The Affordable Care Act, ICD-10 compliance and the growth of retail healthcare are just a few of the realities payer CIOs now deal with. They are also reasons why features like open architecture and consumer accessibility are much-needed.
It's no surprise that recent surveys show a majority of insurers have significant concerns about tracking regulatory changes, as well as maintaining compliance. New IT solutions can make it easier for CIOs to tackle and even capitalize on these challenges. To get the most from their systems, healthcare payers should look for five must-haves:
1. Easy adoption and open architecture. Today's healthcare payer systems, such as core administrative solutions (CAS), are more streamlined than ever before, helping health plans enhance efficiency and accuracy of operational and administrative processes, meet new Medical Loss Ratio (MLR) requirements, and improve member health using analytics.
Keeping systems operating at the highest level has real implications for an organization's financial health and compliance, as well as members' health.
Because uncertainty and change are the new normal, look for platforms and applications with an open system architecture, as applications developed without it can be a challenge to enhance, support and integrate over time.
Those replacing an entire system should look for cloud-based technologies that support fast, fluid implementation without onsite installation, and that are highly scalable for new lines of business and capabilities.
2. Adaptability and scalability. In a marketplace where new regulations arrive frequently and with little notice, your system must be agile and flexible, readily adapting to intrinsic and extrinsic forces.
To support such dynamics, CIOs should look for solutions with rules-based, open architecture platforms. These platforms enable quick deployment of new lines of business, from build to configure to actuate, and are highly modular, simplifying the process of adding and upgrading components as updates require. Modularity also supports external system interoperability with public and private health insurance exchanges, as well as with state Medicaid Management Information Systems (MMIS) for Medicaid managed care plans.
3. Fully integrated, real-time views. Healthcare efficiency and regulatory compliance increasingly demand real-time capabilities, and members expect up-to-the-second information – so batch updates are no longer acceptable. For instance, if a member has a doctor's appointment in the morning, s/he expects near-immediate access to appointment details – coverage, billing, everything – via a secure online portal.
Any move you make with your systems should be in the direction of real-time. The best way to achieve this is through tight integration between platforms, giving customer service a real-time view of claims, premium billing, payment and other system data, thus allowing them to improve responses to members and providers. In addition, using this data in combination with advanced analytics can help healthcare payers identify high-risk populations and proactively manage care.
4. Powerful automation. Administrative efficiency and accuracy are crucial to meeting new compliance and efficiency challenges. Solutions must drive automation of most, if not all, core functions to remove time- and cost-intensive manual processes, and to ensure there are no compliance gaps.
Further, the auto-adjudication of claims helps CIOs improve pass-through rates and eliminate error-prone, inefficient manual data entry. Additionally, automation should extend to billing, cash collections and other processes to expedite and simplify transactions.
5. Accessibility and interaction. Most industries, from banking to transportation to hospitality, long ago moved to a retail-centric model, putting consumers at the center of the experience. At long last healthcare is making this transition as constituents now expect the same levels of interaction and transparency they get when booking a flight or hotel room.
For example, systems should make it easy for consumers to securely view health plan benefits, complete self-service transactions and perform open enrollment activities online. They should also facilitate online submission and follow-up of authorizations, so providers can quickly send and receive updates rather than waiting for faxes or phone calls, expediting the authorization process significantly.
This new generation of healthcare payer technology goes beyond managing back-office processes. Today's systems uncover significant opportunities in the shifting healthcare marketplace. With the right technology in place, your organization can adapt to change and respond to opportunities with ease, capitalizing on valuable insights no matter what challenges come your way.
Daniel Knies is the CTO of Aldera.