Celebrating #InspireInclusion: Part 3 – Creating Inclusive Workspaces: Strategies and Advice

As we reach the culmination of our series in honor of International Women’s Day’s theme, #InspireInclusion, this final installment builds upon the insights and reflections shared in Part 1: Personal Journeys to Enhancing Diversity and Part 2: The Impact of Allyship on Diversity.

In Part 3, we shift our focus to actionable strategies for creating a more inclusive and equitable work environment. Drawing upon the collective wisdom of our HealthAxis staff, we provide guidance and advice for individuals and organizations alike, aimed at fostering a culture where everyone feels valued and empowered.

What advice would you offer to those aiming to foster a more inclusive and equitable work environment?

Consider everyone in everything and unlock the full potential of people coming together to achieve the best outcomes.

Diversity of thought, stemming from individuals with diverse backgrounds, experiences, and perspectives, enriches discussions and fuels innovation. When everyone feels valued and respected, they are more likely to contribute their unique insights and ideas, leading to better decision-making and problem-solving. Companies see improved financial performance, are better able to attract and retain top talent, and adapt to changing market demand.

Embracing inclusivity and equity is a strategic business decision that drives innovation, growth, and success. By harnessing the power of diversity, organizations can create a more vibrant, dynamic, and resilient workplace that benefits everyone involved.

Carmen Alverio

Carmen Alverio
Strategic People Partner

Listening is key. If people feel listened to, then they are more likely to share and contribute. It starts with listening and continues by supporting one another’s opinions with a positive, professional, and respectful attitude.

Beth Doyle

Beth Doyle
Configuration Manager

Leading with empathy is paramount; it’s about actively listening, genuinely understanding diverse experiences, and acknowledging unique challenges. This approach not only cultivates a culture of respect and belonging but also encourages a workplace where every individual feels valued. From my perspective, empathy is the cornerstone of inclusivity, ensuring that our diverse voices contribute to innovation and collective success. I take immense pride in being part of an organization that not only talks the talk but walks the walk when it comes to fostering an environment where every individual is seen, heard, and valued.

Amy Henry

Amy Henry
Senior Director, Marketing

To foster a more inclusive and equitable work environment, educate yourself about diversity issues, listen to diverse perspectives, lead by example, advocate for change, foster a culture of belonging, provide resources and support, and hold yourself and others accountable for promoting diversity, equity, and inclusion. By taking these steps, you can create a workplace where everyone feels valued, respected, and empowered to contribute their unique perspectives, leading to greater innovation and success.

Rebecca Pessel

Rebecca Pessel
Senior Vice President of People

Celebrate the diverse cultures, backgrounds, and experiences of your employees. This can help to foster a sense of belonging and appreciation for diversity. Ensure that all employees have equal access to opportunities for growth and advancement. This includes providing necessary training and resources.

Peggy Dell’Orfano

Peggy Dell’Orfano
Manager, Office of Administration & Executive Assistant

Be open to learning, understanding, and embracing cultural diversities.  We have so much to learn as individuals and leaders.  The best tool for this growth is through our most important resource, which is people.

Kim Bogart

Kim Bogart
Chief Customer Officer

Always seek another person’s opinion on a situation, we don’t have to all agree but we all need to have a safe place to share our voice. We grow by learning from each other.

Tina Shafer

Tina Shafer
Controller

As our blog series celebrating International Women’s Day and Women’s History Month comes to a close, we are reminded that the journey toward inclusivity and equity is ongoing. The advice and strategies shared by our HealthAxis team provide a roadmap for action, but it is up to each of us to bring these practices to life.

Let’s commit to #InspireInclusion every day, making our workplace and community spaces where diversity is not just welcomed but cherished. Together, we can create a brighter, more inclusive future for all.

Navigating the TEFCA Terrain: A Roadmap for Healthcare Payers

In an era of paramount digital transformation, the Trusted Exchange Framework and Common Agreement (TEFCA) emerges as a pivotal beacon for healthcare payers. Established by the 21st Century Cures Act, TEFCA aims to create a standardized methodology for health information exchange across disparate networks.

For healthcare payers, understanding and integrating TEFCA principles into their strategies is not just about compliance; it’s about leveraging opportunities for enhanced efficiency, improved patient outcomes, and streamlined operations.

In this blog, we will delve into the nuances of TEFCA, outlining its fundamental principles, the significant benefits it offers to healthcare payers, and the practical steps that can be taken to align strategies with TEFCA’s overarching goals.

TEFCA’s Impact: Core Objectives and Significance for Healthcare Payers

TEFCA aims to establish a nationwide foundation for secure and interoperable exchange of electronic health information across disparate health information networks. This initiative addresses the long-standing challenge of fragmented data systems, promoting several key benefits for healthcare payers:

  • Improved Care Coordination: Seamless access to a member’s complete medical history, regardless of the provider network, empowers informed decision-making and facilitates better care coordination.
  • Enhanced Administrative Efficiency: Streamlined exchange of administrative data reduces the burden of duplicate data entry and manual processes, leading to improved efficiency and cost savings.
  • Reduced Fraud, Waste, and Abuse: Real-time access to accurate patient information allows for better identification and prevention of fraudulent activities.
  • Empowered Members: Individuals gain greater control over their health information, fostering patient engagement and informed decision-making.

Aligning Your Strategy with TEFCA: A Step-by-Step Guide

While TEFCA participation is currently voluntary, proactively aligning your organization’s strategy is crucial to ensure compliance and reap the full benefits of nationwide interoperability. Here’s a step-by-step guide:

  • Embracing Interoperability: The first stride towards TEFCA alignment involves embracing interoperability standards. Payers should assess their current data exchange capabilities and infrastructure, identifying gaps that may hinder seamless information flow. Investing in technology solutions that support standardized data formats and protocols is essential.
  • Enhancing Data Privacy and Security: TEFCA places a strong emphasis on protecting patient information. Healthcare payers must ensure their data privacy and security measures are robust, compliant, and in line with TEFCA’s requirements. This will require revisiting policies, conducting regular security assessments, and fostering a culture of data protection within the organization.
  • Fostering Collaboration with Providers: Collaboration with healthcare providers is crucial for the successful implementation of TEFCA. Payers should seek to build strong partnerships with providers, facilitating open communication and shared goals. This collaborative approach not only supports TEFCA’s objectives but also enhances the overall quality of care provided to members.
  • Participating in Qualified Health Information Networks (QHINs): Engaging with QHINs is a critical component of TEFCA participation. These networks serve as the backbone of the national health information exchange ecosystem. By participating in a QHIN, payers can access a broader network of health information, improving their ability to manage care and make informed decisions.

Harnessing the Power of Technology and Expertise for TEFCA Readiness

At HealthAxis, we understand the complexities and challenges healthcare payers face in navigating the TEFCA landscape. Our cutting-edge CAPS technology and modern business services, including staff augmentation, consulting, BPO and BPaaS, are designed to support payers in achieving TEFCA compliance while enhancing operational efficiencies and care quality.

From interoperability solutions to comprehensive data management and analytics services, we offer the tools and expertise payers need to thrive in this new era of healthcare information exchange. By partnering with HealthAxis, you gain access to the expertise and resources necessary to embrace the opportunities presented by TEFCA and achieve a future of seamless healthcare information exchange.

Learn more about how we can support your journey towards TEFCA compliance and beyond.

Author:

Chris House
Chris House
Chief Technology Officer
HealthAxis

HealthAxis and InfoMC Announce Strategic Partnership to Revolutionize Healthcare Management

HealthAxis, a leader in health plan administration technology and services, and InfoMC, a pioneer in medical management and behavioral health technology solutions, are proud to announce a strategic partnership that delivers a complete, end-to-end solution enabling organizations to more efficiently orchestrate whole-person care. Leveraging a collective 80+ years of experience in the healthcare industry, this collaboration marks a significant milestone in the integration of cutting-edge administrative technology and services with advanced care management and sets a new standard for comprehensive healthcare delivery.

The partnership brings InfoMC’s innovative technology solutions for behavioral health, care, and utilization management together with HealthAxis advanced core administrative technology and extensive service solutions to create a holistic approach to care. This joint, fully integrated solution simplifies the coordination, authorization and delivery of care to improve health outcomes and increase operational efficiency for all lines of business.

“Through this partnership, HealthAxis and InfoMC are poised to redefine the healthcare landscape. Combining our technological prowess with InfoMC’s innovative care management platform will drive unparalleled innovation in the industry. Our shared commitment to improving healthcare delivery will not only enhance the member experience but also contribute significantly to the advancement of a healthier future.”

Scott Martin

Scott Martin
CEO
HealthAxis

“Together, InfoMC and HealthAxis provide a one-stop shop for whole-person care, delivering a seamless, end-to-end solution integrating medical and behavioral health administration with care management to streamline the care experience for vulnerable populations. Our collaboration enables organizations to more efficiently manage the diverse needs of complex members to improve financial results and the well-being of the people they serve.”

JJ Farook

JJ Farook
Chairman and CEO
InfoMC

The integration between HealthAxis’s AxisCore™ and AxisConnect™ solutions and InfoMC’s next-generation Incedo™ Enterprise Care Management Platform removes data siloes and reduces friction across interdisciplinary teams to support more informed decision-making and facilitate compliance. This synergy will empower healthcare organizations to efficiently coordinate whole-person care to address physical, behavioral, and social determinants of health at the right time and place to remove barriers, improve health equity, and optimize financial and health outcomes.
For more information about HealthAxis and InfoMC, please visit HealthAxis.com and InfoMC.com.

About HealthAxis
HealthAxis is a leader in revolutionizing U.S. healthcare, providing integrated business solutions that support payers, risk-bearing providers, and third-party administrators at every scope and scale. Our portfolio includes AxisCore™, our core administrative technology, and AxisConnect™, a suite of services encompassing BPaaS, BPO, consulting, and staff augmentation. Together, these offerings are designed to optimize operations, boost efficiency, and enhance member engagement. Committed to tackling the unique challenges in healthcare, HealthAxis enhances the experiences of members and providers, driving positive outcomes and contributing to a healthier future. For more information, visit HealthAxis.com.

About InfoMC
InfoMC has more than 25 years of experience driving innovation in the use of behavioral and social determinants and community resources to improve how organizations manage care. Our next-generation care management platform empowers plans and providers to efficiently orchestrate whole-person care—particularly for vulnerable populations—to improve health equity, accelerate time-to-value, and ensure compliance. Available as a fully integrated platform or targeted for care, utilization, behavioral health, or employee assistance/work-life program management, our solution automates and personalizes patient journeys to improve outcomes and the overall member experience and to manage the total cost of care. For more information, please visit www.infomc.com.

Celebrating #InspireInclusion: Part 2 – The Impact of Allyship on Diversity

As we continue celebrating International Women’s Day (IWD) and Women’s History Month under the banner of this year’s IWD theme, #InspireInclusion, we delve deeper into the fabric of inclusivity with Part 2 of our three-part blog series.

Following the personal reflections and contributions explored in Part 1: Personal Journeys to Enhancing Diversity, this installment shifts focus to the cornerstone of inclusivity—allyship. Here, HealthAxis team members share their insights on the crucial role of allyship in promoting diversity and empowerment within our organization.

By emphasizing the transformative power of allies in supporting, understanding, and advocating for each other, we aim to uncover how these actions contribute to a workplace environment where diverse perspectives are not just welcomed but thrive.

How crucial is allyship for inclusivity, particularly in empowering diverse perspectives?

Allies can contribute to creating environments where everyone feels safe, respected, and valued. This can encourage individuals from diverse backgrounds to share their perspectives.

Peggy Dell’Orfano

Peggy Dell’Orfano
Manager, Office of Administration & Executive Assistant

Allyship is absolutely crucial for inclusivity, especially in empowering diverse perspectives. Allies play a vital role in advocating for and supporting individuals from marginalized or underrepresented groups. They use their influence to amplify diverse voices, challenge systemic barriers, and create more equitable opportunities. By actively listening, learning, and taking meaningful action, allies help foster a culture of belonging where everyone feels valued and respected. Additionally, allyship helps to break down stereotypes, promote understanding, and build bridges across differences, ultimately leading to greater innovation, creativity, and collaboration within organizations and society as a whole.

Rebecca Pessel

Rebecca Pessel
Senior Vice President of People

To me, allyship is having one another’s backs. Building trust amongst the team to speak freely, knowing that your managers will listen and have your back and that your team has your interests at heart, is empowering for diverse perspectives. Our teammates must know that it’s safe to state an opinion, even if you are the only one with that opinion, and that it will be listened to and considered to foster allyship. The inclusivity and acceptance of diverse perspectives are fostered by allyship.

Beth Doyle

Beth Doyle
Configuration Manager

I started my career in telecom, which at the time was a very male-dominated industry. I was one of the few women leaders in many organizations, time over time. I was fortunate to have female and male allies who took the time and effort to give me a seat at the table. I see it as a gift that I pay forward every time I can; to open doors for others and to hold the door open for those who come after us. Allyship should not be something we “do.” It’s a gift we pass on to others.

Suraya Yahaya

Suraya Yahaya
President and Chief Executive Officer

To me, allyship expands our growth as individuals. Allyship should be included in our everyday activities, both personally and professionally. Embracing allyship creates an inclusive culture that benefits both individuals and businesses.

Kim Bogart

Kim Bogart
Chief Customer Officer

I believe in asking each member of the group for their insight. Every member has a unique perspective based on their individual journey.

Tina Shafer

Tina Shafer
Controller

In the realm of inclusivity, allyship is indispensable, especially for amplifying diverse perspectives. True allyship transcends passive support, demanding proactive efforts to understand, champion, and elevate underrepresented voices. By actively engaging in allyship, we not only contribute to a more inclusive workplace but also foster an environment where every voice is valued and heard, driving positive change and innovation.

Amy Henry

Amy Henry
Senior Director, Marketing

The stories and insights shared by our team members illuminate the critical role of allyship in building a more inclusive and supportive work environment. Allyship is not just about intentions but actions that make a real difference. As we move forward, let’s carry the lessons of allyship into our daily practices, constantly seeking ways to support and uplift each other. Stay tuned for our final installment, where we will offer practical advice for fostering an equitable and inclusive workplace, drawing from the collective wisdom of our HealthAxis community.

Celebrating #InspireInclusion: Part 1 – Personal Journeys to Enhancing Diversity

Throughout March, HealthAxis joins the global celebration of Women’s History Month and the powerful theme of International Women’s Day: #InspireInclusion. In this three-part blog series, we’ll be featuring the voices of our incredible team members, exploring their experiences and perspectives on fostering a truly inclusive and diverse work environment aligned with the #InspireInclusion theme.

This three-part series seeks to celebrate and encourage actionable insights into fostering an environment where every voice is heard and valued.
In this first installment, we delve into the personal journeys and practices of our team.

In your role at HealthAxis, how do you contribute to enhancing a culture of inclusion and diversity, drawing from your own experiences or personal values?

 

One of the things I enjoy about working at HealthAxis is the culture of inclusion and diversity. We are lucky to have a diverse staff that is listened to and valued. What I’ve learned over the last 30 years of experience working as a member of a team is that everyone on a team has their own individual strengths and viewpoints to bring to the table. If we allow everyone’s thoughts and opinions to be heard, we are much stronger as a combined team than as an individual. Different people will see a problem from a different perspective. Some will notice details that others will not. These diverse perspectives create a more comprehensive team to tackle problems. Some may be analytical, some creative, some supportive, and some persuasive. In my role as a Configuration Manager at HealthAxis, I’ve spent time getting to know the individuals on the Configuration Team, as well as leaders from around the company. Who has strength in analytics? Customer service? Product knowledge? Historical knowledge of the customers? And so on. The strength of a team shores up one person’s weakness with another person’s strength. We share our expertise, historical knowledge, or talent with one another, and with our combined strengths, we can tackle complex problems and create solutions better together!

Beth Doyle

Beth Doyle
Configuration Manager

In efforts to keep things interesting, as well as educational, during our daily meeting, an observance of the day along with a visual, brief explanation, quote, or message is announced and emailed. (i.e. “Pay a Compliment” Day) Some observances acknowledged and celebrated cultural differences, others led to open conversation, and a few encouraged acts of participation. Colleagues are encouraged to share their personal interests and/or experiences on the topic, bringing diversity into discussions. This simple addition to our day grants us the option and opportunity to express ourselves, be included, and feel valued based on our individuality.

Sharon Pena

Sharon Pena
Operations Research Analyst

I treat all users with equal respect and consideration, ensuring that everyone feels heard and valued.

Peggy Dell’Orfano

Peggy Dell’Orfano
Manager, Office of Administration & Executive Assistant

At HealthAxis, my leadership roles provide me with the opportunity to interact with individuals from many backgrounds. I appreciate learning more about the people I interact with and hearing their stories. Everyone has a story, and hearing this from others allows us to journey into cultures and backgrounds we may not otherwise see and experience firsthand. Actively listening and engaging in these conversations expands my personal and professional growth.

Kim Bogart

Kim Bogart
Chief Customer Officer

It’s my personal belief that diversity makes us stronger. When each person brings their own skills and perspectives to the table, we solve problems faster, we are more creative and thoughtful in our actions and we gain from the richness of each other’s experiences. I see my role twofold: bringing visibility to the value of diversity at each and every level in the company and to support my team and the organization in making courageous decisions that value diversity in all its forms.

Suraya Yahaya

Suraya Yahaya
President and Chief Executive Officer

I believe all voices should be heard, and I provide a safe place for all my team members to voice their opinions. Kindness wins every day.

Tina Shafer

Tina Shafer
Controller

Studies have shown time and time again that the best companies in business performance, employee happiness, and customer satisfaction are those that have the most diverse workforces at all levels of the organization. Throughout my career, I have seen a diversified workforce in action and have had the privilege to work alongside some of the brightest and most talented women in our industry. These women have challenged me and have no doubt made me a better leader, business partner, and person in everyday life.

Chris House

Chris House
Chief Technology Officer

As Vice President of People Operations, I spearhead efforts to cultivate a culture of inclusion and diversity by implementing inclusive policies, developing training, fostering recruitment and retention strategies that prioritize diversity, supporting employee feedback, advocating for inclusive leadership development, promoting transparent communication, and continuously evaluating and improving our people initiatives. Through these efforts, I aim to create a workplace where every individual feels valued, respected, and empowered to contribute their unique perspectives, driving innovation and organizational success.

Rebecca Pessel

Rebecca Pessel
Senior Vice President of People

At HealthAxis, my marketing role allows me to weave inclusion and diversity into our brand’s narrative, reflecting the rich tapestry of our community. By intentionally showcasing diverse perspectives and experiences, we not only fuel creativity and innovation but also ensure our marketing strategies resonate broadly. Drawing from my personal journey within diverse teams, I’ve seen firsthand how embracing varied viewpoints leads to richer insights and groundbreaking solutions, ultimately strengthening our connection with our audience and reinforcing our commitment to an inclusive culture.

Amy Henry

Amy Henry
Senior Director, Marketing

Our journey through the narratives of HealthAxis team members underscores the significance of individual contributions to our collective culture of inclusion and diversity. As we continue to learn from these personal stories, we are reminded of the power of our actions and commitments in shaping an inclusive workplace. Join us in our next post as we explore the vital role of allyship in amplifying diverse perspectives and empowering every member of our community.

5 Signs You’re Not Ready for Your CMS Part C and Part D Program Audit Now

In the complex landscape of healthcare administration, being prepared for a CMS (Centers for Medicare & Medicaid Services) Parts C and Part D Program Audit is paramount for healthcare payers. These audits are critical for ensuring compliance with federal regulations and maintaining the integrity of healthcare services. However, several indicators can suggest an organization may not be fully prepared for such scrutiny.

In this blog, we will examine five critical signs that point toward potential vulnerabilities in your CMS audit readiness.

1. Inadequate Documentation and Data Management

At the heart of audit preparedness is the meticulous management of documentation and data. This not only includes the completeness and timeliness of essential records such as contracts, policyholder information, claims, and reimbursement protocols but also extends to the adept handling of audit universes—the comprehensive datasets required for a CMS audit. Inadequate or outdated documentation compromises your organization’s ability to articulate a seamless narrative of compliance, reflecting poorly on operational diligence.

Furthermore, if a healthcare payer faces challenges in swiftly compiling, reviewing, and perfecting these critical datasets before submission, it indicates a significant gap in data management capabilities. The proficiency to promptly access, accurately assemble, and thoroughly vet documentation and data underscores its fundamental role in achieving a successful CMS audit outcome.

You must ensure that all records not only exist but are also up-to-date, accurately mirror current operations, and meet the most recent CMS guidelines, such as those outlined in:

2. Absence of a Continuous Compliance Culture

The essence of enduring CMS audit readiness lies not merely in the presence of a compliance program but in the cultivation of a continuous compliance culture. The lack of such a culture, where compliance is not just an occasional focus but a constant and integral part of daily operations across all departments, starkly signals unpreparedness for a CMS audit.

A truly effective compliance program extends beyond structured frameworks and periodic checks; it is woven into the fabric of a health plan’s ethos, ensuring that every department not only adheres to compliance mandates but also proactively owns and champions these principles throughout the year.

This continuous compliance culture, as outlined in the CMS Compliance Program Guidance for Part C and Part D, underpins the proactive identification and mitigation of risks, fostering an environment where regulatory adherence is a shared responsibility and a perpetual endeavor, thus significantly bolstering your organization’s readiness for a CMS audit.

3. Insufficient Preparation, Practice, and Staff Training

The complexity and ever-evolving nature of CMS regulations demand not just a well-informed staff but also a rigorously prepared and practiced organization. Insufficient training, coupled with a lack of comprehensive preparation and practice, such as engaging in mock audits, reviewing CMS Best Practice Tips documents, and conducting thorough practice sessions aligned with CMS Audit Protocol guidance, signals a significant readiness gap.

Training programs must go beyond mere information dissemination to include documentation of training sessions and evidence of staff engagement and understanding. This ensures that all personnel, particularly those in compliance, appeals and grievances and claims processing roles, are not only conversant with the current regulations but are also adept at applying this knowledge in practice. Moreover, the integration of internal audits and practice webinars into the training regimen serves as a critical component in making all systems and processes audit-ready, thereby solidifying your organization’s compliance framework and readiness for a CMS audit.

CMS Part C and Part D Program Audit Checklist: Be Prepared for Success

4. Poor Audit History, Non-Compliance Issues, and Lack of Coordination

A track record marked by audit challenges or findings of non-compliance is a glaring red flag, signaling deeper systemic issues within an organization’s compliance framework. Such historical non-compliance can have severe repercussions, extending far beyond the immediate audit findings.

Non-compliant program audits can lead to significant financial penalties, loss of accreditation, or even legal action. Additionally, it can tarnish the organization’s reputation, eroding trust among stakeholders and potentially leading to loss of business opportunities.

However, addressing these issues requires more than just a reactive approach. It necessitates proactive measures to foster a culture of compliance, including robust communication and coordination across departments and with First-Tier, Downstream, and Related Entities (FDRs).

The absence of regular, structured forums for discussing compliance matters, sharing regulatory updates, and strategizing on responses to audit inquiries can exacerbate unpreparedness and contribute to recurring compliance failures. It’s crucial not only to dissect and understand the underlying causes of past non-compliance but also to establish robust channels for cross-departmental communication and coordination. By doing so, you can ensure that your organization not only rectifies previous shortcomings but also builds a more cohesive and responsive compliance infrastructure capable of withstanding the scrutiny of future CMS audits.

5. Lack of Audit Team Readiness and Defined Audit Scope

Navigating a CMS audit successfully hinges on having well-prepared audit teams with clear roles, responsibilities, and communication pathways, as well as a precise understanding of the audit’s scope and requirements, as noted in the CMS Program Audit Process Overview. The absence of well-defined audit teams or the lack of active compliance involvement in the audit process can significantly undermine your organization’s readiness. It is crucial for audit teams to not only be delineated but also supported by a compliance presence that provides real-time feedback and guidance throughout the audit activities. This ensures that efforts are accurately aligned with the audit’s focus areas, preventing misdirection and filling potential readiness gaps.

Moreover, uncertainty regarding the audit’s scope and the specific operational aspects under review can lead to inefficient preparation. Healthcare payers must endeavor to gain a comprehensive understanding of the audit’s breadth, the criteria for evaluation, and the requisite documentation and evidence, thereby ensuring that the preparation is targeted and effective. This dual focus on team readiness and audit scope clarity is indispensable for fostering a conducive environment for audit success, demonstrating a proactive and engaged approach to compliance and audit preparedness.

Moving Towards Audit Success: Your Next Steps

Recognizing these signs of potential unpreparedness is the first step towards fortifying your organization against the rigors of a CMS audit. If you require specialized expertise, HealthAxis is prepared to step in.

Our consulting services go beyond basic assessments, aiming to:

  • Address specific gaps in your compliance infrastructure.
  • Enhance your staff training programs.
  • Ensure that your documentation meets the highest standards of completeness and accuracy.

Moreover, HealthAxis offers comprehensive staff augmentation services to complement your team’s capabilities seamlessly. Our experienced professionals integrate with your existing staff, providing additional support where needed to ensure readiness for the audit process.

Additionally, we provide Business Process as a Service (BPaaS) and Business Process Outsourcing (BPO) capabilities, enabling you to:

  • Scale your operations efficiently and effectively.
  • Maintain compliance standards.

With HealthAxis, you can transform the challenge of CMS audit readiness into an opportunity to demonstrate your commitment to compliance and operational excellence. Partner with us to achieve not just readiness but also confidence in facing your next CMS audit. Learn more about how HealthAxis can help you in your journey toward audit success.

Author:

Milonda Mitchell
Milonda Mitchell
Compliance Officer
HealthAxis

New CMS Prior Authorization Final Rule: Is Your Technology and Operations Ready?

The healthcare landscape is constantly evolving, and the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F) introduces significant changes, particularly in streamlining prior authorization (PA) processes for medical services. This rule primarily impacts Medicare, Medicaid, and certain health insurance issuers under the Affordable Care Act, and commercial health plans are excluded from these mandates.

However, it is worth noting that there is a compelling case for commercial plans to voluntarily adopt the CMS-mandated PA timelines. By aligning with these standards, commercial plans can significantly streamline PA and care management processes, advancing care and quality outcomes for all members served.

Setting the Stage for Change

This new rule brings a wave of changes, impacting technology, operations, and overall workflow for healthcare payers, but the transition is staged across 2026-2027:

  • 2026: Operational provisions kick in, requiring faster PA decisions (72 hours for urgent, 7 days for standard) and specific denial reasons for easier resubmission.
  • 2027: API development ramps up, with payers building functionalities to share patient data across platforms and provide patients with access to their information through the Patient Access API.

While adapting can seem daunting, it also presents an opportunity to embrace innovative solutions like core administrative processing systems (CAPS) and streamline PA processes.

Understanding the Challenges

The CMS-0057-F rule sets forth mandates that significantly affect the prior authorization landscape, introducing both opportunities and hurdles:

  • Stricter Timeframes: The rule demands quick turnaround times for prior authorization decisions—72 hours for urgent requests and 7 days for standard ones, challenging payers to ensure efficiency in processing.
  • Enhanced Transparency and Accountability: Alongside requiring detailed reason codes for denials, CMS mandates payers to publicly report specific PA process-related compliance metrics annually, starting January 1, 2026. These metrics, including the percentage of requests approved and denied, the percentage approved post-appeal, and the average time from submission to decision, must be posted on their websites by March 31, 2026. This not only promotes better communication but also enables providers to expedite resubmissions for approval.
  • Data Sharing Expansion: The inclusion of prior authorization data in Patient Access APIs underscores the need for advanced data management and ensures that information is readily accessible, further enhancing patient care coordination.

These mandates aim to enhance patient care but pose significant operational challenges for payers, especially where manual processes are prevalent. Adapting to these changes is crucial to avoid compliance issues and improve stakeholder satisfaction.

Optimizing Your Technology Tools

In response to the CMS Final Rule, healthcare payers are tasked with a comprehensive reassessment of their PA, CAPS, and care management systems. Aligning technology, workflows, policies, and procedures with the mandated timelines for both urgent and non-urgent care requests is critical. This thorough review is pivotal in ensuring your operations meet new regulatory demands, thereby boosting efficiency and enhancing patient care.

CAPS technology is fundamental within the infrastructure of healthcare payers, ready to meet the challenges presented by the evolving regulatory environment. The transition to standardized APIs and the requirement for real-time data exchange necessitate extensive updates to existing CAPS frameworks.

Key focus areas include:

  • Integration Capabilities: To ensure compliance with standardized API requirements and facilitate interoperability across various healthcare platforms, CAPS systems must feature advanced integration capabilities.
  • Automation and Efficiency: The demand for immediate decision-making necessitates the incorporation of heightened automation within CAPS systems, which will minimize manual processes and expedite the prior authorization procedure.
  • Data Security and Compliance: With an increase in data exchange, CAPS technology must include stringent security protocols to safeguard sensitive patient information, in line with HIPAA and other regulatory guidelines.
  • Care Management: The Final Rule emphasizes the importance of advanced care management technologies and tools within CAPS systems, aimed at improving care coordination and enabling healthcare payers to offer more tailored and effective care management strategies, thereby enhancing patient health outcomes.

Additionally, with the CY 2027 reporting requirements on the horizon for both the MIPS payment year and the Medicare Promoting Interoperability Program, healthcare payers must adapt to the simplified Electronic Prior Authorization Measures. Transitioning from a complex numerator/denominator framework to a straightforward yes/no format, these measures necessitate either a positive report or an exemption claim. This change highlights the need for payers to refine their systems not only for operational efficiency and improved care delivery but also to ensure their reporting capabilities meet these streamlined requirements, aligning with the Final Rule’s objective to boost healthcare efficiency and patient outcomes.

Operational Impacts for Healthcare Payers and Members

The final rule’s mandates will have far-reaching impacts on the operational dynamics of healthcare payers and the experiences of their members.

  • Operational Efficiency: Healthcare payers will need to streamline their operational workflows to accommodate the faster, more efficient prior authorization processes mandated by the rule. This includes investing in CAPS and care management technology upgrades and training staff on new protocols.
  • Member Experience: Members stand to benefit from quicker prior authorization decisions and increased transparency in their care journey. The enhanced data-sharing capabilities will enable better coordination of care, improved access to necessary treatments, and a more informed healthcare experience.
  • Compliance and Strategic Planning: Healthcare payers must carefully plan to meet the January 1, 2026, implementation deadline for key provisions, with an extended deadline of January 1, 2027, for API requirements. This involves strategic investments in CAPS technology, compliance efforts, and potential partnerships with technology providers.

Taking the First Step

The CMS Interoperability and Prior Authorization Final Rule heralds a new era in healthcare administration, demanding agility, foresight, and a commitment to enhance patient care from healthcare payers. Navigating these changes requires not just compliance, but a strategic overhaul of existing systems and processes to embrace the efficiencies offered by advanced technological solutions.

At HealthAxis, we understand the complexities and challenges this new rule presents. With our industry-leading CAPS technology, AxisCore™, we are uniquely positioned to guide healthcare payers through this transformative period. Our extensive expertise in the healthcare domain, combined with the sophisticated capabilities of AxisCore™, ensures that we can offer solutions that are not only compliant with the new mandates but also tailored to meet the specific needs of our clients.

Learn more about our technology solution and how we can help you navigate the new landscape of prior authorization, improve operations, and ultimately, deliver better care for your members.

Author:

Lisa Hebert

Lisa Hebert
Senior Vice President of Product Strategy and Management
HealthAxis

AEP Post-Enrollment Reflections Part 3: Harnessing AEP Data – Strategic Advancements for Medicare Plans

In the dynamic world of Medicare, the Annual Election Period (AEP) serves as a critical source of data, offering invaluable insights that can inform and transform future strategies. For Medicare plans, effectively leveraging AEP data is essential for improving service delivery, operational efficiency, and beneficiary satisfaction.

In Part 1 and Part 2 of this three-part blog series, we delved into the complexities of AEP audits. We examined the successes and shortcomings of past strategies and discussed methods for leveraging these insights to forge a path to future triumphs. We also explored the often-overlooked significance of post-enrollment data, underscoring its potential to inform and transform healthcare plan strategies.

In this final installment, we turn our focus to the overarching significance of AEP data. We will outline key strategies for collecting, analyzing, and utilizing this data to refine Medicare plan offerings and operations.

Deciphering Medicare Data

AEP generates a wealth of data, each piece holding potential insights into member behavior, preferences, and needs. This data includes but is not limited to:

  • Enrollment numbers
  • Demographic information
  • Channel preferences
  • Member feedback
  • Service interaction records
  • Member Retention Drivers

The significance of this data lies not only in its volume but in its variety and depth.

Ensuring data quality and relevance is paramount. Health plans should implement rigorous data validation and cleaning processes to ensure accuracy. High-quality data is the foundation of sound decision-making and strategic planning.

Innovative Data Analysis for Medicare Plans

Innovative data analysis stands as a cornerstone for Medicare plans aiming to fully leverage the insights buried within AEP data. To navigate and make sense of this wealth of information, a multifaceted analytical approach is essential. Descriptive analytics play a crucial role in painting a clear picture of past enrollment patterns and member behaviors, offering a historical perspective that lays the groundwork for strategic planning.

Beyond understanding what has happened, predictive analytics steps in to forecast what is likely to happen, using historical data to predict future trends and member needs. This forward-looking analysis is invaluable for Medicare plans as it enables proactive adjustments to services and offerings, ensuring they remain aligned with beneficiary expectations.

The advent of advanced analytical techniques, particularly machine learning, has transformed the landscape of data analysis for Medicare plans. Machine learning algorithms can sift through complex datasets to identify subtle patterns and correlations that might escape traditional analysis, providing deeper, more nuanced insights. This level of analysis empowers Medicare plans to customize and enhance their services with a precision that was previously unattainable, leading to more personalized and effective beneficiary engagement.

Strategic Applications of AEP Data

The strategic deployment of insights from AEP data transcends basic plan performance, profoundly affecting Medicare members’ satisfaction and engagement. By meticulously analyzing AEP data, Medicare plans can unveil deep insights into member behaviors, preferences, and needs, enabling a more member-centric approach in various facets:

  • Personalized Communication: Tailoring communication to member preferences enhances engagement.
  • Streamlined Enrollment: Simplifying the enrollment process improves member experience.
  • Service Enhancements: Addressing specific service needs boosts satisfaction.
  • Benefit Optimization: Aligning benefits with member needs enhances plan appeal.
  • Operational Improvements: Streamlining operations benefits members directly.
  • Proactive Health Programs: Using analytics for early interventions improves outcomes.
  • Community Engagement: Developing programs based on member interests fosters support.

Data-driven insights inform strategic decisions across all plan aspects, from resource allocation to service development, ensuring alignment with member needs and market dynamics.

Empowering Decision-Making with Data

Integrating AEP data insights into decision-making processes empowers health plans to make informed, strategic choices. By placing AEP data at the core of decision-making, from resource distribution to the development of services, health plans can align their strategies with actual member needs and market dynamics.

This data-centric approach not only enhances short-term post-AEP strategy refinements but is also indispensable for long-term planning. It enables health plans to anticipate market trends, adapt to evolving member expectations, and proactively prepare for upcoming AEPs. In the competitive landscape of healthcare, leveraging data for decision-making is key to maintaining a strategic edge, ensuring health plans are well-positioned to meet challenges and seize opportunities.

Technological Empowerment for Data Analysis

Technological empowerment is pivotal for the in-depth analysis and application of AEP data within Medicare plans. To fully harness the wealth of information generated during the AEP, Medicare plans must invest in state-of-the-art data management and analysis platforms. These technological solutions are not just tools but vital assets that enable the efficient processing and insightful analysis of vast amounts of data. By adopting advanced analytics software, Medicare plans can unravel complex data patterns, uncovering actionable insights that drive strategic decisions.

Moreover, the integration of technologies such as machine learning and artificial intelligence can take data analysis to new heights, offering predictive insights that anticipate member needs and market trends. This proactive approach allows Medicare plans to stay ahead of the curve, adapting to changes and member expectations more swiftly and effectively.

The right technology also streamlines the data analysis process, making it more accessible to decision-makers across the organization. User-friendly interfaces and intuitive reporting tools translate complex data sets into clear, actionable information, empowering teams to make informed decisions rapidly.

Charting Success: Transform Data into Strategy with HealthAxis

Leveraging data from AEP is not just a tactical move; it’s a strategic imperative for healthcare plans aiming for excellence. In an industry driven by member needs and regulatory changes, being data-driven is the key to staying relevant and successful.

At HealthAxis, we specialize in transforming AEP data into meaningful strategies. Our expertise in data analytics and extensive experience serving the Medicare and Medicare Advantage organizations uniquely position us to assist health plans in this crucial task. Our consulting services are designed to guide healthcare plans through this critical process, offering expert analysis, strategic advice, and practical solutions.

Partner with HealthAxis to cultivate a culture of data-driven excellence and propel your health plan to new heights. Schedule an assessment today

Technology Investments Shaping the Future for Healthcare Payers

In an era where technological advancement shapes the landscape of industries, healthcare remains at the forefront of significant transformation. The findings from the 2024 Gartner CIO and Technology Executive Survey provide a clear directive for healthcare payers: invest in technology to enhance operational efficiency, improve stakeholder experiences, and ensure sustainability in an ever-evolving market.

Three core areas emerge as focal points for investment:

  • Core Administrative Processing Systems (CAPS)
  • Interoperability
  • Consumer Experience Capabilities

In this blog, we will take an in-depth look at these pillars which are essential for healthcare payers committed to adapting and thriving in the digital age.

Transforming Core Administrative Processing Systems

The modernization of CAPS is a critical investment for 59% of healthcare payers, according to the Gartner survey.1 The drive towards upgrading these foundational systems stems from the need to replace or augment legacy systems that no longer suffice in meeting the complex demands of today’s healthcare landscape.

Modern CAPS offers the flexibility required to adapt to changing regulations, provide better access to data, and enable real-time claim adjudication capabilities. These advancements are not mere enhancements; they are necessary for organizations to deliver the level of service that members and providers have come to expect. Through the integration of modern CAPS, healthcare payers can achieve a level of operational agility and efficiency that was previously unattainable, setting a new standard for excellence in administration.

HealthAxis is responding to this critical industry need with our proprietary CAPS technology, AxisCore™. Designed to transform the backbone of payer operation and meticulously crafted to optimize benefits administration, healthcare claims processing, and overall health plan management, our platform offers unparalleled flexibility, enabling healthcare payers to adapt quickly to changing regulations and market demands. With advanced data management capabilities, our solutions ensure that actionable insights are readily available, facilitating informed decision-making. Moreover, our emphasis on real-time processing capabilities ensures that claims adjudication is both efficient and accurate, enhancing the overall experience for providers and members alike.

Advancing Interoperability for Collaborative Care

Interoperability is a key strategic focus for 59% of healthcare payer CIOs1, 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.

This capability is not just a regulatory requirement; it represents an opportunity to enhance care coordination, streamline operations, and ultimately improve patient outcomes. By investing in interoperability, payers can facilitate a more integrated healthcare environment where information flows freely between payers, providers, and patients, enabling more informed decision-making and efficient care delivery processes.

At HealthAxis, we are committed to advancing interoperability within the healthcare ecosystem. Our CAPS technology, AxisCore™, is designed to facilitate seamless data exchange throughout the healthcare ecosystem, fostering a more collaborative and efficient healthcare environment. Our service-oriented design and extensible APIs allow for easy data access and third-party collaboration. By enabling the integration of clinical data across diverse platforms, HealthAxis empowers payers to optimize their operations, improve compliance, and support value-based care initiatives.

Enhancing Consumer Experience through Technology

The push towards improving consumer experience capabilities is evident, with 53% of payers focusing on this area. 1 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.

The commitment to enhancing consumer experience through technology extends well beyond merely adopting new tools; it encompasses the strategic integration of these innovations into a unified system that ensures a frictionless and engaging user journey. Incorporating artificial intelligence (AI) as a prime example, this approach leverages advanced algorithms and machine learning to personalize interactions, predict user needs, and streamline processes, thereby enriching the overall consumer experience. Through such innovations, payers can build deeper connections with their members, significantly enhancing satisfaction and cultivating loyalty in a market where competition is fierce and consumer expectations are ever rising.

Navigating the Path Forward: A Partner in Progress

As healthcare payers navigate the complexities of digital transformation, the focus on CAPS, interoperability, and heightened consumer experience capabilities provides a roadmap for strategic investment. These areas represent not just opportunities for technological advancement but also the pillars upon which a more efficient, collaborative, and consumer-centric healthcare system can be built.

By prioritizing these investments, healthcare payers can position themselves as leaders in the drive toward a more integrated, responsive, and patient-focused healthcare ecosystem. The journey towards transformation is complex, but with a clear vision and strategic investments, the future of healthcare is bright.

Choosing HealthAxis means partnering with a visionary leader dedicated to your organization’s growth and success in the evolving healthcare landscape. With our comprehensive solutions and expertise, we stand ready to guide you through the complexities of digital transformation, ensuring a future where healthcare is not only more connected and efficient but also more responsive to the needs and expectations of those it serves. Together, let’s shape a brighter, more innovative future for healthcare. Learn More

Author:

Lisa Hebert

Lisa Hebert
Senior Vice President of Product Strategy and Management
HealthAxis

 

Source:
1. 2024 Gartner CIO and Technology Executive Survey

AEP Post-Enrollment Reflections Part 2: Leveraging Medicare Insights for Enhanced AEP Success

In the specialized arena of Medicare plans, the Annual Election Period (AEP) represents more than a key enrollment window; it’s a treasure trove of insights waiting to be unlocked. The period following enrollment is ripe with opportunities to extract valuable data that can profoundly shape future AEP strategies, making them more aligned with the needs and behaviors of Medicare beneficiaries.

In Part 1 of this three-part blog series, we delved into the intricacies of AEP audits, assessing what worked, and what didn’t, and how to leverage these insights for future success. In Part 2, we will explore the critical importance of capturing and utilizing post-enrollment data, a crucial step often overlooked by many healthcare plans.

Collecting Key Data for Informed Decisions

The foundation of post-AEP reflection is robust data collection. For Medicare plans, this involves compiling a wide array of information, from demographic details of enrollees to nuanced behavioral insights during the enrollment journey. Essential data points include enrollment figures, preferred communication channels, beneficiary feedback, and interactions with service touchpoints.

Efficient data gathering combines quantitative and qualitative approaches. While analytics tools can capture enrollment trends and patterns, qualitative insights emerge from beneficiary surveys, feedback, and direct interactions. Utilizing advanced CRM systems and data analytics platforms is crucial for assembling a comprehensive dataset that reflects the unique dynamics of Medicare enrollment.

Deciphering Trends for Medicare-Specific Intelligence

With a rich dataset at hand, the focus shifts to analysis—sifting through the data to unearth trends and patterns pertinent to Medicare beneficiaries. An increase in enrollments through specific channels, for example, may indicate preferred engagement methods, while feedback can spotlight areas for enhancement.

The analysis demands sophisticated tools and expert interpretation. Data visualization software can reveal patterns, but the nuanced understanding of Medicare plan dynamics requires seasoned analysts. This expertise is crucial in translating data into strategic insights that can shape future AEP approaches. To dive deeper into optimizing your audits, check out our blog “Is Your Post-AEP Audit Simply Checking Boxes, or Unveiling Hidden Gems?” where we explore how transformative audits can elevate your strategy in four key areas.

From Intelligence to Strategy: Enacting Data-Driven Decisions

Leveraging post-enrollment data is crucial not just for engagement but also for enhancing member retention. Analysis that uncovers the impact of personalized communication on retention, for example, can lead to prioritizing more tailored outreach in subsequent AEP strategies. Identifying valued services or benefits through data can guide targeted retention programs, increasing member satisfaction and loyalty.

Insights into disenrollment reasons are equally valuable, offering a clear direction for strategy refinement. If data highlights confusion around benefits as a cause for churn, improving transparency in communication becomes a strategic focus for the next AEP, aiming to reduce disenrollment rates.

By integrating data-driven insights on both acquisition and retention into AEP strategies, healthcare plans can ensure a balanced approach that not only attracts new members but also retains existing ones, fostering sustained success in the Medicare market.

Engaging Stakeholders with Insights

Data-driven insights are most effective when they are shared and understood across the organization. Presenting these findings to key stakeholders—from executive teams to marketing and customer service departments—is essential. The presentation of data should be clear, concise, and tailored to the audience. Using visual aids like charts and graphs can make the data more accessible and engaging.

The insights should not just be presented; they should be a catalyst for discussion and brainstorming. Encouraging stakeholders to ask questions and contribute ideas on how to apply these insights ensures a more comprehensive strategy development. This collaborative approach helps in aligning the organization’s goals with data-driven strategies.

Leveraging Data: Shaping Next-Gen AEP Strategies for Medicare

The post-AEP phase is a strategic opportunity to harness insights for future Medicare plan success. By adeptly gathering, analyzing, and applying data, Medicare plans can refine their engagement strategies, better meet beneficiary needs, and achieve superior enrollment outcomes.

HealthAxis stands at the forefront of transforming post-AEP data into actionable strategies for Medicare plans. Our expertise in data analytics and Medicare-specific challenges equips us to guide plans through this essential phase, offering in-depth analysis, strategic counsel, and practical solutions.

Partner with HealthAxis to turn your post-enrollment insights into a blueprint for future AEP triumphs. In the dynamic landscape of Medicare plans, a data-driven approach isn’t just advantageous—it’s essential for staying competitive. Schedule an assessment today.