Month: June 2024

Critical Prep Areas for 2024 Utilization Management (UM)-Focused Audits

The 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) introduced new constraints on Utilization Management (UM) policies, particularly prior authorization, effective January 1, 2024. CMS aims to assess UM-related performance for plans covering 88% of beneficiaries this year through routine and focused audits. From client discussions, I have noted that these UM-focused audits show no sign of slowing down and have ranged from basic to quite extensive, emphasizing the need for thorough preparation.

CMS’s UM-Focused Audits and Goals

CMS-4201-F imposes stringent requirements on Medicare Advantage plans regarding UM policies. These audits are designed to ensure fair and equitable access to care by scrutinizing prior authorization processes to prevent unnecessary barriers. Since late February, CMS has increased audit activities, sending engagement letters and varying the scope of audits from basic checks to comprehensive reviews.

CMS’s objective is to evaluate the UM performance of plans serving the majority of beneficiaries through routine program audits and targeted “focused audits.” With CMS aiming to cover such a high percentage of beneficiaries, the likelihood of your plan being audited is substantial. These audits seek to identify and correct UM practices that may hinder patient access to necessary care, promote transparency and accountability within the Medicare Advantage program.

Four Critical Areas for Audit Preparation

To ensure compliance and readiness for UM-focused audits, Medicare health plans should concentrate on four critical areas:

1. UM Committee Composition

  • Qualified Leadership: Ensure your UM committee is chaired by a medical director with the necessary qualifications and experience.
  • Health Equity Expertise: Include at least one member with expertise in health equity to address disparities in care.
  • Conflict of Interest Management: Establish clear processes for identifying, documenting, and managing conflicts of interest. Regularly review and clear conflicts, and implement protocols for handling recusals.

Key Questions:

    • Is your UM committee chaired by a qualified medical director?
    • Does the committee include a member with health equity expertise?
    • How are conflicts of interest identified and managed within the committee?

2. Policy Review and Approval

  • Comprehensive Review: Ensure that all UM policies, including those related to Part B drugs, are thoroughly reviewed and approved by the UM committee.
  • Supplemental Benefits: Evaluate and approve supplemental benefits and criteria from First-Tier, Downstream, and Related Entities (FDRs).

Key Questions:

    • Have all UM policies, including Part B drug policies, been reviewed and approved by the UM committee?
    • Are supplemental benefits and criteria from FDRs reviewed and approved?

3. Health Equity Analysis

  • Annual Review: Conduct an annual health equity analysis to assess the impact of prior authorization on enrollees with social risk factors.
  • Public Accessibility: Make the results of this analysis publicly accessible on your plan’s website to ensure transparency.

Key Questions:

    • Has the annual health equity analysis been conducted to assess the impact of prior authorization on enrollees with social risk factors?
    • Are the results of this analysis publicly accessible on your plan’s website?

4. Transparency and Accessibility

  • Public Posting: Ensure all internal coverage criteria and clinical guidelines are posted online in an easily accessible format.
  • Timely Updates: Regularly update these criteria and ensure they include those from third-party entities.

Key Questions:

    • Are all internal coverage criteria and clinical guidelines posted online in an easily accessible format?
    • Are these criteria updated timely and include those of third-party entities?

Preparing for UM Audits: Practical Steps

  1. Regular Training and Updates: Conduct regular training sessions for your staff to ensure they are updated on the latest CMS requirements and internal UM policies.
  2. Internal Audits and Mock Reviews: Perform internal audits and mock reviews to identify potential areas of non-compliance and address them proactively.
  3. Documentation and Record-Keeping: Maintain thorough and organized documentation of all UM committee activities, policy reviews, and health equity analyses.
  4. Stakeholder Engagement: Engage with stakeholders, including patients, providers, and advocacy groups, to gather feedback and ensure your UM policies meet the needs of all beneficiaries.

Beyond the Audit: Sustainable Strategies for UM Excellence

Navigating the complexities of UM-focused audits under CMS-4201-F requires diligent preparation and ongoing compliance efforts. By focusing on the critical areas outlined above, Medicare Advantage plans can enhance their readiness for audits and demonstrate their commitment to providing equitable and efficient care.

HealthAxis’ strategic consulting services provide the expertise needed to ensure you are prepared for UM-focused audits and can assist with any necessary remediation. Our experts can help develop ongoing monitoring and oversight plans, ensuring your organization remains compliant. Schedule a call today to learn how we can support your success in the evolving healthcare landscape.

Author:

Milonda Mitchell

Milonda Mitchell
Compliance Officer
HealthAxis

FHIR® in Action: Streamlining Prior Authorization

Traditionally, prior authorization has been a complex, time-consuming process fraught with inefficiencies. Disconnected systems and manual procedures not only slow down care but can also lead to significant administrative errors. These challenges have long plagued healthcare payers, providers, and members, creating barriers to timely and effective care.

The process involves multiple steps which can be prone to delays and mistakes, including:

  • Eligibility verification – benefit coverage and exclusion
  • Clinical documentation support
  • Manual reviews for medical necessity

These inefficiencies not only strain healthcare resources but also frustrate members who are left waiting for necessary treatments. A more streamlined, efficient approach is needed to transform this critical aspect of healthcare administration. Enter FHIR® – Fast Healthcare Interoperability Resources.

What is FHIR® and How Does it Work?

Developed by HL7, FHIR® aims to simplify healthcare data exchange, making it universally interoperable. At its core, FHIR® is a standardized language for exchanging healthcare data. It acts as a common ground, enabling seamless communication between disparate healthcare information systems used by providers, payers, and members.

FHIR® achieves this through a set of modular components, or “resources,” that represent various aspects of healthcare data. These resources can be easily shared and understood across different platforms, eliminating the need for redundant data entry and reducing the risk of errors.

The Power of FHIR® in Prior Authorization

By adopting FHIR® standards, healthcare organizations achieve several key benefits:

  • Automation: One of the most significant benefits of FHIR® is its ability to facilitate automation in the prior authorization process. Automation can handle many of the repetitive and manual tasks traditionally associated with prior authorization, such as eligibility checks and status updates. This not only speeds up the process but also reduces the potential for human error.
  • Real-time Data Exchange: FHIR® facilitates the exchange of data in real-time. This means crucial information about a member’s eligibility, medical history, and treatment plan is readily available at the point of care, allowing for faster and more informed prior authorization decisions.
  • Reduced Errors: Manual data entry is a significant source of errors in the prior authorization process. FHIR® automates much of this process, minimizing the risk of human error and ensuring data accuracy.
  • Enhanced Transparency and Communication: FHIR® fosters clear and direct communication channels between providers, payers, and members. All parties involved have access to the latest information on the authorization status, promoting transparency and trust throughout the process.
  • Significant Cost Savings: Healthcare payers can expect significant cost savings due to reduced administrative burden and streamlined operations. Providers can dedicate more time to delivering quality care, and members experience less stress and delays in receiving necessary treatment.

CMS Final Rule: A Catalyst for Change

The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) further underscores the importance of FHIR® and sets a clear timeline for implementation. This rule marks a transformative phase for U.S. healthcare payers, emphasizing the need for seamless data exchange and interoperability.

Here’s a breakdown of key points:

  • Effective January 1, 2026: This initial phase focuses on non-API requirements, laying the groundwork for a more standardized approach to prior authorization.
  • Focus on Interoperability: The rule emphasizes the use of standardized formats like FHIR® to ensure seamless data exchange between healthcare entities.
  • Future Advancements with APIs: By January 1, 2027, payers will need to implement specific application programming interfaces (APIs) like HL7® and FHIR®. These APIs will enable a more streamlined electronic exchange of healthcare data, further enhancing the efficiency and accuracy of the prior authorization process.

This regulatory push towards interoperability and the adoption of FHIR® standards is expected to revolutionize the healthcare industry. As healthcare payers and providers prepare for these changes, the focus will be on developing and implementing systems that can handle real-time data exchange, automate repetitive tasks, and ensure accurate and timely prior authorization decisions.

The Future of Prior Authorization with FHIR®

As healthcare continues to evolve, the need for efficient and interoperable systems becomes increasingly critical. FHIR® represents a significant step forward in addressing the challenges of prior authorization. By standardizing and automating the process, FHIR® not only improves efficiency but also enhances the quality of care and the member experience.

The future of prior authorization lies in the widespread adoption of standards like FHIR®. As more healthcare organizations embrace this technology, we can expect to see a significant reduction in the administrative burdens associated with prior authorization. This will allow healthcare providers to focus more on member care and less on paperwork, ultimately leading to better health outcomes.

At HealthAxis, we believe in the power of technology to transform healthcare. Our FHIR®-enabled CAPS platform AxisCore™ streamlines prior authorization, improves data interoperability, and enhances member care. By adopting and promoting FHIR® standards, we aim to lead the industry toward a more connected, efficient, and member-centric future.

Schedule a discovery call today to learn how our AxisCore™ platform can revolutionize your prior authorization processes and elevate your organization’s performance.

Author:

Chris House
Chris House
Chief Technology Officer
HealthAxis

Investing in Healthcare IT: AI Innovations for Healthcare Payers

The McGuireWoods Healthcare Private Equity & Finance Conference remains a premier event that convenes healthcare industry leaders to explore innovative strategies for growth and success. As CEO of HealthAxis, I had the privilege of speaking on the panel “Investing in Healthcare IT/Payor Services for a Digital Future” at the 20th anniversary of the event on Thursday, June 9, 2024.

Our panel discussion covered various health tech topics, with a significant focus on artificial intelligence’s (AI) transformative potential in healthcare, the challenges it presents, and the strategic decisions organizations face in integrating AI into their operations. In this blog, I’ll share my key takeaways and insights from that session.

The Evolution and Impact of AI in Healthcare Administration

AI has been a function in healthcare administration for probably the last 10-12 years; we just weren’t talking about it. My first encounter with an AI project dates to 2015 when the costs of implementation outweighed the benefits. Today, the scenario has flipped—AI’s advantages far exceed the investment costs, making it an indispensable tool for healthcare organizations. The benefits AI brings to healthcare are virtually limitless, but it’s essential to navigate this space with caution.

Caution in the AI Landscape

One of the primary concerns is the proliferation of organizations claiming AI expertise. Many new players in the market have only recently begun to explore AI, leading to a lack of genuine expertise. It’s crucial to scrutinize these claims, understanding their credentials and depth of knowledge. Look for their experience with different AI models and their real-world applications. Additionally, ensure that they adhere to the foundational principles of ethics, equity, and data quality to enable the responsible application of AI in healthcare.

The Benefits of AI for Healthcare Payers

At HealthAxis, we focus on the healthcare payer side, where AI offers tremendous opportunities. However, there’s often resistance at various organizational levels. While C-level executives see AI as a pathway to cost savings and operational optimization, resource-level employees may fear job displacement. This necessitates a robust change management strategy to integrate AI smoothly. We have to understand, the importance of the human element in the payer side of healthcare. AI can handle repetitive and data-intensive tasks, but it cannot replace the nuanced decision-making, empathy and personalized care that human professionals provide. AI can augment our workforce, but it can’t replace it. The use of AI will enable our teams to focus on more complex problems, relationship management, and delivering the high-touch service that our clients and their members deserve.

A core facet for healthcare payers is call centers, and AI can revolutionize this function. The AI call center agent that we at HXG are introducing can make interactions nearly indistinguishable from those with human agents. In claims processing, AI can enhance auto-adjudication rates by making accurate, faster decisions, reducing the need for human intervention. These are just a few examples of AI’s potential to streamline operations and improve accuracy.

Strategic Decisions in AI Adoption

The key question for healthcare organizations is how to adopt AI effectively. Should you invest in developing AI capabilities internally, partner with AI specialists, or license AI solutions? Each organization must evaluate its unique value proposition and determine the best approach. The decision hinges on various factors, including cost, expertise, and the specific needs of the business.

Embracing the Future with AI

The discussion at the 2024 McGuireWoods Healthcare Private Equity and Finance Conference highlighted AI’s transformative potential in healthcare IT and payor services. While the journey towards full AI integration involves navigating challenges and strategic decisions, the benefits are undeniable. At HealthAxis, we are committed to leveraging AI to drive innovation and efficiency in healthcare, ensuring better outcomes for all stakeholders.

Investing in AI is not just about staying current; it’s about leading the charge into a digital future that promises enhanced performance and unprecedented opportunities in healthcare.

Connect with our experts to learn about HealthAxis’ latest innovations and how they can transform your healthcare operations.

Author:

Scott Martin
Scott Martin
Chief Executive Officer
HealthAxis

Maximizing Member Retention: Transforming Pain Points into Positive Experiences

Member retention is paramount in a competitive healthcare landscape. A classic Harvard Business Review study revealed that a mere 5% increase in customer retention can boost profits by 25% to 95%. This statistic underscores the critical role satisfied members play in the financial stability and success of healthcare payers and third-party administrators (TPAs).

This blog delves into the common challenges that hinder member experience and explores effective solutions to transform them into positive touchpoints. We’ll explore critical areas that directly impact member retention, especially during key periods like the Annual Enrollment Period (AEP) and Open Enrollment Period (OEP), and other key times such as renewal cycles and special enrollment periods:

  • Core Administrative Process System (CAPS)
  • Contact Center
  • Compliance Adherence

Core Admin Efficiency

A CAPS platform is the backbone of efficient healthcare administration. It directly impacts member satisfaction in several ways. Inefficient systems lead to errors in claims processing, delays in payments, and difficulties in accessing information. This can cause members to feel frustrated and confused, ultimately leading them to switch to a competitor who offers a smoother experience.

Common Issues:

  • Poor Auto-Adjudication (AA) Rates: High manual claim processing can lead to delays and member dissatisfaction.
  • Configuration Limitations and Insufficient Business Rules: These can restrict the flexibility and responsiveness of payers to member needs.
  • Data Management and System Integration Challenges: Ineffective management and integration can result in inaccuracies and inefficiencies, affecting member trust and satisfaction.
  • Reliance on Legacy Systems: Using outdated CAPS technology can hinder operational efficiency and scalability, limiting the ability to adapt to changing member and regulatory demands.

Strategic Core System Enhancements:

  • Predictive Analytics and Data-Driven Decisions: Employing predictive analytics to understand member behavior and preferences can guide personalized service offerings, increasing member engagement and loyalty.
  • Seamless System and Process Integration: Ensuring seamless integration between different systems and processes eliminates operational silos, improving efficiency and member service continuity.
  • Modernizing Legacy Systems: Upgrading from outdated CAPS technology to modern, flexible systems enhances operational efficiency and scalability, allowing for better adaptation to changing demands.
  • Incorporating AI and Emerging Technologies: Integrating AI and other emerging technologies can further streamline processes and enhance system responsiveness, preparing for future advancements without overhauling current infrastructure.

Contact Center Limitations

The contact center serves as a crucial bridge between members and the healthcare payers and TPAs. When a member reaches out for help, a positive experience can build trust and loyalty. Conversely, negative interactions can lead to member churn.

Common Pain Points:

  • Understaffing: Insufficient staffing, particularly during peak periods like AEP and OEP, can lead to long wait times and frustrated members.
  • Inadequate Staff Training: A workforce lacking proper training on complex plans and procedures can result in miscommunication and hinder the effective resolution of member inquiries.
  • Outdated Technology: Legacy call center systems might not provide agents with the tools they need to access member information and resolve issues promptly efficiently.

Strategic Enhancements:

  • Empowered Agents with Advanced Tools: Equipping agents with comprehensive data and advanced tools enables them to address member needs effectively and efficiently, fostering positive experiences and loyalty.
  • Real-Time Feedback and Agile Adaptation: Implementing real-time feedback mechanisms allows for immediate improvements and adaptations in service delivery, enhancing overall member satisfaction.

Compliance and Regulatory Hurdles

Staying compliant with evolving regulations is crucial for healthcare organizations, but it also plays a significant role in member trust. Members want to know their healthcare plan is reliable and operates ethically. Failing to comply with regulations can erode that trust.

Common Pain Points:

  • Outdated Policies and Procedures (P&P): These can lead to non-compliance and operational inefficiencies.
  • Manual Compliance Processes: Time-consuming and prone to errors, manual processes can detract from focusing on member-centric services.
  • Lack of Knowledgeable Staff: Not having enough experts to drive a culture of compliance can result in overlooked regulatory requirements and increased risks.

Strategic Enhancements:

  • Integrated Compliance Management Systems: Utilizing integrated systems for managing compliance tasks ensures that nothing falls through the cracks, maintaining trust and reducing the risk of penalties.
  • Ongoing Education and Training Programs: Continual education and training on the latest regulatory changes and best practices ensure that staff are always informed and compliant, reinforcing member confidence in the payer’s services.

The Path to Higher Retention: How HealthAxis Can Help

Maximizing your member retention strategy requires proactive planning and demands both precision and adaptability. With nearly 60 years of experience in the healthcare industry, HealthAxis is a strategic ally adept at transforming your member experience.

Our modern CAPS technology and integrated business solutions are designed to empower you to:

  • Reduce Member Frustration: Streamline core systems and enhance contact center efficiency to minimize member frustration.
  • Boost Member Satisfaction: Improve accuracy, accelerate resolutions, and provide personalized service to elevate member satisfaction.
  • Drive Loyalty and Retention: Build trust and foster a positive member experience to drive loyalty and long-term retention.

Connect with one of our experts today to learn more about how HealthAxis can help you transform your member retention strategy.

Maximizing Member Retention: A Checklist for Operational Success