In Part One of this series, we examined the initiatives Gartner identified as key areas for acceleration,1 following their extensive evaluation through research surveys and interactions with U.S. healthcare payer business and technology executives.
Building on the foundation of data-driven initiatives explored in Part 1, Part 2 of this series shifts the focus to practical applications and strategic initiatives. We’ll delve into specific areas where payers and TPAs can leverage these insights to accelerate their progress. This includes improving operational efficiencies, enhancing care delivery models, and gaining a competitive edge in the market.
Streamlining Payment Integrity Processes
Payers are increasingly recognizing the need to streamline their payment integrity processes as a strategy to reduce the operational costs stemming from overpayments and complex administrative procedures. More importantly, optimizing these processes directly enhances provider satisfaction and improves the overall member experience. While the focus has traditionally been on medical cost containment, it’s crucial to acknowledge the direct impact that payment inaccuracies have on members’ out-of-pocket expenses. Most claim denials, which significantly affect member satisfaction, are preventable, and a large portion of these can be successfully appealed.
To mitigate preventable claim denials, payers should focus on enhancing and automating the data collection, validation, and reconciliation processes. Moreover, educating both members and providers about the conditions necessary for payment can play a pivotal role in reducing errors. This approach not only supports fair payment practices but also builds trust and transparency with healthcare providers and members.
Additionally, payers bear the responsibility of reducing fraudulent claim activity without inadvertently creating payment hassles for providers. Experts at Gartner have recommended collaborating closely with payment integrity vendors or internal special investigative units (SIU) to achieve this balance.2 By exposing detailed claim submission requirements through provider portals or other communication platforms, payers can help ensure that providers submit complete and accurate claims, thereby reducing the likelihood of denials due to missing or incorrect information. Such proactive measures are essential for maintaining the integrity of payment processes and fostering a positive ecosystem for all stakeholders involved.
Modernizing Technology
In the rapidly evolving healthcare landscape, the modernization of technology infrastructure emerges as a critical priority for payers. As Gartner highlights, in 2024, U.S. healthcare payers are focusing their investments on upgrading core systems, enhancing interoperability technologies, and improving consumer experience capabilities. These strategic areas of investment are essential for payers to maintain competitive advantages, optimize costs, and improve overall member experiences.
To ensure these investments are aligned with industry standards, CIOs are encouraged to benchmark their technology spending against findings from the 2024 Gartner CIO and Technology Executive Survey:
- Core Administrative Processing Systems – The modernization of CAPS is a critical investment for 59% of healthcare payers, according to the Gartner survey. The drive towards upgrading these foundational systems stems from the need to replace or augment legacy systems that no longer suffice to meet the complex demands of today’s healthcare landscape.
- Interoperability Technologies – Interoperability is a key strategic focus for 59% of healthcare payer CIOs in the Gartner survey, highlighting the sector’s recognition of its importance in the current healthcare ecosystem. With new mandates for interoperability on the horizon, the ability to seamlessly share clinical data across the healthcare continuum becomes paramount.
- Consumer Experience Capabilities – The push towards improving consumer experience capabilities is evident, with 53% of payers focusing on this area, according to the Gartner survey. In an age where consumer expectations are shaped by experiences outside the healthcare industry, payers are challenged to provide a level of service that mirrors the convenience and personalization consumers encounter daily.
By prioritizing these technological upgrades, U.S. healthcare payers can address the dual challenges of meeting ever-growing regulatory requirements and rising consumer expectations. Such modernization not only supports efficient administrative processing but also positions payers to lead in delivering innovative solutions that enhance member satisfaction and retention.
Expanding Self-Funded Business
The self-funded business market is experiencing a notable shift as not only large and national employer groups but increasingly smaller employer groups are turning to self-funding to curb healthcare costs. This trend is accelerating growth in the market and presents significant opportunities for payers to expand their administrative services-only (ASO) offerings. However, this expansion also introduces risks, as self-funded ASO employers may choose to bypass traditional payer arrangements, opting instead to contract directly with other service providers within the healthcare ecosystem to manage their employees’ healthcare needs more economically.
To capitalize on this evolving market dynamic, payers must focus on enhancing their service offerings to meet the unique demands of these smaller employer groups. Investing in core administrative technologies is critical. These technologies should support quick data exchanges and offer flexible configurations for benefits, products, provider networks, and reimbursements. Such capabilities will not only meet the diverse needs of self-funded groups but also help in maintaining competitiveness in a rapidly changing market.
Moreover, to create lasting client relationships with self-funded ASO groups, payers need to deliver a superior digital consumer experience. This involves more than just processing claims and coordinating care; it requires providing high-value-added solutions such as cross-carrier analytics that can offer deeper insights into healthcare management and efficiencies. By aligning their services with the complex needs of self-funded employers, payers can position themselves as indispensable partners in the self-funded healthcare landscape.
Enhancing Home Health Capabilities
The trend towards home-based care is accelerating, fueled by a growing prevalence of chronic diseases and the ongoing challenges of managing healthcare costs effectively. As patients increasingly prefer the comfort and convenience of receiving care at home, payers are finding it essential to expand and enhance their home health capabilities to meet these evolving demands.
This shift is not only about accommodating patient preferences but also about tapping into the cost-efficiency that home care can offer. By providing support for home-based care, payers can help reduce the frequency of expensive hospital visits and enable more proactive management of chronic conditions. This approach involves integrating advanced technologies such as telehealth systems, remote patient monitoring, and mobile health applications that allow for effective treatment and management outside traditional healthcare facilities.
Driving Future-Ready Healthcare Solutions
HealthAxis is committed to driving excellence in healthcare through innovative and integrated solutions. With nearly 60 years of experience in the healthcare industry, we understand that every payer faces unique challenges. We offer a tiered suite of solutions designed to meet your specific needs, whether you’re a large, established payer or a smaller organization looking to expand your reach.
Our solutions can empower you to:
- Implement robust data and analytics governance frameworks.
- Increase data transparency and meet regulatory requirements.
- Modernize your technology infrastructure and unlock new possibilities.
- Leverage FHIR APIs for seamless data exchange.
- Expand your home health capabilities and deliver cost-effective care.
- Streamline payment integrity processes and improve efficiency.
- Capture the growing self-funded business market.
Learn more about how HealthAxis can tailor a solution to fit your needs and help you navigate the ever-changing healthcare landscape.
Sources:
1. Business Outlook for Critical U.S. Healthcare Payer Initiatives, Gartner
2. Quick Answer: Rethink Your Denial Strategy to Increase Provider Satisfaction, Gartner
