Is your health plan's administrative platform a well-oiled machine or an antiquated contraption pieced together with multiple, disparate point solutions? Does it work in synchronous perfection, or does it produce a cacophony of noise, becoming less harmonious with each upgrade, addition or change?
The answers to these questions hinge not only on the quality of the solutions on your platform, but on the quality of their integration. Plans that opt to patch together several point solutions—for claims processing, risk adjustment, medical management and more—take on the challenge of keeping all the pieces working in unison to support efficient plan operations and top-quality member care.
However, as organizations demand more from their services and software partners to meet the many challenges of operating a health plan, more leaders are discovering that connecting point solutions isn't the answer.
So how do you know whether your platform is suited to support today's challenges, whether it's on the road to becoming obsolete or— even worse—already there? Here are four signs that you should stop and take stock of your organization's approach to health plan administration.
- Integration limitations are causing your medical management teams to work in silos. Despite the need for care and utilization management teams to partner on a member's overall health care experience, they use separate systems. Care managers rely on a point solution, while utilization management workflow is tied into the claims processing system. Instead of being able to work collaboratively on decisions such as medical necessity, discharge planning and care plan development, these teams work in operational silos, which can lead to gaps in care, missed opportunities for interventions, and unnecessary utilization. Integration here is critical. By breaking down these historical data barriers, care teams get much clearer line of sight on relevant utilization activity for their members while providing additional clinical context for nurse reviewers and medical directors to make appropriate medical necessity decisions.
- Minor IT changes become major fixes. Many solutions out there say they're integrated, but in reality, their "integrated" solution is a complex web of disparate vendor data interfaces that sucks up your valuable IT and administrative resources to keep the solution working correctly. Software solutions upgrade their systems from time to time, so when you're patching together multiple point solutions, IT or product changes to one of your vendors can have a major ripple effect across your entire platform. Your IT resources are consumed to ensure data formats align, and subcontractor management becomes unwieldy. Instead, when you're working in a controlled, truly integrated platform, solution updates contemplate impacts to other areas, and subcontractors are managed through a single partner entity, reducing the IT burden on your organization.
- Provider data management issues are causing significant operational challenges. Provider data management is a challenge for every organization, and issues with poor provider data can manifest themselves in many ways. These include lower than desired claims auto-adjudication rates and inappropriate provider attribution, causing contracted providers to question the accuracy of the data and disengage. Having accurate provider data is too important to be an afterthought within your administrative platform. An integrated provider data management application that serves as a dynamic directory of your networks and contracts should be at the core of your platform and act as the single source of truth for all clinical and administrative functions that your technology solution supports.
- Your platform isn't allowing you to meet providers where they are—working in the EMR. With a national shortage of providers, and increasing regulatory and reporting pressure being applied, physicians are overwhelmed with the multiple systems, tools and reports they need to keep track of. Instead of simply being another solution that providers need to navigate, a modernized administrative platform should be able to integrate with the providers' primary workflow system, the EMR, and pushes actionable information to providers at the point of care. This means sharing data that historically has sat outside of the four walls of the clinic, including member care plans and information from your plans' care management efforts, such as member goals, interventions and barriers. In addition, your platform should be able to send relevant risk adjustment insights directly into the EMR, which enable providers to document members' clinical complexity correctly and results in better financial accuracy for your plan.
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About the AuthorMore Content by Michael Miller