Author: Victoria Bucci

Reducing Costs and Complexity with EHR Workflows for Prior Authorization

The healthcare industry faces a constant challenge: balancing rising costs with the imperative to deliver high-quality care. Prior authorization has become a crucial tool for payers, helping to ensure medical necessity and control spending. However, the current process is often bogged down by administrative complexities, creating a burden for both providers and patients.

A JAMA study found that a staggering quarter of all healthcare spending could be classified as waste. While prior authorization helps rein in these costs, a staggering 88% of physicians report feeling overwhelmed by the administrative burden of processing authorization requests.1 However, there’s a solution waiting to be embraced: integrating prior authorization seamlessly within Electronic Health Record (EHR) workflows.

This blog post will dive into the transformative potential of embedded prior authorization. We’ll explore how leveraging open-source solutions and automating clinical data retrieval can unlock real-time authorization determinations, leading to a win-win scenario for healthcare payers and their members.

Here’s what we’ll cover:

  • Efficiency & Cost Savings: Streamlined workflows and reduced administrative burden.
  • Improved Member Experience: Faster approvals and a smoother experience.
  • Effective Data Integration: Ensuring seamless information flow between systems.
  • Choosing the Right Partner: Key qualities for a successful implementation.

Streamlining Operations and Reducing Costs

The current state of prior authorization is riddled with inefficiencies. Manual processes for requesting and reviewing authorizations are time-consuming and prone to errors. This translates into significant administrative burdens for both payers and providers, diverting valuable resources away from patient care.

Integrating prior authorization with EHR workflows represents a paradigm shift. By leveraging existing clinical data within the EHR, the process becomes automated. This eliminates the need for manual data entry, reduces the risk of errors, and streamlines the entire authorization process. The result? Significant cost savings for payers due to:

  • Reduced administrative overhead associated with manual processing.
  • Improved accuracy in authorization requests, leading to fewer denials and rework.
  • Enhanced staff productivity through automation.

According to the 2023 CAQH Index Report, the adoption rate for electronic prior authorizations (ePAs) in the medical industry has increased by three percentage points, now standing at 31%.2 Despite this progress, prior authorization continues to be one of the most burdensome administrative tasks for providers, with significant time and cost implications. The report highlights that fully electronic transactions could save the medical industry approximately $494 million annually.

Enhancing the Member Experience

The benefits of streamlining prior authorization extend far beyond cost savings. For patients, the traditional process can be frustrating and lead to delays in receiving necessary care. Imagine a scenario where a patient requires a specific medication, but their provider’s authorization request gets caught in bureaucratic red tape. This can have a negative impact on the patient’s health outcomes and overall satisfaction with the healthcare system.

By enabling prior authorization within EHR workflows and ensuring payers can receive and respond to ePAs via data transmissions, real-time determinations become possible. With access to relevant clinical data at their fingertips, payers can make informed decisions quickly. This translates to:

  • Shorter wait times for patients, ensuring they receive timely access to necessary care.
  • A smoother and less stressful experience for patients, fostering trust and satisfaction with their healthcare provider and payer.
  • Improved health outcomes for patients due to timely access to necessary treatments and medications.

Interoperability Standards: The Key to Seamless Integration

The true potential of EHR-integrated prior authorization lies in interoperability standards such as FHIR® (Fast Healthcare Interoperability Resources) and initiatives like the Da Vinci Project. These standards enable seamless data exchange between providers’ HER systems and payers’ systems, ensuring that authorization requests and responses are transmitted electronically, accurately, and efficiently.

Providers can generate prior authorization requests directly with their EHRs, leveraging the FHIR® and Da Vinci standards to send and receive information. This eliminates the outdated practice of dropping authorizations to PDF and eFax, which only perpetuates inefficiencies. Payers must be prepared to accept ePAs, as failing to do so will result in missed opportunities for automation and increased administrative burden.

The Importance of the Right Partner

The success of integrating prior authorization into EHR workflows hinges on choosing the right technology partner. A true partner understands the unique challenges faced by healthcare payers and their members. They bring not just the technology but also the expertise and ongoing support necessary for a seamless transition and long-term success.

Here are some key qualities to look for in a technology partner:

  • Deep understanding of healthcare payer operations: They should possess a comprehensive understanding of the challenges payers face with prior authorization, including administrative burdens, member satisfaction, and cost containment.
  • Proven track record in technology integration: Look for a partner with a history of successful implementations and a strong reputation within the industry.
  • Commitment to ongoing support: A successful integration requires ongoing support and collaboration. Your partner should be invested in your long-term success and provide the resources necessary to optimize the solution and address any challenges that may arise.

Embrace the Future of Prior Authorization

The integration of prior authorization within EHR workflows represents a significant leap forward for healthcare payers. By streamlining processes, reducing costs, and enhancing the member experience, this innovative approach paves the way for a more efficient and patient-centered healthcare system.

At HealthAxis, we understand the complexities of healthcare payer operations and the critical role that prior authorization plays. We are a leading provider of CAPS technology, with a proven track record of helping payers achieve significant improvements in efficiency, member satisfaction, and cost containment.

In addition to our proprietary CAPS platform, HealthAxis offers strategic consulting services that adapt to any scale, ensuring organizations thrive. We empower our clients to optimize their technology and operations to meet their unique challenges. Our approach goes beyond simply offering technology. We build partnerships with our clients, working collaboratively to understand their unique needs and develop a customized solution that integrates seamlessly with their existing EHR workflows. We provide ongoing support and guidance to ensure a smooth transition and maximize the return on investment.

Schedule a discovery call today to explore how our CAPS solutions and strategic consulting services can help you transform your prior authorization processes and achieve your operational and financial goals. Together, we can build a future where prior authorization serves its intended purpose without sacrificing efficiency or member satisfaction.

 

Sources:

  1. Waste in the US Health Care System, JAMA Network
  2. 2023 CAQH Index Report, CAQH

Navigating the Complexities and Opportunities of the Medicare Prescription Payment Plan for Health Plans

The Centers for Medicare & Medicaid Services (CMS) introduced the Medicare Prescription Payment Plan (M3P) as a part of the Inflation Reduction Act of 2022. It represents a significant shift in the Medicare landscape, offering Medicare Part D enrollees a new way to manage the cost of their prescription drugs. While this initiative aims to alleviate financial burdens for beneficiaries, it also introduces complexities for health plans.

This blog provides a high-level overview of the key components and implementation of the M3P, helping health plans understand its significance and benefits.

What is the Medicare Prescription Payment Plan?

The M3P is an option for Medicare Part D beneficiaries to manage their out-of-pocket (OOP) prescription drug costs. Instead of facing large, one-time payments, enrollees can distribute their OOP expenses throughout the year rather than requiring them to pay in full at the pharmacy counter each time they fill a prescription, making their medication costs more predictable and manageable. The program is set to kick off in the 2025 plan year, marking a significant change in how prescription costs are handled.

M3P Impact and Challenges for Health Plans

The Medicare Prescription Payment Plan (M3P) introduces several complexities for health plans, significantly increasing their administrative burden and necessitating changes in various processes.

  • Increased Administrative Complexity: The M3P program demands significant modifications in billing, reimbursement, and member communication processes. Health plans must adapt to new operational requirements to ensure smooth implementation and management of the program.
  • Reimbursement and Collection: Health plans are responsible for reimbursing pharmacies at the point of service and subsequently collecting patient responsibility payments from members. Since enrollees will have no upfront financial liability at the pharmacy, it is crucial for health plans to manage these financial flows efficiently.
  • Enrollment Management: Ensuring that enrollees can easily opt into the M3P program, either at the beginning of the plan year or upon reaching a certain cost threshold, requires robust enrollment systems and clear member communication.
  • Compliance and Termination: Health plans must handle cases where members fail to pay the billed amounts. This may result in program termination but must not affect Medicare Part A and B medical coverage or Part D pharmacy coverage.
  • Financial Risk: Health plans assume the financial risk of reimbursing pharmacies upfront and collecting payments from members over time, introducing new cash flow challenges.
  • Member Communication: Effectively communicating the M3P to members and ensuring they understand their options and responsibilities is crucial for program success.
  • System Integration: Integrating M3P functionality into existing core administrative processing systems (CAPS) is essential for efficient operations. Health plans must develop new processes for enrollment, payment collection, and reconciliation to ensure seamless integration and operation.

How Health Plans Can Optimize M3P Implementation

While the M3P introduces complexities, health plans can still identify opportunities to optimize their operations and potentially improve financial performance:

  • Streamlined Operations: Efficiently implementing M3P processes can lead to cost reductions through automation and improved workflows.
  • Data-Driven Insights: Leveraging M3P data can provide valuable insights into member medication usage patterns and cost trends, enabling targeted interventions and cost-saving strategies.
  • Risk Management: Effective risk management strategies can help mitigate potential financial risks associated with M3P, such as payment defaults or increased administrative costs.
  • Member Engagement: While not a competitive advantage, proactive member communication and education about the M3P can enhance member satisfaction and improve adherence.

CMS has released comprehensive guidance on the implementation of the M3P in two parts:

  • Part One Guidance: Released on February 29, 2024, it details the requirements for Medicare Part D plan sponsors concerning operational topics. It covers identifying enrollees likely to benefit from the program, the opt-in process for enrollees, participant protections, and data collection necessary for program evaluation. These requirements apply to the program’s first year, 2025.
  • Part Two Guidance: Released on July 16, 2024, it outlines the requirements for Medicare Part D plan sponsors related to outreach and education, pharmacy processes, and other operational considerations. These requirements also apply to the program’s first year, 2025.

Moving Forward with Confidence with Your M3P Strategy

The M3P is a complex program with far-reaching implications for health plans. By understanding the challenges and opportunities, health plans can develop effective strategies to implement the M3P while minimizing disruption to their operations.

HealthAxis can be your partner in navigating the complexities of the Medicare Prescription Payment Plan through our expert consulting services. We provide tailored strategies to help you seamlessly integrate M3P into your offerings, ensuring compliance and maximizing benefits for your members. Connect with our experts today to learn how we can support your transition to the M3P and enhance your service offerings.

HealthAxis InFocus: Leveraging AI Effectively

Welcome to the first installment of HealthAxis InFocus, a video series where we share insights and perspectives from our leaders based on our interactions with clients, prospects, and industry experts.

In this episode, our CEO, Scott Martin, discusses the transformative impact of artificial intelligence, machine learning, and robotic process automation in the payer space. Discover how HealthAxis is using these technologies to streamline claims processing, enhance call center operations, and improve overall efficiency.

Ready to transform your operations? Connect with our experts to learn how HealthAxis can help you leverage cutting-edge technology for your health plan.

Ensuring a Successful Open Enrollment: Key Areas for Healthcare Payers & TPAs

As healthcare payers and third-party administrators (TPAs) gear up for the open enrollment period (OEP) and annual enrollment period (AEP), ensuring a smooth and successful process is paramount. With increased volumes of inquiries, transactions, and member interactions, preparation is crucial.

In this blog, I’ll outline three critical areas that healthcare organizations should focus on to ensure readiness for AEP/OEP:

  • Operational Efficiency and Scalability
  • Compliance and Regulatory Preparedness
  • Member Engagement and Communication

Operational Efficiency and Scalability

Staffing and Training

AEP/OEP brings a surge in member inquiries and activities. Ensuring that your call centers and support teams are adequately staffed and trained is essential for handling this increased volume efficiently.

Consider the following strategies:

  • Staff Augmentation: Hiring additional staff during peak periods can help manage the increased workload. Temporary staffing solutions can provide the necessary support without long-term commitments.
  • Managed Services: Partnering with managed services firms can offer scalable support, allowing you to meet demand without overburdening your existing teams.
  • Comprehensive Training Programs: Ensure that all staff members are well-trained in enrollment processes, plan options, and customer service best practices. Regular training sessions can help keep skills sharp and up to date.

Technology and Infrastructure

A robust technological infrastructure is the backbone of a seamless AEP/OEP process. Assessing and upgrading your technology can help handle increased traffic and data processing needs. Key areas to focus on include:

  • Scalable Solutions: Implement technology solutions that can scale with demand. Cloud-based platforms and scalable servers can accommodate high volumes of transactions and interactions without compromising performance.
  • System Upgrades: Regularly update your systems to ensure they can handle the latest software and security requirements. Upgrading your technology infrastructure can prevent downtime and improve overall efficiency.
  • Performance Monitoring: Continuously monitor system performance to identify and address potential issues before they escalate. Implementing performance-tracking tools can help ensure smooth operations during peak periods.
  • Compliance with CMS Final Rule: Reassess prior authorization, core administration, and care management systems to align with the new CMS Prior Authorization Final Rule timelines for urgent and non-urgent care requests.

Check out this blog post by HealthAxis Senior Vice President of Product Strategy and Management, Lisa Hebert, to learn how to optimize your technology tools for the CMS Final Rule.

Compliance and Regulatory Preparedness

Regulatory Updates

Staying informed about the latest regulatory changes is crucial for compliance and smooth operations. Ensure your organization complies with all relevant healthcare laws and standards by focusing on:

  • Healthcare Regulations: Stay compliant with the latest healthcare regulations, including the CMS Final Rule, the Affordable Care Act (ACA), and the Health Insurance Portability and Accountability Act (HIPAA). Regularly review updates from regulatory bodies and adjust your processes accordingly.
  • Internal Audits: Conduct regular internal audits to ensure compliance with regulatory requirements. Identifying and addressing compliance gaps proactively can help prevent potential issues.
  • Employee Training: Train staff on the latest regulatory changes and compliance best practices. Ensuring that your team is well-informed can help maintain compliance and reduce risks.

Data Security and Privacy

Protecting sensitive member information is a top priority for healthcare payers. Implementing robust data security measures is essential to comply with regulations such as HIPAA. Key steps include:

  • Security Protocols: Implement strong security protocols to safeguard member data. This includes encryption, secure access controls, and regular security assessments.
  • Policy Updates: Regularly review and update your data privacy policies and procedures. Ensuring that your policies align with current regulations can help maintain compliance and protect member information.
  • Incident Response Plans: Develop and maintain incident response plans to address potential data breaches. Having a clear plan in place can help mitigate the impact of security incidents and maintain member trust.

Member Engagement and Communication

Personalized Support

Offering personalized support can help members choose the best plan for their needs. Utilizing data analytics can provide insights into member preferences and tailor your outreach efforts accordingly.

Key strategies include:

  • Data Analytics: Use data analytics to understand member behavior and preferences. Analyzing data can help you identify trends and personalize your communication and support efforts.
  • Online Tools: Provide online tools such as chat support, decision aids, and plan comparison tools. These resources can help members make informed decisions and enhance their enrollment experience.
  • Proactive Outreach: Reach out to members proactively to offer assistance and answer questions. Personalized outreach can demonstrate your commitment to member satisfaction and support.

Clear Communication

Developing a comprehensive communication strategy is essential to keep members informed about their plan options, benefits, and the enrollment process. Effective communication can enhance member satisfaction and ensure a smooth enrollment experience.

Focus on:

  • Multi-Channel Approach: Utilize multiple communication channels, including email, social media, direct mail, and webinars, to reach a broad audience. Different members prefer different channels, so a multi-channel strategy can increase engagement.
  • Consistent Messaging: Ensure that your messaging is consistent across all channels. Clear and consistent communication can help prevent confusion and provide members with the information they need.
  • Educational Content: Provide educational content that helps members understand their options and the enrollment process. Informative guides, FAQs, and video tutorials can be valuable resources.

Partnering for Open Enrollment Excellence

Preparing for open enrollment requires a comprehensive approach that focuses on operational efficiency, compliance, and member engagement. By ensuring that your staffing, technology, and communication strategies are robust and scalable, you can provide a seamless enrollment experience for your members.

At HealthAxis, we specialize in helping healthcare organizations prepare for open enrollment. Our expertise in operational efficiency, regulatory compliance, and member engagement makes us the ideal partner to ensure your success. HealthAxis offers more than just services; we provide cutting-edge solutions to help you excel.

Our integrated business solutions include:

  • BPaaS (Business Process as a Service)
  • BPO (Business Process Outsourcing)
  • Staff Augmentation
  • Consulting

By blending industry expertise with advanced technology, we ensure seamless OEP/AEP execution and enhance your member experience. Partner with HealthAxis to be prepared and thrive in the healthcare landscape.

Author:

Lisa Kemp

Lisa Kemp
Vice President of Service Excellence
HealthAxis

The Impact of Non-Compliance for Healthcare Organizations

In the intricate realm of healthcare, healthcare organizations confront the daunting challenge of adhering to stringent regulations. Non-compliance can precipitate severe financial penalties, erode trust, and impair operational efficacy. Understanding these risks is paramount for maintaining the equilibrium of financial stability and reputational integrity.

According to the January 2024 Gartner Healthcare Payer Research Panel Survey of 46 U.S. leaders, regulatory shifts ranked as the #1 factor influencing healthcare payer decision-making.

In this blog post, we explore the critical impacts of non-compliance on financial penalties, reputational damage, and operational efficiency.

Financial Penalties

Reputational Damage

  • Lower Net Promoter Score (NPS): According to consumer surveys, the typical health insurer scores just below 30 on the NPS scale, which measures customer loyalty. Health plans with strong reputations tend to score closer to 50.
  • Trust Erosion: Non-compliance breaches member and provider trust, crucial for payer relationships.
  • Negative Media Exposure: Non-compliance cases attract media attention, leading to public scrutiny and brand damage.
  • Market Share Decline: Reputation damage can result in lost contracts and diminished market position.

Operational Setbacks and Efficiency Losses

  • Workforce Morale: Compliance failures can lead to employee dissatisfaction and high turnover, affecting organizational stability.
  • Service Disruptions: Non-compliance causes operational delays, affecting patient care and payer service efficiency.
  • Imbalanced Medical Loss Ratio (MLR): Post-COVID utilization rates can disrupt the medical loss ratio, leading to financial imbalances. Until underlying process issues are resolved, new technology alone won’t fix these problems.

Protect Your Organization. Invest in Compliance.

Non-compliance in healthcare can lead to severe financial penalties, reputational damage, and operational setbacks, making it essential to prioritize regulatory adherence. The stakes are high, and the consequences of falling short are substantial. To navigate these challenges effectively, strategic support is indispensable.

HealthAxis offers strategic consulting services that specifically emphasize helping healthcare organizations maintain compliance and mitigate risks. Deploy our skilled compliance specialists to fortify your regulatory practices. From entry to senior levels, they ensure stringent adherence to industry standards, mitigating risks and safeguarding your organizational integrity and reputation.

The ever-changing regulatory landscape is no longer a burden. With our compliance expertise, you’re equipped with gap analysis, workflow assessments, and tailored training programs to not only meet but exceed regulatory standards, ensuring peace of mind and industry leadership.

Schedule a call with our experts to learn how we can help fortify your organization against risks and ensure continuous alignment with healthcare regulations.

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

Celebrating Insight and Inspiration: 2024 National Nurses Week Spotlight on HealthAxis’ LPNs and RNs

At HealthAxis, we’re immensely proud of our team’s diverse experiences and expertise. This National Nurses Week, we’re spotlighting some of our incredible staff members who come from nursing backgrounds. Their unique insights significantly enhance our mission in the healthcare technology and services sectors.

Join us as they share heartwarming stories from their nursing careers, advice for aspiring nurses, and how they seamlessly transitioned their clinical expertise to excel in their roles at HealthAxis.

Devan Frison, RN

Concurrent Review Nurse

Shanese Frison, LPN

UM Nurse

Sonja Petermann, RN, BSN, MSM

Manager, Utilization Management

Shantrell Mayo, LPN

Concurrent Review Nurse

Can you share a memorable moment from your time working as an LPN/RN?

A heartwarming moment from my journey was being a preceptor and seeing my preceptors thrive in the nursing world after being terrified to work alone.
– Devan Frison

My patients from my old jobs still send my old company messages about me and always want to keep up with me and letting me know how great of a person I am.
– Shanese Frison

I was the primary nurse for a patient in a coma in the ICU for 6 weeks. She recovered and came to visit me in person many months later. She stated that she could hear everything that was going on while in the coma and said that I was the only one who continually talked to her and explained everything that I was doing as if she were awake. She was so appreciative and that always stuck with me; it still brings tears to my eyes.
– Sonja Petermann

One of the best moments for me is when I was out shopping one day after work, and I ran across a child that I had given vaccinations earlier that day. I had a really hard time with this child and felt bad because the child had to be restrained and was obviously terrified. I did my best to calm and soothe the child but as a nurse we always feel we could have done better. However, when I saw the child in the store that day, he ran up to me and hugged me like I was family and thanked me. I have never forgot that moment or that feeling.
– Shantrell Mayo

 

What advice would you give to someone starting their nursing career today?

Always be open-minded and take in everything. You never know where your nursing career will take you.
– Devan Frison

I would tell them to keep pushing through, when you reach challenges in school or in your career, keep pushing through.
– Shanese Frison

Treat every patient with dignity and respect; always explain their treatment/care and why; and even if in a coma or somnolent, they may hear you so always choose your words wisely.
– Sonja Petermann

Mistakes will be made, it’s how you handle the situation that will determine what kind of nurse you are. Integrity and Accountability are key.
– Shantrell Mayo

How have the skills and experiences you gained as a nurse been beneficial in your current position at HealthAxis?

My clinical experience and skills started in the Emergency Department and other acute settings. The knowledge and experience over the years paved the way for success in my current role in utilization because I am able to paint a picture in my head and understand what happened on the other end of the clinical notes that’s being reviewed for medical necessity.
– Devan Frison

Being a nurse, you learn to multi-task, communicate, and think fast. All those skills come in handy here at HealthAxis.
– Shanese Frison

My clinical background and experiences with patients definitely help in the UM review to know if a patient needs the services being requested. They may not specifically meet criteria, but I know they need that care, so I am an advocate for the patient in my review recommendation to the MD Reviewer. And even though I am not providing direct patient care, there is a real patient behind the medical records I review, and their care may be dependent on my timely and thorough review, so I strive to keep that in mind.
– Sonja Petermann

I have worked in several different areas of nursing, from Geriatric Care, Family Medicine, Women’s Health, to Immunizations. I feel that this has equipped me to look at situations more objectively and helps me to better understand the patient’s needs.
– Shantrell Mayo

Our journey through the heartfelt stories and professional insights of our nursing staff only scratches the surface of the vast expertise within HealthAxis. Each story not only highlights the profound impact of nurses in healthcare but also underlines the invaluable skills they bring to the healthcare technology sector.

As we conclude our National Nurses Week celebration, we are reminded of the critical role nurses play in every sphere of healthcare, including here at HealthAxis, where their insights continue to drive innovation and excellence.

To all nurses, both in traditional roles and beyond, your contributions are truly indispensable. Thank you for the compassion, dedication, and expertise you bring to the healthcare community every day.