Author: Victoria Bucci

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.

 

Ethics, Equity, & Data: The Core of Artificial Intelligence in Healthcare

The healthcare industry is poised for a transformative era driven by artificial intelligence (AI). AI’s role in automating tasks and generating insights has the potential to drastically improve efficiency, accuracy, and, ultimately, health plan member care. However, amidst this wave of technological enthusiasm, it’s crucial to underscore that AI’s effectiveness is contingent upon its foundational principles: ethics, equity, and data quality.

In this blog, we will explore how these core principles not only support but fundamentally enable the responsible application of AI in healthcare

Ethical AI: The Backbone of Trustworthy Healthcare Technology

The use of AI in healthcare raises important ethical considerations, especially as AI algorithms are trained on vast datasets. These datasets often carry inherent biases, which, if not addressed, can be perpetuated by AI systems. For instance, imagine a hypothetical scenario where claims processing software is developed using historical data that reflects unequal healthcare access. Such an AI system could inadvertently continue to propagate these disparities, leading to unfair outcomes for certain demographics. The role of ethics in AI is thus to ensure that these technologies are transparent, accountable, and fair to all users.

To achieve ethical AI, healthcare organizations must implement systems that are compliant with regulations and proactive in identifying and addressing biases. This involves establishing a robust framework for continuous learning and adaptation, ensuring that AI decisions are made with fairness and integrity. Moreover, ethical AI practices are vital in maintaining the trust of patients and healthcare providers, as they rely on these systems for critical healthcare decisions.

Equity: Ensuring AI Serves All Demographics

Equity in AI refers to the unbiased application of technologies across all demographics. Historical data in healthcare is rife with biases, which can lead AI systems to reinforce existing inequalities if these data issues are uncorrected. This is particularly critical in healthcare, where disparities can have significant impacts on patient care outcomes.

A commitment to equity in AI entails designing systems that recognize and correct historical biases in the data rather than replicating them. This approach not only fulfills a moral obligation but also enhances the overall effectiveness and reliability of healthcare services by ensuring that AI-driven solutions cater equitably to all member groups.

Data Quality: The Foundation of Effective AI

The axiom “garbage in, garbage out” resonates deeply with AI development, where the quality of input data directly determines the quality of output. In healthcare, the integrity and accuracy of data fed into AI systems are paramount. High-quality, well-curated data is essential for training AI models that are effective and dependable.

In a theoretical example, high data quality in claims management software would ensure that claims are processed efficiently and accurately, minimizing errors and reducing the administrative burden on healthcare providers and payers. Maintaining stringent data quality standards is crucial for enabling AI systems to perform their intended functions reliably and effectively.

Building a Responsible AI Future

At HealthAxis, our journey into the realms of AI is driven by the aspiration to lead transformative change in healthcare. Our approach is not only about creating smarter systems but also about ensuring these innovations are deeply personalized to meet the unique needs of each member. The principles of ethics, equity, and data quality are integral to our development strategy, shaping the way we envision the future of healthcare technology.

As we explore AI’s capabilities, we are committed to enhancing solutions like our claims management software with these principles at the forefront. This ensures that as we move forward, our technologies enhance operational efficiencies in an ethically sound, equitable, and reliable manner.

Learn more about how our innovative solutions are transforming healthcare. Together, we are forging a path toward a future where technology elevates every aspect of member care.

Author:

Chris House
Chris House
Chief Technology Officer
HealthAxis

Insights from the 2024 HIMSS Conference: Exploring the Future of Healthcare Technology

The HIMSS Global Health Conference & Exhibition, held in Orlando, Florida, from March 11 to 15, 2024, provided a profound glimpse into the current and future states of healthcare technology. This pivotal event brings together industry leaders and innovators to discuss, offering a glimpse into the latest advancements and future trends shaping the industry, and this year’s conference was no different.

In this blog, we will explore the top takeaways identified by Gartner related to trends, challenges, and opportunities in clinical technologies:

  • Artificial Intelligence (AI)
  • Virtual care
  • Electronic health records (EHRs)

The Practical Shift in AI Applications

Presenters emphasized the importance of AI governance, a framework that ensures the safe and effective use of AI in healthcare. This governance structure should encompass an evaluation framework for both internally developed and externally sourced AI solutions. This framework would assess factors like accuracy, bias, and potential unintended consequences. Additionally, ongoing monitoring tools and processes are crucial for continuously evaluating the performance of AI models in real-world use.

The lack of industry-wide standards for AI development creates challenges. In the absence of such standards, many organizations have been forced to develop their own evaluation and monitoring processes. Further complicating matters, the U.S. Office of the National Coordinator for Health Information Technology’s (ONC) recent HTI-1 rule, aimed at increasing transparency in AI development, only applies to a limited segment of the industry – U.S.-based, ONC-certified developers (e.g., EHR vendors). Additionally, concerns have been raised regarding the feasibility of meeting the rule’s aggressive timelines.

Recognizing the need for broader collaboration, industry stakeholders are forming alliances to address these challenges. Initiatives like the Trustworthy & Responsible AI Network (TRAIN), spearheaded by Microsoft at HIMSS, aim to establish best practices for AI development, deployment, and monitoring. This consortium, comprised of leading healthcare organizations, seeks to ensure the responsible and equitable use of AI across the entire healthcare landscape.

These efforts highlight the industry’s commitment to harnessing the power of AI for good. By prioritizing responsible development and fostering collaboration, healthcare can leverage AI to deliver exceptional patient care while mitigating potential risks.

Virtual Care Moves Up the Acuity Ladder

Virtual care adoption is maturing, with healthcare providers transitioning from basic telehealth solutions to more complex models. Virtual inpatient nursing and Hospital-in-the-Home (HITH) programs are gaining traction, driven by ongoing clinician shortages and promising results like cost reduction, improved patient experiences, and lower staff turnover.

Vendors are offering a variety of solutions to cater to these evolving needs. Some specialize in “smart hospital” solutions, integrating software and hardware with advanced sensors for in-patient and in-home monitoring. Others take a platform-agnostic approach, offering flexible solutions compatible with diverse hardware setups. Additionally, the integration of AI and Generative AI (GenAI) into virtual care platforms holds promise for enhanced patient monitoring, proactive interventions, and improved clinical decision-making.

Cloud-Powered EHRs Embrace GenAI

Enterprise EHR vendors displayed their latest offerings at HIMSS, highlighting their commitment to cloud-based solutions and GenAI development. Partnerships with tech giants like Microsoft (Azure OpenAI Service) and Google (MedLM) are accelerating the development of GenAI use cases in EHRs. These functionalities initially focus on streamlining workflows and reducing clinician burden, such as auto-generating hospital course summaries.

Cloud platforms are essential for EHR vendors to deliver new AI and GenAI features. Oracle, for example, is migrating its EHR products to Oracle Cloud Infrastructure (OCI) to facilitate the development of the Clinical Digital Assistant (CDA) – a multimodal solution with features like digital dictation and ambient digital scribing. Oracle Health also announced new GenAI-powered features for increased care management efficiency within its Health Data Intelligence (HDI) platform.

Collaboration and Innovation: The Path Forward

The HIMSS conference provided valuable insights into the evolving healthcare landscape. AI, virtual care advancements, and cloud-powered EHRs are shaping the future of patient care. As these technologies continue to develop and integrate, healthcare leaders must prioritize responsible AI development, ensure equitable access to virtual care solutions, and leverage the power of cloud-based platforms to enhance patient outcomes and clinician experiences.

At HealthAxis, we are committed to contributing to this dynamic landscape with our integrated business solutions. Our offerings are designed to be scalable and adaptable, ensuring they meet the evolving needs of healthcare organizations at every scale and scope. Learn more about how our solutions can support your organization in embracing these technological advancements to improve patient outcomes and operational efficiencies.

Learn more about how HealthAxis can tailor a solution to fit your needs and help you navigate the ever-changing healthcare landscape.

Strategic Accelerations: Critical Business Initiatives for U.S. Healthcare Payers Part 2

In Part One of this series, we examined the initiatives Gartner identified as key areas for acceleration,1 following their extensive evaluation through research surveys and interactions with U.S. healthcare payer business and technology executives.

Building on the foundation of data-driven initiatives explored in Part 1, Part 2 of this series shifts the focus to practical applications and strategic initiatives. We’ll delve into specific areas where payers and TPAs can leverage these insights to accelerate their progress. This includes improving operational efficiencies, enhancing care delivery models, and gaining a competitive edge in the market.

Streamlining Payment Integrity Processes

Payers are increasingly recognizing the need to streamline their payment integrity processes as a strategy to reduce the operational costs stemming from overpayments and complex administrative procedures. More importantly, optimizing these processes directly enhances provider satisfaction and improves the overall member experience. While the focus has traditionally been on medical cost containment, it’s crucial to acknowledge the direct impact that payment inaccuracies have on members’ out-of-pocket expenses. Most claim denials, which significantly affect member satisfaction, are preventable, and a large portion of these can be successfully appealed.

To mitigate preventable claim denials, payers should focus on enhancing and automating the data collection, validation, and reconciliation processes. Moreover, educating both members and providers about the conditions necessary for payment can play a pivotal role in reducing errors. This approach not only supports fair payment practices but also builds trust and transparency with healthcare providers and members.

Additionally, payers bear the responsibility of reducing fraudulent claim activity without inadvertently creating payment hassles for providers. Experts at Gartner have recommended collaborating closely with payment integrity vendors or internal special investigative units (SIU) to achieve this balance.2 By exposing detailed claim submission requirements through provider portals or other communication platforms, payers can help ensure that providers submit complete and accurate claims, thereby reducing the likelihood of denials due to missing or incorrect information. Such proactive measures are essential for maintaining the integrity of payment processes and fostering a positive ecosystem for all stakeholders involved.

Modernizing Technology

In the rapidly evolving healthcare landscape, the modernization of technology infrastructure emerges as a critical priority for payers. As Gartner highlights, in 2024, U.S. healthcare payers are focusing their investments on upgrading core systems, enhancing interoperability technologies, and improving consumer experience capabilities. These strategic areas of investment are essential for payers to maintain competitive advantages, optimize costs, and improve overall member experiences.

To ensure these investments are aligned with industry standards, CIOs are encouraged to benchmark their technology spending against findings from the 2024 Gartner CIO and Technology Executive Survey:

  • Core Administrative Processing Systems – The modernization of CAPS is a critical investment for 59% of healthcare payers, according to the Gartner survey. The drive towards upgrading these foundational systems stems from the need to replace or augment legacy systems that no longer suffice to meet the complex demands of today’s healthcare landscape.
  • Interoperability Technologies – Interoperability is a key strategic focus for 59% of healthcare payer CIOs in the Gartner survey, highlighting the sector’s recognition of its importance in the current healthcare ecosystem. With new mandates for interoperability on the horizon, the ability to seamlessly share clinical data across the healthcare continuum becomes paramount.
  • Consumer Experience Capabilities – The push towards improving consumer experience capabilities is evident, with 53% of payers focusing on this area, according to the Gartner survey. In an age where consumer expectations are shaped by experiences outside the healthcare industry, payers are challenged to provide a level of service that mirrors the convenience and personalization consumers encounter daily.

By prioritizing these technological upgrades, U.S. healthcare payers can address the dual challenges of meeting ever-growing regulatory requirements and rising consumer expectations. Such modernization not only supports efficient administrative processing but also positions payers to lead in delivering innovative solutions that enhance member satisfaction and retention.

Expanding Self-Funded Business

The self-funded business market is experiencing a notable shift as not only large and national employer groups but increasingly smaller employer groups are turning to self-funding to curb healthcare costs. This trend is accelerating growth in the market and presents significant opportunities for payers to expand their administrative services-only (ASO) offerings. However, this expansion also introduces risks, as self-funded ASO employers may choose to bypass traditional payer arrangements, opting instead to contract directly with other service providers within the healthcare ecosystem to manage their employees’ healthcare needs more economically.

To capitalize on this evolving market dynamic, payers must focus on enhancing their service offerings to meet the unique demands of these smaller employer groups. Investing in core administrative technologies is critical. These technologies should support quick data exchanges and offer flexible configurations for benefits, products, provider networks, and reimbursements. Such capabilities will not only meet the diverse needs of self-funded groups but also help in maintaining competitiveness in a rapidly changing market.

Moreover, to create lasting client relationships with self-funded ASO groups, payers need to deliver a superior digital consumer experience. This involves more than just processing claims and coordinating care; it requires providing high-value-added solutions such as cross-carrier analytics that can offer deeper insights into healthcare management and efficiencies. By aligning their services with the complex needs of self-funded employers, payers can position themselves as indispensable partners in the self-funded healthcare landscape.

Enhancing Home Health Capabilities

The trend towards home-based care is accelerating, fueled by a growing prevalence of chronic diseases and the ongoing challenges of managing healthcare costs effectively. As patients increasingly prefer the comfort and convenience of receiving care at home, payers are finding it essential to expand and enhance their home health capabilities to meet these evolving demands.

This shift is not only about accommodating patient preferences but also about tapping into the cost-efficiency that home care can offer. By providing support for home-based care, payers can help reduce the frequency of expensive hospital visits and enable more proactive management of chronic conditions. This approach involves integrating advanced technologies such as telehealth systems, remote patient monitoring, and mobile health applications that allow for effective treatment and management outside traditional healthcare facilities.

Driving Future-Ready Healthcare Solutions

HealthAxis is committed to driving excellence in healthcare through innovative and integrated solutions. With nearly 60 years of experience in the healthcare industry, we understand that every payer faces unique challenges. We offer a tiered suite of solutions designed to meet your specific needs, whether you’re a large, established payer or a smaller organization looking to expand your reach.

Our solutions can empower you to:

  • Implement robust data and analytics governance frameworks.
  • Increase data transparency and meet regulatory requirements.
  • Modernize your technology infrastructure and unlock new possibilities.
  • Leverage FHIR APIs for seamless data exchange.
  • Expand your home health capabilities and deliver cost-effective care.
  • Streamline payment integrity processes and improve efficiency.
  • Capture the growing self-funded business market.

Learn more about how HealthAxis can tailor a solution to fit your needs and help you navigate the ever-changing healthcare landscape.

 

Sources:
1. Business Outlook for Critical U.S. Healthcare Payer Initiatives, Gartner
2. Quick Answer: Rethink Your Denial Strategy to Increase Provider Satisfaction, Gartner

Strategic Accelerations: Critical Business Initiatives for U.S. Healthcare Payers Part 1

U.S. healthcare payers and third-party administrators (TPAs) face a complex array of business and technology initiatives driven by evolving market conditions and increasing consumer demands. Successfully navigating this dynamic landscape requires a clear understanding of how to manage these challenges effectively.

To assist in this endeavor, Gartner conducted an extensive evaluation1, tapping into periodic research surveys and detailed interactions with U.S. payer business and technology executives. Gartner’s team of payer industry experts assessed each initiative, providing a rating to guide investment decisions:

  • Explore: Continue to allocate resources to assess the potential and use cases of the initiative.
  • Accelerate: Increase resources for initiatives showing favorable conditions.
  • Maintain: Keep current resource levels and plan for an increase when conditions improve.
  • Harvest: Optimize the initiative for minimal resource use and maximum profitability.
  • Divest: Discontinue initiatives that are no longer viable.
  • Reposition: Allocate resources differently to refocus strategy and maximize benefits.

This two-part blog series focuses on initiatives that Gartner recommends for acceleration. By prioritizing investment in these areas, healthcare payers and TPAs can achieve substantial benefits in today’s market.

Investing in Data Transparency

As consumer demands for upfront pricing information increase, along with strict regulatory mandates such as the Consumer Price Transparency final rules and the No Surprises Act, it’s crucial for payers and TPAs to prioritize investments in data transparency. These initiatives are essential not only for compliance but also for enhancing customer experiences and meeting price transparency requirements. U.S. healthcare organizations must leverage this research to strategically position their organizations in a rapidly changing market.

Currently, many payers and providers struggle to provide accurate cost estimates through their digital health navigation tools. This shortfall can lead to consumer dissatisfaction, care abandonment, and increased call volumes for customer service teams fielding coverage and cost inquiries. The Transparency in Coverage final rule and the Hospital Price Transparency final rule mandate clear, accessible cost information, presenting challenges that require strategic collaboration and the tactical implementation of advanced technologies.

By investing in robust digital tools that improve transparency, payers, and TPAs not only adhere to regulatory demands but also enhance consumer trust and operational efficiency. This strategic focus is integral to transforming the healthcare experience, making transparency a cornerstone of modern healthcare economics and consumer interaction.

Accelerating Data and Analytics Governance

The imperative for robust data and analytics governance in healthcare is growing as ecosystems become more interconnected and the volume of data surges. Enhanced governance is crucial not only for improving data quality and sharing capabilities but also for addressing persistent issues related to technology integration, data ownership, privacy, security, and IT resource constraints. By establishing a comprehensive data and analytics governance framework, payers can ensure their data infrastructure is primed for advanced AI applications and support a more decentralized analytics approach.

Per Gartner’s 2023 Hype Cycle for Data and Analytics Governance, experts in data and analytics governance are advised to focus on technologies and methodologies that are likely to reach the “Plateau of Productivity” within the next two to five years.2 This includes investing in cross-enterprise Master Data Management (MDM), advanced data cataloging, metadata management solutions, and stringent data quality protocols. These elements are pivotal for enhancing the accuracy, accessibility, and security of data across healthcare organizations.

Furthermore, payers should consider exploring less mature yet promising innovations such as adaptive Data and Analytics (D&A) governance and D&A governance platforms. Although these areas may require a longer time horizon to mature fully, they hold significant potential for providing a competitive edge. Actively evaluating and integrating these emerging innovations can help healthcare payers not only meet current regulatory and operational demands but also position them favorably within an increasingly data-driven industry.

FHIR APIs: The Future of Data Exchange

U.S. healthcare payer CIOs are emphasizing investments in interoperability use cases to align with top enterprise priorities. These initiatives are not only about meeting regulatory requirements but also enhancing the quality of healthcare through improved data exchange mechanisms. FHIR (Fast Healthcare Interoperability Resources) APIs are at the forefront of these efforts, providing a standardized method for robust data exchange across the healthcare sector. The adoption of these APIs is crucial for achieving interoperability goals and enhancing Health Information Exchanges (HIEs) as the main source of clinical data.

The HL7 community continues to develop evolving standards that meet the growing needs of the healthcare ecosystem, significantly boosting the value proposition of HIEs. Regulatory and market forces are also reinforcing the importance of robust data frameworks, making FHIR APIs an essential component of modern healthcare infrastructure. Early adopters of FHIR APIs are finding themselves well-positioned to scale these initiatives, leveraging their early experiences to guide expansion and optimization.3

As the healthcare landscape continues to evolve, the strategic focus on FHIR APIs will play a critical role in optimizing healthcare delivery. This focus on advanced data exchange frameworks not only supports current operational needs but also sets the stage for future innovations in healthcare technology. Early investments in these areas are proving to be strategic, enabling organizations to lead in a data-driven healthcare market.

Stay tuned for Part 2 of this series, where we will delve into three additional initiatives critical for U.S. healthcare payer and TPA success:

  • Streamlining Payment Integrity Processes
  • Modernizing Technology
  • Expanding Self-Funded Business
  • Enhancing Home Health Capabilities

Empowering Data-Driven Success

Leveraging data for success in healthcare requires a trusted partner with a deep understanding of the industry. HealthAxis brings nearly 60 years of experience to the table, helping you navigate the complexities of data governance, advanced analytics, and FHIR interoperability.

Our comprehensive suite of integrated business solutions unlocks the full potential of your data, empowering you to gain a competitive edge in the healthcare market.

Learn more about how HealthAxis can help you navigate the data landscape and achieve your strategic goals.

Sources:
1. Business Outlook for Critical U.S. Healthcare Payer Initiatives, Gartner
2. Hype Cycle for Data and Analytics Governance, 2023, Gartner
3. HL7 FHIR = Health Level Seven Fast Healthcare Interoperability Resources

National Minority Health Month: Be the Source for Better Health

April marks an important observance in the healthcare calendar: National Minority Health Month. This month is dedicated to raising awareness about the ongoing health disparities that affect racial and ethnic minorities and American Indian/Alaska Native communities. Health disparities—variances in health outcomes across different groups—are influenced by social determinants of health such as access to healthcare, economic stability, education, neighborhood and physical environment, as well as social and community context.

The U.S. Department of Health and Human Services (HHS) Office of Minority Health sets an annual theme to guide the observance. This year’s theme, “Be the Source for Better Health: Improving Health Outcomes Through Our Cultures, Communities, and Connections,” highlights the importance of community and cultural engagement in addressing these disparities.

We encourage you to learn more about how addressing social determinants can help eliminate health disparities. Visit the U.S. Department of Health and Human Services’ National Minority Health Month page for valuable resources and ways to engage in your community.

At HealthAxis, we are deeply committed to supporting health equity through our streamlined healthcare solutions. By enhancing operational efficiency for health plans, we contribute to better access and quality of care for minority populations. Our proprietary CAPS technology and modern services facilitate improved data management and member services, allowing healthcare providers to tailor their approaches to effectively meet the specific needs of diverse communities. By optimizing healthcare processes, we help ensure that all members have equal opportunities to achieve their best health outcomes.

Together, we can be the source for better health, creating more equitable health outcomes for all. Learn more about how HealthAxis is driving changes in healthcare delivery.