Try Before You Buy: A bottom-up approach to health plan technology adoption

Try Before You Buy: A bottom-up approach to health plan technology adoption

Why flipping the script on enterprise software is the future of digital transformation 

Have you ever tried a piece of technology at your health plan before it was adopted by the broader organization? Think about solutions like MailChimp, Survey Monkey, Slack and Zoom. Even in our highly regulated industry, many of these tools are in place. And, more often than not, the path to adoption started with a trial by a small group of end users, without budget approval or a lot of red tape. Either by trying the entire ecosystem for a limited time, or by testing limited functionality, all for free. 

Now, you may be wondering how these consumer-facing, relatively low-cost examples apply to enterprise software, and it comes down to end users. No matter how “big” or “small” a solution, if it’s not adopted by end users, its benefits will elude your organization. In fact, end user adoption is arguably more critical to the success of broader digital transformation initiatives than edicts from the top. In McKinsey research on internal change management, they found that “when people are truly invested in change it is 30 percent more likely to stick.” 

When your health plan invests resources in new technology, increasing the odds of success holds serious appeal. One surefire way to get end users to embrace digital change is to involve them heavily in the selection process. We’ll cover the benefits in depth, but first a couple of definitions. 

Freemium and Free Trial

Modern technology vendors that offer opportunities for users to vet their solutions tend to pursue one of two paths. 



The basic solution is always free forever while more advanced features, additional users, custom configurations, high number of exports, etc. are reserved for paid plans.


Free Trial

The full solution is offered for free for a limited time. Not to be confused with sandbox demo environments, free trials enable users to input their own data and use the application as they would upon full adoption, activity that is preserved upon upgrade to a paid plan. 

No matter the path to bottom-up technology adoption, the end users and the organization are able to realize significant benefits. Let’s explore the five most important reasons to support end user trials of technology. 

Establish Trust 

Especially useful if your health plan is considering a solution provided by an unproven or unfamiliar vendor, testing what it’s like to be a client provides valuable information that you can’t get another way. During this test period, you’ll be able to answer key questions: 

  • What is the customer support experience like? 
  • How easy is it to get started with the product? 
  • Do I like working with this company and its people? 

Getting input from other clients of the vendor may predict some of your experiences, but every situation is unique. There is no substitute for firsthand knowledge. This mitigates the risk health plans take when they evaluate a SaaS technology solution through a traditional RFP process. It’s hard to take every factor into consideration, and trying to do so in one RFP will often solicit unwieldly amounts of information from a health technology vendor. Instead, trying before buying may answer unknowns, inspire better questions, and uncover hidden value. 

Prove Value 

It’s all too easy for a vendor to make claims that aren’t entirely representative of the reality. Not because we strive to be intentionally misleading – quite the opposite. Rather, vendors’ abilities to assure your specific value is limited to application data and anecdotal evidence from analogous health plansThink about how you might request a proof of concept from a vendor in a traditional technology evaluation and purchasing model. That proof of concept confirms that a solution works for organizations like yours.  

On the other hand, when a vendor offers their solution for actual use, you are able to prove that value for youIn addition to your health plan’s long list of feature/function requirements, this opportunity to explore your exact path to ROI is invaluable. As we wrote in a previous article, the benefit lies in transparency. “Lack of access to broader, contextualized data may limit your ability to see ‘big picture’ challenges you need to solve, which can strangle the potential of you and your staff members.” Trialing a solution with end users breaks down that barrier. 

How Other Industries Handle Technology Buying Decisions

Applying the Freemium concept to health plan SaaS technology may seem novel, but other industries do this regularly. Borrow these tried and true strategies from outsiders and apply them to your technology  adoption process   

  • Secure proof of concepts from multiple vendors. 
  • Ask for departmental demos – ensure the technology vendor that you are evaluating has the right expertise by narrowing your scope. 
  • Utilize a freemium environment to trial and error functionality. Follow up with your account rep to answer outstanding questions. 
  • Ask for solutioning plans to solve pressing problems, rather than broad lists of feature/functionality. Request vendor training resources, implementation specialists and product account owners be on calls with your team as you progress through the buying process  
  • Don’t be afraid to ask questions – as often as needed 

Determine Usability 

If proving value is important to organization-wide goals, usability makes it more likely you will get there. Usability affects end users most acutely and, as a metric, can’t be established outside of using the product. You can measure usability with as few as 3-5 users completing a set of tasks, based on the following metrics: 

  • Success rate 
  • Time to completion 
  • Error rate 
  • Users’ subjective satisfaction 

Any product that lacks usability wastes time and energy – both the organization’s and the end users’ -so an opportunity to interact with the solution in the real-life setting is a bonus. In fact, it only behooves vendors to offer a freemium or free trial of their solution if the “product sells itself.” Meaning, intuitive solutions that are relatively simple to self-serve given a reasonable baseline of knowledge. Users are unlikely to pay for a solution they know to be substandard, given the choice. 

Move Faster 

Why is the path to adopting enterprise technology solutions so slow? Your health plan, like any large organization, can’t afford to get it wrong. The time and money that go into evaluating, selecting, implementing, training and using a new system must yield significant improvements, and proceeding deliberately should mitigate unwelcome surprises. 

But doing your due diligence doesn’t have to mean moving at a glacial pace. Hands-on access to a solution before your health plan makes a long-term commitment allows you to address concerns more quickly and authoritatively. And, should you decide to move forward with an organization-wide implementation, those early user experiences provide insights for broader adoption. Informing you of lessons learned on workflow and where to concentrate training, for instance, so you can realize ROI more quickly. 

Minimize Risk 

Organizations tend to delay taking on a new technology solution until the current pain outweighs the potential risk. These potential benefits of a low-commitment opportunity to try software before you buy it all add up to minimizing your health plan’s risk. By establishing trust in your vendor, proving solution value, and confirming usability up front, you can position yourself to avoid roadblocks and make a more informed decision. 

Additionally, delays on new technology implementations may occur if your health plan does not have adequate buy-in or designated project resources. A freemium model allows user groups to engage with the technology and become in-house SMEs ahead of a full implementation, meaning that your health plan will have knowledgeable internal resources at its disposal – a move that should make your implementation all the smoother! 



Talk to ClarisHealth about your fraud initiatives and how Pareo® can help.

Health Plans: Take These 4 Steps to Comply with New Information Blocking Rules

Health Plans: Take These 4 Steps to Comply with New Information Blocking Rules

Now that the rules promoting interoperability have been finalized, here’s how payers can prepare to take full advantage of the freer exchange of healthcare data. 

On March 9, 2020, the two separate rules issued by CMS and ONC against Information Blocking became final. The administration lauded the release by touting the consumer benefits: “Americans will now have electronic access to their health information on their smartphone if they choose.” While that impact is undeniable, health plans, on the other hand, likely have a more pressing near-term question, “Now what?”

As we wrote in our last article on this topic, just over 40% of health plans report progress on interoperability, which leaves some work to do. One industry leader echoes concerns about the complexity of complying with the rules in a recent comment. “In the near term, information is going to be messy and incomprehensible, for the most part, but over the long term, it creates a dynamic where access is the first step to be able to do something important with the data.”

With that very astute observation in mind, we have outlined a 4-step plan for health plans to move forward during the “messy” beginning and make progress toward the actionable data goals of interoperability.

1. Get important stakeholders on board

If you haven’t done so already, your first step should be to form a steering committee made up of knowledgeable contacts from affected areas of the health plan: privacy and security officers, compliance, IT, finance, member support. Their input will be invaluable as you assess your current state of readiness.

The team can collectively identify: 

  • Where all electronic health information is held within the organization. List all systems and the type of information each contains. Go deep and wide to corral everything that could possibly fall under this broad definition, as well as to set yourself up beyond compliance toward strategic advantage. 
  • Policies and procedures that address information sharing. Includes HIPAA compliance, IT policies, and internal agreements covering confidential and proprietary information. 
  • What workflows have been implemented to accommodate EHI requests. Includes how they are processed, who reviews, turnaround times, security tests, and any documentation around these processes.

2. Highlight barriers to compliance

While your team assesses the current state of affairs, they are bound to find roadblocks keeping your health plan from sending and receiving EHI in a timely manner. The look-back period for consumer inquiries is 5 years, including for members who have changed plans. Can you aggregate and return information to members within 1 to 2 days?

Technical challenges are the most likely barriers that health plans will have to grapple with. Of note, the myriad of disconnected systems that house EHI. Consider initiating a trial request to send and receive information on a tight turnaround and evaluate your success along the way. 

You’ll want to look for potential blind spots now, before it’s an emergent situation. For instance, if you’re able to accommodate the request, but in doing so, it sidelines key personnel from their primary work functions. Or, maybe the process falls through a communication gap — either internal or with a third-party. Perhaps it’s impractical to retrieve information from systems at all. Document any obstacles.

3. Make a plan

Your audit to reveal the current state of your organization’s ability to share EHI likely highlighted some known quantities as well as a few surprises. The next step is to make a plan to overcome those gaps in communication and technical requirements.

Communication. Initiate new internal processes, and amend contractual agreements with third-party vendors and business associates and providers, if needed. The EHI ecosystem is vast, and eliminating information blocking will require these relationships to evolve accordingly. 

Technology. The ONC rule provides more specifications on the technical side. The finalization of these rules could finally urge all healthcare stakeholders to settle upon the normative version of FHIR (v. 4) to standardize APIs. We have written before how APIs promise to help connect our disconnected systems and promote information sharing. A great deal of patient healthcare claims information has already been made available through open APIs, with more planned; it’s only a matter of being able to receive that information. Because your adjudication and processing systems likely use the EDI X12 standard, you may have to support both for a while.  

Image source

In addition, new algorithms, analytic capabilities, blockchain and machine learning (ML) capabilities can help parse unstructured data, deal with increased data volume, and otherwise unlock the value of the data.  

4. Communicate about your progress

This rule demands transparency, so start by communicating openly about your progress with internal stakeholders as well as providers, service suppliers and technology vendors. Opening the lines of communication is essential to breaking down the work silos that hinder interoperability.

Also, consider getting involved in the FHIR community, by piloting and testing at connectathonsThe process may not be as onerous as you imagine; providers and health plans alike have been pleasantly surprised by 90-day infrastructure compliance timelines. Communicating with the governing body for future-ready standards and exchanging best practices with like-minded stakeholders promises to move the entire industry forward. 

Bottom Line: The Carrot Before the Stick

If your health plan maintains their focus on the benefits to members, progress towards your strategic goals are sure to follow. According to Don Rucker, M.D., national coordinator for health information technology, “A core part of the rule is patients’ control of their electronic health information which will drive a growing patient-facing healthcare IT economy, and allow apps to provide patient-specific price and product transparency.” 

While penalties for information blocking have yet to kick in (the stick), the strategic advantage carrot is particularly enticing. The U.S. healthcare system has been “promoting interoperability” for years, and the finalization of these rules finally codifies the standards that enable that goal. Now is your opportunity to fully embrace advanced technology and the freer exchange of health information to enhance care coordination, lower costs and improve outcomes.   


Talk to ClarisHealth about your fraud initiatives and how Pareo® can help.

Should Your Health Plan Build or Buy a Technology Solution?

Should Your Health Plan Build or Buy a Technology Solution?

Flexible solutions offer greater value to health plans

Whether your health plan has decided it has outgrown its manual paper-based processes or existing technology, at some point you will likely ask, “Should we build our own custom solution or buy something off the shelf?” No matter your choice, there will be trade-offs, primarily between cost and control: 

  • Build: more cost, more control 
  • Buy: less cost, less control 

How will you make that decision? Let’s explore the considerations of each.  

“We invested 5 years and $12 million in developing a custom software solution — and it still wasn’t usable.”

CEO, National Health Plan 

To Build: Consider the Costs 

The impulse to build software in-house to answer a company’s technology needs isn’t uncommon. In fact, it’s a very traditional approach. Many companies prefer to keep their business activities under the corporate umbrella, and in some cases there may not be a software solution that suits the unique needs of a particular company 

The build versus buy argument often comes down to core issues, such as cost, proprietary rights, and usability. Before you go down the path of custom development, evaluate the costs of the best-match off-the-shelf solution. Then, take that figure for licensing and implementing that solution and multiply it by 10. If your organization has a successful track record of commissioning custom software projects, this estimate will be reliable. If this experience is lacking, multiplying by 20 is a safer bet. 

To build or to buy? Take the quiz.

Will your custom software development project be successful? Evaluate the best solution for your health plan and gain insights by taking our quiz. 

If you experience sticker shock at these estimates, remember that the developer of the off-the-shelf system is able to amortize the cost of the solution across many health plan clients because that is their core business focus. For health plans, the costs of building software in-house are often misaligned with bottom line figures for many reasons.  

Beware Hidden Costs

It’s not just the cost of development you are taking on when you build your own solution. Often, the costs to implement and manage custom software in-house are not fully considered when the project is initialized. Remember to factor in ongoing and hidden costs related to your custom-built software:  

  • Support
  • Administrative personnel
  • Updates
  • Training
  • Outside experts
  • Technology upgrades
  • Sole responsibility for integrations with third-party applications

While building software internally is the right decision for some, it certainly pays to consider all your options.  

The Cost of Distraction

Many software professionals feel that in-house development offers fewer advantages than purchasing an external solution, due to a hefty “soft” cost that is difficult to predict and calculate: Internal development of software sways a company off-course from their actual core business focus.  

Once you decide to develop… you are no longer just in [your primary] business; you are now in the software development business,” says Wes Trochlil, founder of Effective Database Management and author of this article. Trochill goes on to explain that when you enter the realm of software development, your internal resources also become responsible for scoping the project, testing and documenting the software, and the development and delivery of a training program.  

An analysis of 1,471 IT projects revealed that “the average cost overrun was 27% — but that figure masks a far more alarming ‘fat tail’ risk. Fully one in six of the projects in the sample was a Black Swan, with a cost overrun of 200%, on average, and a schedule overrun of almost 70%.” If your health plan is already facing common issues  slim margins, rising cost pressures, etc an out-of-control tech project can compound these factors.  

Investing in buying a solution means that your vendor assumes all software development responsibility, which frees up a health plan to focus on other important issues 

To Buy: Consider the Control 

In a highly regulated and sensitive environment like health plans operate in, it’s intuitive to prioritize control at any cost. But, how much control are you actually sacrificing by finding a strategic technology partner? 

For one, unless your internal IT and development resources have the bandwidth to dedicate to your custom software project, you likely will be contracting with outside development resources anyway. In that scenario, even owning the code won’t be an advantage when it comes to pursuing updates down the road. 

Secondly, it is in a technology company’s best interest to listen to and respond to their clients’ feedback. With the right vendor, your voice will be heard, acknowledged and considered with their development roadmap and enhancements process. 

Custom vs. Configurable

Ask yourself: is it really “custom” software that you need, or something “configurable”? By that, we simply mean that in many industries  healthcare included  multiple needs have been resolved by third-party software providers.  

In essence, are you “re-inventing the wheel” by embarking down the path of customized software, only to find at the end of the journey there was a flexible, credible, highly effective solution already on the market? Start by defining the business processes that make your organization truly unique: fields, workflows, permissions. Prioritize solutions that make these elements configurable.  

In the end, even if configurable elements don’t satisfy all your requirements and you need to commission truly custom development additions to a vendor’s technology, it’s easier to predict the cost investments when you purchase external software.  

“IT leadership understood how time consuming, resource intensive, and costly it would be to build something internally. Fortunately, we came across ClarisHealth and they had the solution. A similar self-built solution, to really get something that has the functionality of Pareo, would have astronomical costs associated with it.”

Erik Chase, Director of Payment Integrity, L.A. Care Health Plan. Download the case study

Bonus Expertise

Whether you outsource your custom software development (the most common scenario) or rely on internal IT resources, you most likely will be defining your process and functionality needs yourself. Consequently, you risk replicating those existing processes and workflows that bog down your effectiveness and efficiency into your new system. 

By contrast, those organizations that adopt an industry-specific technology solution benefit from a community of expert usersWe work with our clients every day to discover novel solutions to entrenched challenges, and they provide us with ample opportunity to hear directly from industry leaders what works and what doesn’t in terms of technology for payers.    

Additionally, our in-house experts have worked extensively with our payment integrity platform as Auditors, Data Miners and Overpayments Specialists — just like you. It’s a unique position that allows us to, as one client put it, “see the problem as if you’re working alongside us.”

Control and Innovation: You can have it all. 

In the case of ClarisHealthour top competitor is typically a health plan’s self-developed software solution. And many times, a plan is fairly happy with the performance of that homegrown software. However, that technology is often times lagging when it comes to updates and innovative upgrades.  

It isn’t uncommon for our team to implement a software system that replaces an in-house system that a health plan has outgrown. Our best advice? Think through your software needs, and only consider in-house development if cost is no consideration and you cannot find a pre-existing solution on the market. 

Talk to ClarisHealth about how Pareo® can transform your health plan’s payment integrity operations.

Data Privacy Concerns Meet Digital Progress

Data Privacy Concerns Meet Digital Progress

Data privacy and security will always be top of mind for health plans in an environment where access to data is crucial to growth. Here are some safeguards for payers.

How do payers balance their need for broader access to data with their need to improve trust with members and providers? Data privacy is a careful balance that leaves healthcare payers as the keyholders in an ecosystem that requires data be protected but also shared. Luckily, advancements in integrative technologies promise to make data more accessible to payers, providers and — most importantly — consumers. But just because a technology can offer API doesn’t mean they will, and health plans will have to proactively face perception problems when it comes to data privacy. 

In this article, we’ll look at API capabilities and how they promise to make data sharing easier and secure. We will also look at why health plans may get pushback on data sharing initiatives, both from technology vendors who are hesitant to “plug and play” as well as stakeholders that may have (well founded) trust issues when it comes to PHI. 

API and Your Digital Strategy 

Transformation in the healthcare industry is reliant on the ability to seamlessly share data between vested entities. The ability to quickly and easily utilize data has been a huge issue, however, in an environment that relies on legacy systems and manual processes. And as payment models move more to value-based care, patients are more responsible than ever for their PHI, and they expect payers as well as providers to readily provide them with information. This is where APIs hold the most promise, allowing technology to make discrete data exchanges in a secure manner. 

Regulatory agencies have welcomed the promise of API with open arms, and last year’s proposed Information Blocking and Interoperability Rules showed health plans just how serious the government was about making rapid change. Health plans want this, too; in fact, it’s hard to imagine any stakeholders along the healthcare continuum that wouldn’t appreciate the ability to access secure, specific data. 

 “Health plans require discrete data exchanges, “calls” that respond back with the minimum data needed for the task at hand. API integration makes streamlined data access possible, a more elegant solution than outdated, clunky HL7 2.0 interfaces. When a user requests data, API allows that data to be delivered in real-time (as opposed to batch FTP). With quick, secure access to information, health plans are able to break down silos and seamlessly interface between departments, suppliers and providers.”

Using API Integration To Create A “Central Hub” Of Data


API is a communication protocol that delivers information securely, either bi-directionally or one way, by only answering calls with the required information (and nothing else). Many healthcare technology vendors (and non-industry technology providers) will allow API for open integration to promote greater data sharing and opportunities for achieving greater user value. Consumers may be utilizing APIs without even knowing it, at work or on their personal electronic devices.  

Data Sharing Detractors

Unfortunately, personal health data is particularly valuable to hackers — and historically, healthcare organizations have not proved particularly trustworthy with it. In fact, according to a recent study conducted on behalf of AHIP, “a majority (62%) of patients and consumers said they would be willing to forego easy access to their health data if it meant greater privacy protections were in place to protect their health information.”

Health organizations are concerned, too, about how healthcare data may be used. In particular, when it comes to PHI that is collected on personal devices (like wearables), stakeholders have expressed fears that this PHI  may be utilized by third-parties without the consumer even knowing their information is being shared. These specific concerns were brought up in some of the criticism that circulated during the review period for the proposed Information Blocking Rule. 


“Too often, health privacy violators don’t know where all of their electronic protected health information (ePHI) is, how the data flows through the environment and the risks of each step.”



Concerns about data privacy and security may be holding payers and other healthcare stakeholders back from adopting modern digital strategies. Does HIPAA, even though designed to be flexible, go far enough in protecting sensitive healthcare data generated by new consumer devices and apps? Experts have called on Congress for stronger oversight of healthcare data issues that they believe fall outside of HIPAA protection, issues that stem from the fact that currently third-party apps are not required to comply with data blocking policies.

Moving Digital Strategies Forward

Data security and privacy remain a prevalent concern of payers when they consider adopting digital strategies. A recent survey indicates that 94% of health plan executives have concerns. On the other hand, current methods for accessing and exchanging PHI — mail, fax, storage on local devices/dongles — are inherently vulnerable and add to the administrative burden. Modern technology, in fact, may give you even more control because it allows you to be more granular with granting access to PHI, and that access leaves digital fingerprints.

Understand that your security posture doesn’t weaken when you make the necessary transition to digital-first; rather, its focus shifts. To successfully embark on your health plan’s digital transformation, we offer two recommendations:

  1. Greater data sharing is a big mindset change. Practice radical transparency in your communications to overcome this barrier, along with emphasizing the greater good achieved by freeing information from its silos. Members, for instance, are far more likely to be on board if they understand what data is being collected and why and the expected benefits (e.g., more relevant communications specific to their needs).
  2. Rely on your technology partners to share the data privacy and security burden. They should be the ones managing end-to-end encryption of data exchanged through APIs, as an example. Make sure you deeply question their security posture to put your mind at ease. 

You’re Secure with Pareo

Ensuring the security and confidentiality of our customers’ and their members’ data is the number one priority at ClarisHealth. The ClarisHealth security program encompasses and represents the security, privacy and compliance controls that are in place to protect our customers’ most sensitive data.

ClarisHealth maintains an active security program that involves physical, network, data access and application security controls. Policies and procedures have been developed and implemented to ensure appropriate controls are in place and actively monitored. ClarisHealth is HITRUST CSF and SOC 2 Type 2 Certified, certifications that demonstrate the organization’s payment integrity solution Pareo has met key regulatory and industry-defined requirements and is appropriately managing risk.

Talk to ClarisHealth about how Pareo® advanced payment integrity technology is helping health plans deliver on their most advanced digital strategies.

Will AI finally make good on its promise to healthcare?

Will AI finally make good on its promise to healthcare?

Artificial Intelligence continues to be a much-hyped “trend” for healthcare technology but adoption lags. Here’s what AI is — and isn’t — and why this may be the decade it takes hold for health plans.

When IBM Watson, the AI supercomputer created by IBM, won Jeopardy! and then moved on to a career in healthcare (via Watson Health in 2015), the industry was abuzz with possibilities. Sci-fi speculation ran rampant and then fell flat, when in 2017 it was revealed that IBM Watson wasn’t exceeding — or even meeting — expectations. AI capabilities were muddied by the hype, and adoption of the technology continues to be slower than expected. 

However, AI is a powerful force in technology and crucial to disrupting the healthcare industry. And in 2020, AI is poised to improve rapidly (it was recently reported that Google’s AI system was more accurate than experts in finding breast cancer).  Let’s explore what AI is — and isn’t — and why it’s here to stay. But first, a few definitions:

Artificial Intelligence: Intelligence applied to a system with the goal of mirroring human logic and decision-making. AI is utilized for the purpose of successful knowledge acquisition and application, which it prioritizes over accuracy. AI simulates intelligence (the application of knowledge). It is a combination of technologies, comprised of machine learning and predictive analytics.


Machine Learning: An application of AI that allows a system to learn on it’s own. ML learns from data, and it aims to increase accuracy (success is a lesser concern). ML simulates knowledge. Source


Data Mining: Unstructured data that is collected, often for the purposes of data analytics.


Predictive Analytics: Data that has been collected is utilized to try and predict behavior/outcomes (often called Data Science). To analyze data, it is routed into a report, at which point humans or artificial intelligence apply multiple factors to make predictions about expected outcomes. Predictive Analytics often implies that a machine has performed the analysis and offered a prediction (rather than a human).

Is 2020 the year for AI?

Experts predicted that AI would grow rapidly in 2019, but adoption waned. Additionally, a growing number of consumers (and regulators) are becoming uncomfortable with “black box” AI. Forbes points out, “As humans, we must be able to fully understand how decisions are being made so that we can trust the decisions of AI systems. The lack of explainability and trust hampers our ability to fully trust AI systems.” 

In all industries, AI can vary greatly by product and generalized claims can be misleading. In healthcare, relying on AI before explainability has been satisfied is a large risk. Yet, creators of the algorithms that power AI will often refuse to disclose how they work, citing proprietary information.  

The lack of explainable AI is a huge hurdle to applying (and approving) the technology’s use in clinical care settings. For example, when a study showing that AI could interpret risk of patient death based on ECG test results with greater accuracy than physicians, without being able to explain how it did so, doctors expressed amazement — and discomfort. “It’s still unclear what patterns the AI is picking up, which makes some physicians reluctant to use such algorithms.” Furthermore, lawmakers are still grappling with how to regulate the technology, and those outcomes can play a significant role in health tech.

Early adopters in the healthcare payer sector understand the benefits and risks associated with AI all too well, and skepticism of vendor claims of AI is high (and rightly so). However, the value of AI is steadily increasing, and AI compute has been doubling every three and a half months. In fact, 2020 was a remarkable year for the advanced technology. The AI Index 2019 Annual Report calls out the following technical performance achievements: 

  • In just a year and a half, large image classification systems are training much faster on cloud infrastructure, down to 88 seconds in mid-2019 from three hours in late 2017. Costs to train these systems have also fallen.
  • Progress on natural-language processing classification tasks is “remarkably rapid,” though performance on NLP tasks that require reasoning has not kept up

If investment dollars are any indication, AI technology will continue to boom. Last year, global private investment dollars in AI topped $70 billion: 6.1% of those investment dollars were attributed to drug, cancer and therapy while 3.9% was given to fraud detection and finance. 

How AI is Applied to Healthcare Technology

AI is expected to permeate every facet of healthcare, with annual spending on advanced technology estimated to be more than $34 billion in 2025. But AI is not a solution in and of itself; it’s an application of various methodologies, and this causes some confusion. The current applications of AI in healthcare are narrow and highly functional, especially given that the quality of the technology itself can vary based on the vendor.  

Some current applications of AI for health plans include: 

Fraud, waste and abuse solutions

Value-based care initiatives

Claims Management

Coordination of Benefits

Predictive Analytics

Potential applications for advanced technology are much broader and include increased efficiencies and improved patient outcomes. Surveyed physicians have reported that AI is already improving the time they spent with patients, and 78% of healthcare business leaders say that the advanced technology “has helped drive workflow improvements, streamlining operational and administrative activities and delivering significant efficiencies toward transforming the future of healthcare.” Yet, explainability may hamper some AI adoption in the coming year. 

“Differentiating on price isn’t going to be the way to win in healthcare; differentiating on experience will be.”

Heather Cox, Humana’s chief digital health and analytics officer, on why Humana is investing in AI to enhance patient experience

In the coming year, healthcare payers will see technology disruptors enter the market. For many plans, a selection of effectively managed vendors will be the most effective strategy to drive ROI, though health payers will have to be careful of hype, particularly from tech vendors who lack industry experience. What works for one sector — say, finance — does not easily translate into healthcare, which is often more complex, more heavily regulated, and more data sensitive. 

Health payers will need to see all the moving parts of their tech ecosystem, including real-time metrics on vendor performance, in order to be able to see vendor lift, even if AI capabilities are touted. Increasing visibility across disparate departments and retrieving data from silos are exactly the type of improvements that show AI at its best. 

How Your Health Plan Can Utilize AI

You might think that being a fax/email/spreadsheet organization means your health plan is woefully out of date, but you might not be as behind as you fear. While AI can offer much-needed technology advantages to health plans, it isn’t capable of solving all payment integrity problems on its own. If a technology vendor is touting its AI capabilities, the solution should be more than a “black box of mystery.” You can and should deeply question and demand specific capabilities in regards to AI from a technology vendor. 

That said, AI is a crucial technology for health plans to adopt or expand upon within their organization. The massive amounts of data inherent in healthcare systems have presented a problem for the industry as a whole. With AI, data can be mined and utilized to harvest useful insights. Historical data can be loaded into the system and utilized alongside real-time data for predictive analytics. Pareo® offers multiple applications for AI as part of a broader “one-source” system insight platform for health plans and payers.

Despite IBM Watson falling short of expectations, AI technology will only continue to improve and the past year has proved that. At this stage, AI technologies may be more commonplace than you realize, but the true abilities of artificial intelligence vary between technology vendors. The most powerful way to harness AI capabilities is when they are applied as part of a broader solution, an advantage provided by an integrative platform like Pareo®

Talk to ClarisHealth about how Pareo® can transform your health plan’s payment integrity operations.

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Top 10 Reasons Health Plans Choose Pareo

Top 10 Reasons Health Plans Choose Pareo

It’s almost 2020, and forward-thinking health plans have a choice when it comes to total payment integrity solutions.

From smaller regional plans with 100k members to large national health plans with millions of lives covered, Pareo scales to accommodate all needs. Here are the top 10 reasons that health plans choose Pareo:

1. Reduce Administrative Spend

Health plans often seek out Pareo as a total payment integrity solution that eliminates administrative complexity, reducing overall spend. It’s estimated that 10% of all health care spending in the U.S. is wasteful, attributed to administrative costs that would be eliminated by more efficient processes.

The burden of cumbersome, manual admin processes lead MCOs to miss timely provider payments, tightening their provider network and placing an unnecessary burden on patients and providers.

For managed care organizations (MCOs), the cost to coordinate benefits is estimated at 12% of a health plan’s entire spend. ClarisHealth’s solution simplifies and automates workflows, allowing our clients to quickly optimize operations and reduce costs for coordination of benefits.

2. Optimize Relationships with Business Partners

For many health plans, bringing on more business partners to improve recoveries is a top-level goal. However, the inability to see the “bigger picture” makes it extremely difficult for health plans and their business partners to plug in easily or operate at maximum utilization. Pareo is able to optimize relationships with business partners, allowing health plans to grow their recoveries and easily coordinate goals with third-party payment integrity partners.

Pareo is able to benefit both health plans and business partners by offering easier onboarding, real-time feedback, fast turnaround on new concepts, and multi-beneficial sharing of information that’s customized to each business partner. We view our technology as a crucial connection that improves technology capabilities for health plans.

3. Eliminate Work Silos

Work silos are a byproduct of company structures, based on natural development of ideas and workflows within departments. However, it’s widely understood that these silos prevent the overall growth of an organization. The healthcare industry in particular has suffered from data siloing in large part due to manual, inefficient work processes.

As health plans seek to centralize their payment integrity efforts and break down data silos, they turn to Pareo. Our total payment integrity technology supports initiatives that break down silos, such as change management techniques, by culling system-wide data and presenting it through a single portal.

4. Organize Big Data

Data is an integral part of health plan operations, but many organizations struggle with the task of managing so much information. Pareo assists with process digitization, allowing our clients to move beyond spreadsheets and into a more dynamic platform.

When managing data is no longer of primary concern, health plans can move into activities that generate a higher return on their investment. Faster decision making and utilizing predictive analytics (both available with Pareo) can take a standard data report and turn it into actionable insights — all in real-time.

5. Modernize fraud,  waste and abuse mitigation

Health plans that want a more robust fraud prevention program seek also to address waste and abuse, a holistic approach that keeps a tighter cap on improper payment rates. Our clients use Pareo to …

  • Analyze post-adjudicated and post-pay claims data (useful as the Federal government is starting to look at how health plans do this)
  • Intelligently flag potential waste and abuse claims
  • Automate claims and auditing workflows
  • Introduce the application of AI technology 

Waste and abuse actually outsize fraud, but the terms are perceived as more ambiguous, resulting in the use of limited technology rather than broader solutions. Health plans may mistakenly think they’ve got payment integrity “covered” when they really only have fraud-prevention technology in place. By addressing a health plan’s entire payment integrity continuum, Pareo helps our clients transition more post-pay activities to prevention. 

6. Improve Provider Engagement

As more providers collect payment upfront and more payers look closely at member satisfaction, the intersection between the two has narrowed. Proactive health plans are seeking to improve provider engagement with the understanding that doing so has a direct effect on member satisfaction rates, and they’re choosing Pareo as the technology that supports this.

Keeping your health plan’s providers happy will also keep your members satisfied.

By automating activities, providing access to necessary claims documentation, and removing redundancies, Pareo is able to significantly minimize provider abrasion. We are firm believers in tracking a Net Promoter Score with your health plan’s providers as way of measuring improved engagement.

7. Control Claim Spend

Why settle for 1-2% as the rate of return on claims when you can get up to 10% by using Pareo? Total system visibility is required in order to control claim spend, but without understanding what’s possible, many health plans settle for less.

Overspending is a huge problem in healthcare, accounting for about $1 trillion of total healthcare expenditures in the U.S. With Pareo, you can actively track your spending on claims in real-time, allowing your health plan to quickly correct course. Excessive administrative costs, missed prevention opportunities, and unnecessary services are all causes of overspending. Pareo’s advanced analytics module allows health plans to gain traction on claim spend, improving recoveries and furthering ROI.

8. Access a community

I think by now many of us understand that organizations suffer when information isn’t shared. Health plans are seeking technology solutions that afford them access to shared expertise. While accessing a group of people who are looking for the exact same solutions that you are is incredibly valuable, another perk of being a member of a community of users is reaping the benefits sown by early adopters. Those first movers are often working closely (whether they know it or not) with QA to ensure your software experience is all the better. In addition, first movers can easily become super users and a source of community knowledge for other members.

Numerous health plans — of all different sizes, with different lines of business, etc. — all working within a common platform is a feature of the SaaS model, not an accidental by-product.

True, health plans have not historically unified on matters of business practice. At a time of rapid disruption, it’s helpful to realize that collaborative organizations have proven more effective. Real benefits of collaboration among departments, with other stakeholders and even with other health plans include: reducing administrative costs, fast-tracking innovation, and improving working relationships.

9. Integrate fragmented systems

Disparate data systems are being abandoned, but as API integration becomes the norm, many health plans are learning not all technology is created equal. With the declaration of APIs as the “better” solution for interoperability, health plans will need technology ecosystems that support integration and allow them to connect and visualize data in a meaningful way. 

The ability for a health plan to share data is mandated — and will continue to be closely watched and regulated once the Proposed Rules become final. For many, the ability to meet or exceed interoperability rules brings health plans to a “disrupt or be disrupted” type of choice. 

10. Transition more efforts to prepay

Post-pay concepts in a prepay environment? That’s just a pipe dream for health plans. Or is it? Payment accuracy isn’t a problem that’s going away anytime soon, but pay-and-chase is expensive for health plans to maintain. Leaders are looking for more ways to prevent improper payments from ever occurring but in order to do so, comprehensive insight and management is needed. 

ClarisHealth works with health plans to develop a specific implementation and use plan for Pareo that meets and often exceeds the goals you’ve outlined for your plan. The ability to transition more claims to prepay requires transformative technology solutions that can integrate disparate systems, such as those offered by Pareo. 

Talk to ClarisHealth about how Pareo® can transform your health plan’s payment integrity operations.

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