the uniqueness of your team members

As a manager, you have the great responsibility and wonderful opportunity to lead and develop a group of individuals. You get to engage your employees in their current role, help them grow their skills, build the bridge to their next role, and develop the framework for the trajectory of their career.

The key is to get to know your people for who they really are – their unique interests, strengths, and ambitions. How does this role, that’s so vital to your team, fit into their career? How can you help them develop and prepare to be ready for that next step?

Good questions to consider and discuss include:

• What are their career goals?
• In what ways do they need to grow and develop to achieve that next career goal?
• How can you help them achieve their career goals?
• What skills do they need for the future?
• What are creative ways to help them achieve those skills?

2. Understand the Many Facets of Development

When we talk about development, many often think only of attending formal training. Training can be a relevant component of learning – however, it’s only a small part of how we learn and master a new skill. Research (link) shows that learning takes place by doing, trying, and experiencing. It means working on new projects, interacting with new people, and experiencing new things.  All of this can be done “in the flow of work”, meaning deliberate learning can take place while someone is working in today’s role.  This keeps employees engaged and more likely to stay because they are continuously developing new skills.

Facilitate your team members to:

• Attend meetings at the next level above – to see the level of discussion, level of preparedness
• Work on an assignment within a different functional group
• Take on a stretch assignment
• Creatively think about team members, their unique skills and who they can connect with
• Connect with senior leaders and facilitate mentoring opportunities
• Get more exposure – such as speaking opportunities and interactive panels. This is especially helpful for emerging leaders.

3. Leverage Hybrid Work

The rise of flexible and hybrid work environments has led to fewer spontaneous hallway chats, chatter around the watercooler, and opportunities to have those unexpected run-ins with folks from different departments. In this new flexible world, employees often work exclusively with their functional team and only see folks around Zoom meetings.

With the importance of creating opportunities for your employees to grow and learn, how can we do this in a hybrid environment?

Here are some ideas to consider:

• Be purposeful & bring people together when it makes sense – for in-person team meetings or 1/1s, to brainstorm or workshop a topic, to celebrate, socialize, and/or participate in fun or team building activities
• Encourage and empower your team members to come together in the office and create norms that help the team feel engaged and productive
• Create networking opportunities for your team – invite folks from other teams, departments, and levels (both in person and virtually)

4. Change your Mindset to Our Talent to Enhance Engagement, Retention, & Company Performance

Employees join a company to perform a specific role, and it’s common for managers to think about them as my person, my talent, who adds so much value to my team, what would I do without them?

However, when we shift our mindset to being enterprise- and employee-centric, we bring a host of value to the employees, company, and company culture. Each employee represents not only the value they bring to their current role, but the time, energy, and expense of finding, training, and folding them into the company. Retaining employees reduces waste, cost, time, and energy.

When we focus on this enterprise- and employee-centric mentality, our company culture is strengthened. With this outlook, we help employees navigate the organization, grow and expand, and continuously develop so they remain constantly engaged and challenged at the company.

Investment in employee development is priceless.

Learn more about continuous development & life at HealthEdge here.

March 2020 represented a critical shift in business operations for local and global companies. For many companies, it was just another day at the office – albeit you were working remotely versus coming to the physical office. Were you prepared? Was it an IT and cybersecurity scramble or were you appropriately equipped? The difference is derived from proper business continuity and disaster recovery readiness, communication, and continuous preparation.

HealthEdge understands the requirements needed to keep up in a fast-paced world. At a moment’s notice, things could change, whether it is a natural disaster, cyber-attack, or other unforeseen events that could have an impact on our ability to meet customer needs. HealthEdge prepares for the unexpected with Business Continuity Planning and Disaster Recovery to mitigate damage, minimize downtime, and reduce the impact on business operations.

Similar to the Global COVID Pandemic, HealthEdge ensures that our business processes, workforce, IT infrastructure and cybersecurity controls are ready for unexpected events – large or small. Our team identifies critical business functions, which includes systems, applications, and essential data that is needed for business operations to continue. Risks and vulnerabilities are assessed for critical business operations and considerations are made for the likelihood of various disasters and the potential impact of data loss or disruption.

Plans

Disaster Recovery and Business Continuity Plans are developed to outline how our teams will quickly recover, relying on backup and contingency plans and alternate work arrangement locations. These plans are tested and updated regularly to ensure they remain effective. While aligned with common themes and content, individual and custom product and facility-centric Disaster Recovery, Business Continuity and Emergency Preparedness Plans are maintained to ensure we are prepared based on geography and product group. The HealthEdge IT Security and Compliance teams maintain these plans. We augment internal efforts with external expertise to help ensure we identify and constantly mature the program based on emerging best practices and global threats. Copies are maintained in the HealthEdge Governance Repository for offsite backup purposes and are readily available should the need arise.

Testing

Team simulations help us to identify gaps or weaknesses in the plans, as well as ensure the plan is consistent with changes to business operations or IT infrastructure. These simulations and live tests occur among small teams, multi-offices and business products, or directly with customers. The ultimate objective is to stress test and be prepared – whether our workforce is located in a major metropolis with regional redundancy or in their village in India where local Internet and communications systems could have reliance issues.

Recent examples include:

• Testing Key Leadership Response Times – Our team uses recent regional events, such as flooding, to determine how prepared Leadership, Human Resources, and IT are to account for and maintain communications with the workforce as the community recovers.
• Testing Remote Access – Our team sends groups to work remotely to assess latency, communications system constraints or home bandwidth issues.
• Testing Alternative Work Sites – Our team evaluates the potential impacts of destruction of physical office space and safely reroutes employees to an alternate location.

As the Boy Scouts motto says, “Be Prepared” since that is what our customers expect of us: safeguard their data, maintain high availability, and deliver as promised.

Education and Awareness

Employee awareness is key in ensuring everyone knows their role should a response be initiated. HealthEdge conducts regular training for employees who work onsite, hybrid, and remote. In addition to this training, we produce education alerts and messages to not only support the employees but also their families. We are accountable for ensuring our systems, networks and data centers are prepared, as well as the home environment of our employees and their families. Protecting the family and home is critical for a “family first HealthEdge”, but to also ensure they are prepared in the event they are called upon to primarily work remotely.

Getting Our Ducks in a Row When Disaster Strikes

We value the trust our customers place with our business and strive to always deliver service, even when the unexpected occurs. As with other facets of information security, business continuity and emergency preparedness is another critical way HealthEdge protects you, your members, and the entire HealthEdge family. It’s also another way we ensure our ducks are in a row.

Improving payment integrity has been a challenge for health plans since the beginning of time as the constant battle for accurately pricing claims rages on. To help the market better understand the current state of payment integrity and expose the need for alternative approaches to solving payment integrity challenges, HealthEdge^® Source recently commissioned independent research firm, In90group Research, to survey more than 100 health plan leaders.

Current State of Payment Integrity in Healthcare

Respondents represented all types and sizes of health plans along with leaders from virtually every department, and here is what they had to say about the current state of payment integrity:

• Multiple third-party editors: 90% of respondents depend on two or more payment integrity vendors. That means they must maintain multiple datasets, update schedules, and sometimes even multiple instances across their lines of business. The IT burden and workflow complexities associated with approach have become overwhelming for many health plans.
• Claims rework: 55% of payers report that greater than 20% of their claims require rework due to inaccurate first-pass adjudication. Not only does claims rework require additional time and effort from the payment integrity team, but it also creates downstream work for other teams, such as provider relations.
• Number of dedicated FTEs: 70% of payers have more than 10 full-time employees (FTEs) dedicated to prospective payment integrity and 45% have greater than 25 FTEs. When asked what the future looks like when it comes to dedicated resources, 56% of respondents said they expect the number of internal FTEs dedicated to payment integrity to growth in the next one to two years. Unfortunately, this comes at a time when workforce shortages are at an all-time high.

Clearly, the traditional approach to payment integrity is not producing the results that health plans want. That’s likely because payers have historically relied on payment recovery vendors to help facilitate prospective payment integrity.

The result? Stacks of editing solutions, ever-expanding contingency fees, and mountains of siloed data sets that provide limited visibility into opportunities for operational improvement. As staff members attempt to hunt for answers across different systems, the time versus value equation begins to erode. Plus, business leaders are unable to identify and resolve root-cause issues across the organization or make more informed business decisions based on comprehensive data.

Payers are rightfully frustrated with the limited progress they are able to make when it comes to payment integrity improvements. Survey respondents shared their top five barriers to success when it comes to payment integrity:

• 64% – Limited resources makes it hard to keep up with fee schedules and policy updates. As both IT and business resources remained strained across the organization, modernizing payment integrity processes and systems often fall behind other priorities, such as changing regulatory requirements that carry hard-and-fast deadlines. But with constantly changing fee schedules and policies – at both federal and state levels, complexities compound and payment integrity improvement initiatives fall further behind.
• 58% – Hiring and retaining qualified resources to perform complex payment integrity tasks. Furthermore, survey respondents expect this problem to persist, as 58% say they must increase the number of manual resources in payment integrity just to keep pace with the demand over the next two years.
• 56% – Limited visibility into third-party vendors’ findings for root-cause analysis. This is likely due to the contingency-based incentive models that payment integrity vendors have in place.
• 43% – Legacy technology is not flexible enough to meet their unique needs. Historically, the focus of payment integrity has been on content, not the technology that enables the content to be accessible across the organization.
• 41% – Conflicting departmental initiatives/ Key Performance Indicators (KPIs) limit ability to improve payment integrity. With payment recovery goals conflicting with payment integrity KPIs, health plans find themselves challenged to make meaningful progress.

Payers are also frustrated with their third-party vendors. When asked, payers shared the following top challenges with their vendors, and the top five most commonly mentioned challenges included:

• 58% – Cost
• 47% – Lack of innovation/upgrades and solutions
• 37% – Limited savings/value
• 32% – Ineffective at getting results
• 27% – Limited content

What’s most concerning about these challenges is that most of these exactly align with the purpose of these types of solutions.

As the complexities of and frustrations with payment recovery and integrity continue to grow, interest in taking a fresh, enterprise-wide approach to improving the accuracy of payments is growing. This is evident in the research findings where survey respondents were asked to choose their top three payment integrity goals through 2025.

Top Goals for Payment Integrity Through 2025:

When comparing these top goals to the top challenges health plans face, it becomes clear that health plans must take a thoughtful approach to payment integrity, one that relies on highly interoperable technology solutions that can reduce dependencies on editors, minimize the burden on IT teams, and bring insights together from multiple systems and departments to provide a clearer picture of payment issues across the enterprise.

To learn more about how HealthEdge Source can help your organization rethink your payment integrity improvement strategies to make a meaningful difference in 2023, visit the Source page on the HealthEdge website.

1. Working with groups of members requiring very complex care plans
2. Inefficient and costly processes resulting from manual, fragmented workflows
3. Siloed systems that make it difficult to access up-to-date, accurate member data
4. Collaboration with social services groups and systems that don’t talk to each other across organizations
5. Extensive tracking and reporting that creates more administrative burden

All of these challenges come amidst the backdrop of even broader health insurance industry challenges, such as workforce shortages that are driving up costs of labor and care. Regulatory changes are requiring payers to adapt processes and technology to meet new guidelines. Evolving business models are creating new opportunities while driving demand for greater business agility. And today’s healthcare consumer expectations are rising to match their everyday retail experiences.

These challenges were echoed by a recent survey of nearly 300 health plan leaders serving Medicaid, Medicare, Duals, and Marketplace members. The survey showed the top two challenges were managing costs & creating new operational efficiencies. The top goals for the year were increasing quality, enhancing regulatory compliance, and improving provider relationships. The primary steps to achieve these goals were to better align business and IT goals, make significant investments in innovation, and modernize technology.

These findings point to the fact that health plans are ready to start their digital transformation as they bring IT and business stakeholders together and invest in innovative solutions to move the business forward. Now is the time for payers to become digital payers.

What is a digital payer?

Digital payers are identified by five attributes that enable them to rise above the competition and lead the way to better outcomes across the entire healthcare delivery system. Digital payers focus on:

1. Leveraging digital tools to improve end-user and member centricity
2. Achieving higher levels of quality to deliver better outcomes for members and communities
3. Increasing business transparency, breaking down siloes and improving exchange of information
4. Advancing customer service by empowering teams to support inquiries with next-generation solutions
5. Constantly reducing transaction costs through automation and connectivity

These are the payers that will emerge as leaders through this dynamic period of change and truly improve outcomes for every patient and stakeholder across the healthcare ecosystem.

Story of a Digital Transformation: VillageCare

VillageCare is a community-based, not-for-profit organization serving nearly 20,000 seniors, people with chronic care, continuing care, or rehabilitation needs in New York. VillageCare set out on a journey to transform business processes with a next-generation digital foundation that could:

• Support clinical and business operations through integrated work processes
• Support a data-driven organizational culture
• Support VillageCare’s healthcare clinical partnerships through data integration
• Expose data to members and clinical partners using data standards
• Use best-in-class applications that integrate to create a seamless systems environment

VillageCare wanted to implement a digital foundation that would enable mission-critical clinical workflows in a value-based, patient-centric, and fully integrated ecosystem. Their ecosystem of connected SaaS solutions powers mission-critical areas of the business including:

• Care Management
• Utilization Management
• Appeals & Grievances
• Authorization Portal
• Business Intelligence
• Population Health
• Member Services

Impactful Results with HealthEdge

By developing this digital foundation with HealthEdge, VillageCare experienced transformational experiences for stakeholders.

• Members:

Prior to VillageCare’s digital transformation, health plan members struggled through disconnected touchpoints to navigate the process of finding a provider, determining eligibility & costs, utilizing available benefits, & communicating with their care team. As a digital payer, VillageCare streamlined processes by shifting these touchpoints to easy-to-use, self-service tools that consumers expect – delivering all in a single access point.

VillageCare uses digital solutions from GuidingCare® to simplify workflows and improve access to data and information. As a result, they can deliver a frictionless member experience and increase member engagement and satisfaction, while ultimately improving health outcomes.

• Providers

Many of VillageCare’s providers were frustrated by time and manual effort required to gain insight into patient benefits, inefficiencies in the process of seeking authorizations, multiple systems required to get answers, inaccurate claims payments, and managing reimbursements.

VillageCare eliminated provider abrasion by delivering instant access to real-time patient benefit and claims data through GuidingCare. They provided connectivity and access to collaboration tools that enable steps to be completed and information accessed in a single solution.

• Member Services

Prior to their transformation, VillageCare’s member service teams experienced inefficiencies that negatively impacted the member experience, including wasting hours searching for member & provider information, navigating multiple software systems, and uncovering inaccurate and out-of-date information.

VillageCare transformed member services engagement by providing self-service tools and access to accurate, real-time data for members.

• Care Managers

Prior to the organization’s digital transformation, VillageCare care managers were challenged by disparate technology systems, disconnected workflows, and manual workarounds. They spent countless hours hunting for member & provider information, attempting to connect with at-risk members, tracking authorizations & compliance, and accessing and completing care plans & educational programs.

VillageCare empowered care managers by putting real-time important member data at their fingertips in one location, so they can focus on building trust with members and optimizing care outcomes. They now automate authorization and utilization management workflows. This improved the experience for the care managers and improved efficiencies. They also use unified care team communications and real-time care alerts to improve health outcomes.

• IT Teams

At VillageCare, the pre-transformation experience for the IT team involved navigating communications across multiple vendors, managing updates across multiple systems on different schedules, dealing with disconnected workflows and broken integrations, addressing regulatory changes with outdated systems, and advancing business and IT alignment.

After transforming the organization with next-generation solutions from GuidingCare, the VillageCare IT team could operate more efficiently and deliver on business needs more effectively. Now, they have greater flexibility to collaborate with the business and use available tools to ensure technology investments are achieving business objectives. The modern solutions are designed with interoperability as a priority, leveraging HealthEdge’s robust API framework and industry standards, such as FHIR. As a result, the IT team can optimize how their workforce is deployed, improve access to data for end users, and quickly and easily adapt technology to address emerging business opportunities and regulatory changes.

Stuart Myer, Chief Information Officer at VillageCare shared, “Our digital transformation journey has truly changed the way our teams operate, improving the experience for members, providers, member services, care management, and IT. It has allowed us to become a data-driven organization that operates more efficiently and creates better outcomes for the community we serve.”

Learn more about HealthEdge’s care management software GuidingCare.

Dual-Eligible Special Needs Plans (D-SNP) are a special kind of Medicare Advantage Plan for dual-eligible individuals who qualify for both Medicare and Medicaid and Part D coverage.

With such growth in this population comes a growth in the number of health plans serving these complex beneficiaries, with hundreds of health plans now supporting one or more D-SNP populations.

However, the complexities of the dual-eligible experience, from a medical and social perspective, coupled with the highly fragmented nature of Medicare and Medicaid systems, often presents significant care coordination challenges that health plans must be prepared to address.

In addition to the high prevalence of issues such as high food insecurities, behavioral health issues, and cognitive impairment, most D-SNP members live in rural communities that can have limited access to proper healthcare professionals, as well as limited access to broadband services. Other challenges health plans must be prepared for include the ever-evolving regulatory environment that exists at both the federal and individual state levels.

With the modifications CMS made in its 2023 Final Rule, it’s now more important than ever for health plans to have a modern, flexible, and highly interoperable infrastructure, including:

• Robust care management platform
• Flexible and configurable CAPS
• Modern member engagement solutions

Track Record of Success

HealthEdge has supported health plans that service government-covered lives for decades, including those who cover D-SNP. For example, Eldercare, the only 5-star Medicaid Advantage Plus (MAP) plan in New York State, uses HealthEdge’s care management platform, GuidingCare^®.

According to Craig Azoff, Senior Vice President, Health Plan Information Services, “Elderplan specializes in intense, complex care management of our membership, and GuidingCare supports these care management goals as well as our compliance goals, as far as STARS ratings, HEDIS scores, and other initiatives.”

Here are a few additional samples of success stories health plans have experienced by turning to HealthEdge:

• Customer Spotlight 1: The midwestern state was looking to reduce the number of Medicated Managed Care Organizations by one third, and the health plan had to prepare to recompete for its Medicaid business, which represented a significant portion of its members. Its outdated legacy care management system could not accommodate the ever-increasing complexities of state requirements.
  • The solution: GuidingCare + Mobile Clinician + HealthEdge’s years of experience with safety net plans.
  • The results: The plan won the bid with advanced care management capabilities and mobile clinician in addition to HealthEdge’s years of experience with safety net plans.

• Customer Spotlight 2: This health plan needed to transform its operations to reduce operational inefficiencies and eliminate redundant manual tasks. The team was challenged with 30-40% of incoming claims being marked with a pricing inquiry or set up to require manual pricing.
  • The solution: Source payment integrity platform designed to manage both claims pricing and editing in one place using the latest regulatory data.
  • The results: Reduced repetitive building, reduced dollars spent on maintenance, generated six-figure range in annual savings, reduced the number of claims requiring rekeying by 40%, generated 25% savings over previous processes by eliminating hundreds of manual tasks.
  • “The biggest benefit we have seen from Source is the capability it has to do one-stop pricing and editing. When it comes to building and managing claims, I never want to go back to anything else.” – Director of Policy and Editing
• Customer Spotlight 3: This independent, non-profit health plan serving more than 2 million customers, was seeking to deliver more human-centric experiences for members, providers and staff. Other goals for the team included: identify and act on operational inefficiencies; gain a more comprehensive view of member services; and bring new solutions to the market faster.
  • The solution: HealthRules ® Payer + GuidingCare® + Source
  • The Results: Average auto-adjudication rates increased from 50% to 80%, ease of configurability improved speed-to-market and ability to identify sustainable savings, integration between HealthEdge systems delivered new opportunities for automation of manual processes, and greater access to authorization data across systems is reducing gaps in care.
  • “HealthEdge understands the everyday challenges we face, like manual processes, workflow inefficiencies, and data disparity. They are bringing solutions to the table that address those challenges and facilitate greater integration across our claims, care management, and payment platforms because they are now all under one roof. HealthEdge is the source that is fueling our digital strategy.” Staff VP of the Advancement Office

• Customer Spotlight 4: This Pittsburg-based managed care plan servicing more than 534,000 Medicaid and Medicare beneficiaries across Pennsylvania and Delaware was looking for a better way to effectively and affordably deliver government member services while maintaining high levels of quality care. The team knew they needed to become more agile to keep pace with complex and rapidly changing federal regulations and state issued mandates, reduce the overhead costs associated with financial reconciliation for provider payments, as well as correct issues related to managing maximum out-of-pocket, claims tied to duplicate providers, and mismatches between old and new contacts
  • The solution: HealthRules Payer + GuidingCare + Source
  • The results: Improved auto-adjudication rates 50%-93% through better authorization matching capabilities and more accurate pricing, increased the volume of electronic claims submissions, and improved business agility through the use of advanced benefit, and improved payment accuracy through the seamless integration of HealthRules Payer and GuidingCare
  • “As a user of multiple HealthEdge products, we see tremendous value in the tight integration between the platforms. Things like being able to match on authorizations can not only help streamline care management, but also improve payment accuracy to facilitate better relationships with our providers.” — Director of Strategy & Operations

Health plans serving D-SNP members need a comprehensive, highly interoperable platform for end-to-end care management and population health that is effective at simultaneously reducing overall costs and improving care, while ensuring the plan is compliant with state and federal regulations.

To learn more about how HealthEdge solutions can help your organization address the unique challenges of D-SNP, visit the Dual Eligibles page on the HealthEdge website.

The variability of the data that is available plus the lack of integration between systems that can automate the capture and processing of SDOH data have been key barriers in payers’ ability to rapidly integrate SDOH into their care management programs.

But given the most recent push for health equity and SDOH by CMS and accrediting bodies like NQHA, now is the time for payers to implement practical plans that enable them to embrace SDOH data and strategies in a more systematic way. Going forward, their ability to do so will have a significant impact on their quality scores, member outcomes and satisfaction scores, as well as their financial reimbursements.

Here are five things payers can do today to leverage SDOH to optimize care management programs that optimize both member health and organizational financial outcomes.

• Collect data on SDOH: Payers can start by collecting data on SDOH for their members. This can include information on factors such as income, education, housing, food security, transportation, and social support. By gathering this information, payers can identify which members are at higher risk for health disparities and target interventions accordingly.
• Analyze data and identify gaps: Once the data is collected, payers can analyze it to identify gaps in care related to SDOH. For example, they can look at which members are more likely to have unmet needs related to transportation or housing and develop targeted interventions to address these issues.
• Develop partnerships: Payers can partner with community organizations, social service agencies, and other stakeholders to address SDOH. These partnerships can help payers connect their members with resources that can address their social needs and improve health outcomes.
• Integrate SDOH into care management: Payers can integrate SDOH into their care management programs to ensure that members receive the support they need to address their social care needs. This can involve connecting members with community resources, providing care coordination services, and developing care plans that address both medical and social needs.
• Track outcomes: Payers should track the outcomes of their SDOH interventions to evaluate their effectiveness. This can include tracking changes in health outcomes, healthcare utilization, and member satisfaction.

The GuidingCare^® solution suite helps HealthEdge^® customers rapidly bring SDOH data and insights into their care management programs in several ways, including by capturing member’s data relating to age, gender identity, preferred language, sexual orientation, race/ethnicity, zip code etc. Through GuidingCare’s integration with Findhelp, a leading social services search-and-referral platform, care managers have instant access to localized listings and programs in every ZIP code in the United States, enabling a more efficient process for managing referrals for critical services for members.

Further, GuidingCare is integrated with Wellsky, which enables care managers on the GuidingCare platform to identify, refer, confirm delivery, and track outcomes for member social services needs.

To learn more about GuidingCare’s unique approach to empowering care management teams with the content and tools they need to optimize member care, visit the GuidingCare page.

Incorporating SDOH into care plans can help payers improve health outcomes, reduce healthcare costs, and promote health equity for their members.

If your organization strives to improve member health outcomes and better manage costs, these are the 9 care management platform must-haves:

1. Deep Clinical Expertise

Robust understanding of clinical operations, regulatory compliance and technical aspects of the business, bridging the clinical and technical is critical.

2. Leading Innovations

Market-leading capabilities enable the most complex clinical models today, with significant investment and growth toward composable digital health solutions.

3. Ease of Integration

An out-of-the-box integration suite facilitates easy connectivity across your vendor ecosystem for lower costs and better member outcomes.

4. Operational Efficiency

An advanced rules engine and user-friendly workflow capabilities automate business processes to streamline operations.

5. Reimagined Implementation & Upgrades

Using the latest technology innovations makes it easy for payers to incorporate standard new functionality and innovations frequently and easily for a lower cost.

6. Resiliency to Change

Highly configurable features and workflows enable payers to embrace change, stay competitive, and take advantage of opportunities created by a variety of market dynamics.

7. Actionable Insights

Near real-time business intelligence arms your leaders to make informed key operational and clinical decisions.

8. Regulatory Support

Managing the ever-evolving state and federal requirements so you can stay compliant while improving member engagement and satisfaction, STAR ratings, health outcomes, and more.

9. Security & Compliance

HITRUST certification is a must to reinforce robust enterprise compliance and security safeguards.

HealthEdge’s GuidingCare

The GuidingCare suite of solutions enables health plans to support care management, utilization management, appeals and grievances, authorizations, and population health in a next-generation, fully integrated platform. The unique solution enables digital payers to transform care management by improving mission-critical workflows and delivering access to real-time data that drives superior financial and health outcomes. Learn more here.

According to Melissa Rusk, VP of operations at SummaCare, “Listening to our customers, whether it is our members, brokers, or even our employees in our own self-funded plan, is the first and most important step to success. But what really sets us apart is our ability to use modern technology to help us put our ideas into action fast. Products like HealthEdge Source really give us that edge.”

The System Behind the Success

For more than 20 years, SummaCare has trusted Source, the industry’s leading payment integrity platform that is now a key component of the HealthEdge suite of solutions, for its claims editing and pricing. Originally implemented to support its employer group customers who had members traveling to and living in multiple states, Source helped SummaCare navigate the complexities of pricing in many different states. However, as the business grew, so did the need for other pricing tools that addressed the complexities of commercial payers.

“For years, we were dependent on multiple editing solutions for our different lines of business. But when we upgraded to the latest version of Source, we were able to move everything to the new platform. Now, we are running all of our claims, including Medicare and commercial, through Source. It’s now a one-stop shop. This not only reduces the IT burden of having to maintain and update multiple systems, but it also makes it easier for our team members to investigate claims issues. They only have one place to go.”

In addition to finding new efficiencies in the editing process, the team was able to move all pricing data out of its legacy claims system, freeing them to evaluate more modern core systems that can help them adapt even faster to customer input and competitive threats. They also brought the edits into their provider portal so members and providers can see the edits themselves and submit questions or appeals directly through the application. This has reduced the phone calls and emails coming into the provider engagement teams.

Rusk added, “No one holds a candle to the information you have at your fingertips with Source. For example, you can look at fee schedules that existed 10 years go if you need to. You can model future things, like new contracts and the reimbursement implications, so you can make better decisions. We’ve seen Source evolve over the years, and we’re pleased with how they actively engage their own customers’ voices, just like we do with our customers. It’s been a great partnership.”

The Future Looks Bright

As SummaCare looks to the future, the team plans to move to more modern systems that allow them to collaborate with their customers and respond to changing regulatory and competitive market dynamics on a whole new level. Functions such as contract modeling and exploring new payment models are definitely on the horizon, according to Rusk. “We look forward to being more innovative and forward-thinking when it comes to what our contracts should look like. And as new payment models, such as bundled payments, emerge, modern technology like what HealthEdge provides will give us even greater flexibility.

Learn more about Source here.

Top 4 Health Plan Challenges 

1. Staffing  

80% of health plans are having self-described staffing problems, including:

• Overworked staff & high turnover
• Extended replacement time
• Over-reliance on senior staff
• Employee burnout

2. Regulatory Environment

Managing and adhering to regulatory requirements & changes is a constant challenge. Health plans are consistently faced with:

• Reaction time to mandated changes
• Knowing what comes next

3. Administrative Costs 

In a 2022 survey of 300+ health plan leaders, when survey respondents were asked to report the top three challenges that their organizations face today, managing costs and driving operational efficiencies were top of the list – jumping dramatically from the prior year’s fourth and fifth positions.

4. Consistent CAPS Quality of Service

Many factors can impact CAPS quality of service, including:

• Manual processes
• Issues/defects impacting operations
• Maintaining high auto-adjudication rates
• Reducing operational PMPM costs

Introducing EDGEcelerate: A Path to Minimize the Challenges 

Health plans need flexibility and personalized solutions as they grow and respond to market pressures. HealthEdge’s new tiered services solution, EDGEcelerate, can offer the targeted, personalized solutions health plans need to tackle these multi-dimensional challenges.

HealthEdge EDGEcelerate  provides customized, full life cycle support of the CAPS system HealthRules® Payer. With this, health plans can:

• Create efficiencies through automation
• Experience a reliable CAPS system tuned to your needs
• Reduce manual work arounds
• Improve KPIs
• React & respond faster to regulatory mandates

Every health plan has challenges. Let’s solve them together. Learn more about HealthEdge’s personalized service solutions with EDGEcelerate.

However, one of the most effective ways to improve the member experience is to improve prospective payment integrity. That’s because a retrospective approach continues to add strain and create complexities that drives a wedge further between payers and their members. Prospective payment integrity improvements can eliminate many of the issues before they become challenges.

“By investing in a prospective payment integrity solution that highlights inaccuracies before the payment is made, you can stop the costly retroactive repayment process that negatively impacts your providers and members through administrative costs”[2] – Gartner®,  U.S. Healthcare Payer CIOs Must Invest in Prospective Payment Integrity to Improve Member Experience, 24 March 2023, Austynn Eubank, Mandi Bishop

When taking an enterprise-wide approach to payment integrity, payers should consider focusing on these four areas:

1. Improve accuracy: To build trust with their members, payers must strive to be proficient and transparent in their payment integrity processes. Payment integrity platforms, such as Source, that offer a single API, automated and regular cloud-based updates, and a single source for fee schedules and payment policies, create a more seamless and centralized data source that informs more accurate payments.
2. Address root cause payment issues upstream: The traditional approach to payment integrity is stacking third party payment recovery services on top of one another. Most of these services are based on contingency fees, so there is no incentive for these vendors to provide insight into the root cause of issues. As a result, payers continue to make the same mistakes month after month, never really having the opportunity to make meaningful changes that can deliver meaningful results.
3. Take a member-centric approach to payment integrity: When payment integrity takes a singular, departmental approach that is focused on payment recovery, members are typically last in line for consideration. The responsibility of recovering inaccurate payments are then passed off to other departments who are left to deal with member communications. An enterprise approach to improving payment integrity and more accurate payments are made more often, there are fewer opportunities for member abrasion and less manual work for staff. Everyone wins.
4. Shift to prospective payment integrity: Looking forward and improving payment accuracy in advance of payments makes logical sense, but until Source started delivering a transformative approach to payment integrity, the cost vs. value was simply not there. Forward-leaning payers who are implementing the Source Platform Access and suite of solutions are able to experience continuous process improvements across their enterprises, and ultimately reduce member abrasion while gaining significant efficiencies.

To learn more about how Source’s transformative approach to payment integrity can help your organization reduce member abrasion, visit the Source page on the HealthEdge website.

[1] Infographic: Top Priorities, Technologies, and Challenges for Healthcare Payers in 2023

[2] U.S. Healthcare Payer CIOs Must Invest in Prospective Payment Integrity to Improve Member Experience, Gartner 24 March 2023, Austynn Eubank, Mandi Bishop. GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved.

• Data retention
• Geographic data storage
• Identity and access management
• User onboarding and offboarding
• Data classification
• Acceptable use
• Risk management