From Volume to Value: Alternative Payment Models Win During a Healthcare Crisis

From Volume to Value: Alternative Payment Models Win During a Healthcare Crisis

As patient volumes drop due to the COVID-19 pandemic, fee-for-service payment models hurt providers. Is this finally the time for value-based care? 

COVID-19 is decimating provider finances. Hospitals are losing over $40 billion per month in lost revenue due to canceled non-emergent inpatient and outpatient procedures. Physician practice revenue has been cut in half. These financial impacts are the direct result of the volume-based contracts in place at many providers, leading some to ask if this might finally be the right time for value-based care. In the words of one payer executive, “If there’s a silver lining to the crisis, it’s that we will now explore a value-based model which is going to be good for patients, good for providers and good for the community.” 

Let’s examine how fee-for-service reimbursement became the norm in healthcare, how it compares to value- and risk-based agreements, and how health plans are better positioned than ever before to successfully promote and implement alternative payment models like value-based care. 

A Brief History of Healthcare Payments 

Our last article in this series on the far-reaching impacts of the novel coronavirus pandemic called out that the structure of our healthcare industry has been in place for almost a hundred years. For the first half of the 20th century, fee-for-service payments made sense as there were limited numbers of interventions and medications that could be offered, and those were relatively low-cost.  

Medical advancements raise complexity, cost  

As medical advancements were made, complexity and cost increased. When the Medicare and Medicaid programs were created to help the elderly and low-income population receive care despite higher costs, their method of reimbursing for services provided the foundation for fee-for-service reimbursement. Later, as costs continued to increase, payment reform concentrated on payment caps but kept FFS reimbursement intact, which led to providers increasing the number of reimbursable services and patient throughput to maintain revenue.  

The rise of managed care and value-based care 

In the 1990s, “managed care” initiatives slowed the growth of healthcare spending by reducing utilization. But they also concentrated healthcare decision making outside of the patient-provider relationship, which unnecessarily increased friction and led to their demise. In 2010 the Affordable Care Act mandated a few value-based care programs administered by CMS. Bundled payments that offered higher fees for higher-quality providers were also introduced as a middle ground between FFS and capitation. 

Though there have been gains in value-based care contracts, most provider revenues are still based on patient volume. A recent survey revealed that while 57% of provider respondents were participating in value-based care arrangements, 48% report that over three-quarters of their organization’s revenue is tied to FFS. 

It’s not just finances, it’s personal: Provider burnout exacerbated by COVID-19 

The financial hit that providers are taking is secondary to the fact that many are putting their lives on the line as they stand at the forefront of the novel coronavirus crisis. But health plans are paying attention to an underlying issue many providers face: professional burnout. 42% of physicians surveyed in 2018 reported feeling burned out while 15% admitted experiencing some form of depression. Those most likely to be burned out are the same ones most likely to be working the front line: critical care, internal medicine and emergency medicine.  

It’s possible that a shift to value-based care and telehealth could offer more work-life balance for medical professionals, and health plans are taking note as they look to support their networks of providers during and after this healthcare crisis.  

Why Continue Fee-for-Service 

Especially in the short-term, fee-for-service reimbursement provides a straightforward, familiar model that encourages providers to continue to offer healthcare during a time when its most needed. And, as many states lift restrictions on elective procedures, many providers expect pent-up demand for healthcare to rebound patient volume and revenue right along with it. Close to 40% of people who had elective procedures canceled plan to reschedule. 

ACO experiences 

Accountable Care Organizations make up a big chunk of the providers participating in alternative payment models. But with their large Medicare populations, the coronavirus pandemic created more risk than they had planned on. In a survey, more than half of ACOs, which earn shared savings based on total spending, were considering exiting the program due to uncertainty and expected financial losses. 

Fortunately for ACOs, CMS stepped in with a new rule that aims to protect them from unforeseen financial impacts. These changes remove spending on COVID-19 patients from performance calculations, expand the definition of primary care services to include telehealth, and more. Nevertheless, this scare may deter other providers from participating in value-based care arrangements. 

Risk-averse providers

Historically, providers have been reluctant to take on the additional risk inherent in value-based care contracts. And, who can blame them? It has been difficult to come to consensus on what “value” and “quality” really mean, and lack of data interoperability only exacerbates that issue by keeping essential information on outcomes out of reach for providers. Furthermore, even before the COVID-19 crisis, many providers were already struggling due to burnout, financial issues and hospital closures. 

When providers enter into alternative payment models, it takes significant resources. With increasing Medicaid and uninsured populations, they may not have it to spare. Physician practices are closing and increasing consolidations are expected in the wake of the novel coronavirus pandemic. This translates into reduced capacity for preventive care and less provider incentives to engage in risk-sharing.   

6 Primary Payment Models

While fee-for-service will likely always exist in some form, in response to growing healthcare costs (now almost 20% of GDP), public and private payers have launched innovative provider payment models designed to reward value over volume. Source 

  • Fee-for-service 
  • Bundled payment 
  • Capitation 
  • Pay-for-performance / Shared savings 
  • Blended payment 
  • Salary 

Why Transition to Value-Based Care  

While an immediate switch to at-risk contracts may not be advisable, long-term, value-based care promises to position the U.S. healthcare system to better respond to future healthcare crises. Those providers currently participating in alternative payment models haven’t experienced the same drop in revenues as those whose survival depends on patient volume. And they are more likely to pursue population health improvements that stand to keep their patients healthier during the pandemic. 

Surprise assist from telehealth 

One unexpected boon from the pandemic is the increased adoption of telehealth. Investments in telehealth and other methods of virtual care are key moves by providers that lend themselves nicely to value-based care initiatives of lowering the cost of care and increasing patient engagement. These investments were made because payment parity kicked in. Before, according to one survey, 60% of primary care clinicians reported the majority of their work was not reimbursed or funded, a big portion of which was telehealth.  

Now, telehealth allows them to accommodate surges in capacity, if needed, and focus on caring for vulnerable populations, so important during a pandemic that disproportionately affects these groups. As one physician says about the pandemic recovery and the role of virtual care in population health management, “This is going to be a phased-in thing and the sickest of the patients are the ones that we need to continue to be able to see to provide care for and get reimbursed for in a virtual modality.” 

Change slow but inevitable 

Those providers who continue to cling to FFS may be left behind and unable to participate in many future healthcare initiatives. CMS, in particular, has been transitioning to value-based care at an accelerated rate since the ACA was passed 10 years ago. A 2019 report showed that 35.8% of total U.S. healthcare payments in 2018 were tied to alternative payment models, a year-over-year increase of 34%. 

Moreover, the industry has begun to come together on value measurements and alternative payment model frameworks. Government payers and commercial health plans are still the primary drivers of value-based care, but universal standards go a long way towards removing uncertainty by increasing transparency. 

How Health Plans Can Support Alternative Payment Models 

We’ve written before about how payers can best support the transition to value-based care: improve provider relationships and data transparency with the help of advanced technology. That advice hasn’t changed, though the COVID-19 crisis may have increased the importance of these initiatives. 

Provider communication 

Collaboration and shared understanding enabled by real-time, two-way communication with providers is essential to the success of value-based care programs, and there is still plenty of work to do in this arena. A recent survey showed that as many as 18% of providers have zero trust in the payers they work with, and more than a third have no communication with those payers. We wrote in a previous article that the COVID-19 crisis has led payers to increase their support of providers, which may provide an opening for health plans to shore up these relationships.   

Without trust, it’s difficult to ask providers to assume more risk. In fact, a survey found that primary care physicians who trust the health plans they work with are more than twice as willing to engage in risk-sharing. As a stakeholder at a regional commercial health plan puts it, “Value-based care is payer driven, but provider and hospital partners need to come together and recognize something bigger. We’re not just trying to do something niche. We’re trying to help people prosper across our population.” 

Data transparency 

Value-based care initiatives depend on data as well. Data that reveals which populations need targeted outreach and how healthcare impacts outcomes is valuable to payers and providers alike. Lack of data interoperability between payers and providers is the number one roadblock that prevents healthcare innovation.  

Breaking down data silos can help mitigate the differing interpretations of value and quality that hold back progress on alternative payment models. So, measure everything. Every impact—clinical quality, consumer experience, return on investment, and more—should be quantified, analyzed, improved, reanalyzed and continually improved in collaboration with providers. Work with providers to implement an analytics and communications platform to share data insights and work together on continuous improvements and innovations.  

Advanced technology essential 

Value-based care promises to lower the cost of healthcare and improve outcomes. These goals were important before the emergence of the novel coronavirus and are now essential directives. But these risk-sharing contracts require advanced technology in order to implement them. CMS has suspended data collection and quality reporting so providers can focus on patient care, but health plans executing on advanced digital strategies won’t miss a beat.  

With integrative technology like Pareo in place, health plans can seamlessly communicate with providers and ingest electronic clinical care and claims information without unduly burdening these valuable relationships. They can come together in identifying and engaging those members who are in most need and find efficiencies without sacrificing quality or the doctor-patient bond. It’s the future of healthcare and it’s achievable now. 


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

Coronavirus New Normal: What does it mean for health plan members?

Coronavirus New Normal: What does it mean for health plan members?

25 million Americans projected to lose employer-sponsored healthcare coverage due to the COVID-19 recession. How will this disruption affect the relationship between health plans and consumers? 

As of the end of April 2020, about 30 million people in the U.S. are newly unemployed due to the pandemic-fueled economic shutdown, a sharp uptick from the recent historically low unemployment rate. Because, on average, about half of the people in this country receive health insurance through an employer, this situation is threatening healthcare coverage during a healthcare crisis. How is this disruption affecting health plan operations and consumers, and will it create longer-term changes in how the majority of Americans receive health insurance? 

The Financial Impact 

A variety of government and social policies in the 1940s and 50s led to the current state of healthcare coverage in the U.S. where most individuals receive insurance through an employer-sponsored health plan. While that structure functions fairly well during periods of low unemployment and underemployment, it can leave a gap during a climate of economic and job uncertainty. 

In the 6-week period between mid-March and the end of April, the unemployment rate soared from sub-5% to over 16% as efforts to stem the spread of the novel coronavirus ravaged the economy and led to widespread furloughs and layoffs of workers. By some estimates, that massive job loss has resulted in 12.7 million Americans losing their healthcare coverage at the same time they can least afford to replace that coverage. 

Health plans started to see the fallout of this rapidly changing situation almost immediately. One of the largest health plans in the nation reported that the number of its premium base requesting grace periods and payment plans increased from 0.4% to over 3% by mid-April. However, this standard practice of 60- or 90-day grace periods is expected to be not nearly enough relief for many members, leading one to offer premium credits and other financial assistance. 

Recognizing the potential impact to cash-strapped consumers, assorted medical and insurance groups are lobbying for assorted financial and healthcare coverage support measures: 

  • Offer employer subsidies 
  • Subsidize or cover COBRA benefits cost 
  • Open special enrollment periods 
  • Increase subsidies for ACA marketplace plans 

Already enacted is a 6.2% increase in federal matching Medicaid funds to help states handle the pandemic for the duration of the national public health emergency. Included in the eligibility requirements for the enhanced funds are provisions that require states to not unduly prevent qualifying individuals from receiving Medicaid coverage. 

The Healthcare Impact 

Consumers losing their income and reliable health insurance coverage during a healthcare crisis is an untenable situation. recent survey revealed a potentially precarious financial situation for a segment of the population. When asked if they would seek medical attention if they presented with the signature symptoms of COVID-19, 14% said they would avoid care due to cost. Even when asked specifically to imagine a suspected coronavirus infection, 9% still would avoid treatment. These responses were especially likely for those with lower incomes, a group that has been disproportionately affected by the current economic crisis. 

This hesitation to seek care couldn’t come at a worse time as the delays promise to derail chronic condition outcomes as well as public health initiatives related to the pandemic. However, putting off care due to financial constraints isn’t an entirely new experience. An annual poll, most recently conducted in November 2019, showed that a record 33% of Americans put off needed medical care due to costs, a rate that has increased 50% over the past 20 years. 

Health plans and the government have stepped in to encourage people to continue to seek healthcare if they need it. Health plans by temporarily waiving cost sharing for coronavirus testing and treatment, as well as other services for vulnerable Medicare members, and the government by compensating providers for uninsured care at Medicare rates so providers don’t unnecessarily burden patients without a safety net. 

Health Insurance by the Numbers

The latest healthcare coverage data available is from 2018. After years of improvement in the uninsured rate, starting in 2010 with the enactment of the ACA, the rate has increased for 2 years in a row, particularly in states that haven’t expanded Medicaid. 

  • Employer Insurance 55.1% 
  • Medicaid 17.9% 
  • Medicare 17.8% 
  • Individual Market 7.5%  
  • ACA Marketplace 3.3% 
  • Military 3.6% 
  • Uninsured 8.5% 

The Future of Healthcare Coverage 

With the rising costs of healthcare coverage shouldered by employers, and the opening of the ACA marketplace, some analysts predicted that 90% of employers would have abandoned sponsored health benefits packages by now, in the same way pensions gave way to 401(k) plans. That projected reality hasn’t yet come to fruition, though the rates of “underinsured” individuals with employer plans are increasing  

The number of uninsured employed people is also increasing, according to a recent studyIn fact, 70% of the uninsured were employed but not offered an employer-sponsored health plan while 30% didn’t enroll in employer coverage because of high costs. At the same time, high rates of unemployment bring into focus the potential gaps created by tying healthcare to jobs, and we likely have not reached peak unemployment in the COVID-19 recession. 

Single Payer Unlikely for Now 

Though the past couple of years saw single-payer policies gaining traction, strong lobbying against the structure has prevailed for now. However, much depends on how quickly the economy rebounds and to what degree. Large corporations make up much of the enrollment in employer-sponsored health plans and continue to drive that segment, and many of them have weathered this economic downturn with greater resilience thus far 

Though healthcare independent of the workplace is currently more important than ever before, the current system is still working for many people. Enhancing ACA plans and subsidies and expanding Medicaid to more people are the most cost-effective – and quickest to implement – efforts and stand to benefit those most affected by income hardships. 

Higher Medicaid Enrollment 

Experts released a new report that projects unemployment will reach 20% by June 2020, which would lead to between 25 million and 43 million individuals dropping out of employer health plans. Of those, 12 million to 21 million will enroll in Medicaid, 6 million to 10 million will receive individual coverage through the ACA marketplace, and 7 million to 12 million will become uninsured. According to a senior policy advisor, “Our safety net is about to be tested, and it’s going to work a lot better in states that expanded Medicaid.” 

Data Insights Key to Health Plan Response 

Short-term, for health plans this shift means a dramatic change in their lines of businessHealth plans that cannot quickly pivot based on data and market changes are at risk. If employer-sponsored coverage changes for the long-term, are health plans positioned to navigate these twists and turns 

Some payers are already making moves specifically focused on expanding their Medicaid and Medicare portfolios. As stated in the announcement of one of these deals, the health plan’s “strengths and capabilities will be critical to successfully serving new populations if a recession increases Medicaid membership.” At the same time, health plans report uncertainty in their 2020 projections, as small group enrollment drops and Medicaid rolls increase. Health plans are having to prepare for all eventualities, and advanced integrative technology – along with the data insights it provides – can provide the edge they need. 

Evaluate Consumer Behavior Changes 

Health plans are keen to harvest business insights from member behavior during this time. They anticipate the pandemic changing the way care is delivered for at least 1-2 years and likely, forever. Most health plans are anxiously awaiting the emergence from the “first wave” of COVID-19 cases (possibly this Summer) to see how user behavior is affected and try to strategize on long-term effects. 

With so many workers furloughed or laid off, we may see a return to insurance after this first emergence, which provides a strong opportunity for health plans to find an early indicator of longerterm behavior change that would impact their bottom line. Data on utilization of care, self-insured rates, changes in plan levels and HSAs, and more will prove valuable. 

Reduce Administrative Complexity 

Administering Medicaid MCO plans is a more complex operation, especially as CMS has issued waivers to help states be more nimble in responding to coronavirus. Medicaid lines of business also tend to be less profitable than employer-sponsored insurance. Increasingly, health plans and payers are turning to advanced payment integrity technology like Pareo to streamline coordination of benefits and otherwise ensure proper payments to providers.  

And, by virtue of being an integrative platform, it helps reduce administrative lift in tangential operations related to traditional payment integrity efforts as wellPareo supports health plans in seamlessly shifting internal resources to more easily accommodate changes in LOB, and automating communication with suppliers and providers to ensure changes are relayed effectively and efficiently.  

Improve Engagement 

Leaders of health plans know that the way insurance is delivered may change for many consumers and, particularly for Medicaid enrollees, engagement is paramount. Technology enables them to proactively address at-risk populations, like those with chronic conditions who may be particularly vulnerable to disruptions in care. By delivering broader data insights and supporting communication with internal and external stakeholders, Pareo aligns with a broader strategic effort at health plans to “improve engagement in healthcare.”  


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

Coronavirus Crushes Providers. Health Plans to the Rescue!

Coronavirus Crushes Providers. Health Plans to the Rescue!

To support healthcare providers financially impacted by COVID-19, health plans rush to provide funds, ease administrative burden with prepay and engagement initiatives. 

Right now, the healthcare industry is in the thick of the novel coronavirus pandemic, with providers bearing the brunt of the impact. Already risking their health in service of sick and scared patients, providers of all stripes – hospitals and private practice alike – are facing another dilemma. How will they survive financially? With the understanding that healthcare providers are one of our best assets in fighting COVID-19 and ensuring a healthy population, the government and private payers are taking short-term and long-term action to shore up this valuable resource. Immediately, by directly and indirectly paying out funds to providers. Longer-term, by investing in prepay and engagement tools to decrease providers’ administrative burden. 

In recent weeks, there’s not a health plan we’ve spoken with that isn’t striving to support those on the front line as best they can. But we know that health plans will also need support. We have had numerous internal discussions around how we view the current industry situation. Here are some of the short-term and long-term actions we see occurring 

Short-Term Action: Inject Monetary Support 

The COVID-19 crisis has created a perfect storm of financial issues for providers:  

  • In order to keep exposure to a minimum, elective procedures have been delayed indefinitely, and patients are self-selecting to avoid preventive care and other non-emergent healthcare. In our largely fee-for-service (FFS) environment, that means a huge chunk of revenue has evaporated for hospitals and physician practices 
  • In some locations, patient volume is not an issue because of the sheer number of patients needing COVID-19 treatment. However, the number of uninsured and patients with high-deductible health plans means the considerable treatment costs – $20,000-70,000 according to some estimates – will be difficult to recoup. 
  • At the same time, providers are having to devote what little funds they do have to high-priced personal protective equipment (PPE) and ventilators, as well as infrastructure to support telehealth visits. 
Direct payments 

From the government, CMS has released the first $30 billion of the $100 billion earmarked for providers in the Coronavirus Aid, Relief and Economic Security (CARES) Act. This federal stimulus money is based on Medicare FFS volumes and does not have to be repaid. In addition, CMS is offered $34 billion in accelerated payments to providers, again based on Medicare FFS revenueas a loan to be repaid within seven months to one yearAdditional stimulus funds, particularly to providers who serve primarily Medicaid populations as well as those in COVID-19 hotspots, are likely forthcoming. 

Commercial health plans also have stepped up with direct cash grants to providers, in one instance providing up to $200 million through financing guarantees, advance payments and the restructuring of contracts. 

Indirect relief 

In addition to directly paying providers, new policies directed toward members promise to relieve providers of the costs incurred to treat COVID-19 patients. Many health plans have pledged to waive cost sharing for testing and inpatient admissions and reimburse telehealth at the same rate as in-person visits. The First Coronavirus Response Act (the FFCRA) and the CARES Act require commercial health insurers to provide testing and care visits at no cost to further increase the chances of providers being reimbursed for expenses incurred. 

Additionally, health plans are relieving providers’ administrative burden short-term by reducing prior authorization requirements, including for those patients not affected by the virus, and providing triage tools so they can make best use of limited resources. Health plans are also re-thinking payment integrity activities most likely to cause provider abrasion and pausing aggressive post-pay claims audits. 

Long-Term Action: Reduce Administrative Burden 

No matter the short-term relief provided, if the “business as usual” response kicks in, providers – many of whom are either at the front lines or have lost revenue – are likely to grow increasingly frustrated with the red tape that characterizes their payer relationships. The goodwill generated by financial support will dwindle as time goes on. But these challenges aren’t unanswerable. Health plans can rapidly innovate, prioritizing technologies that reduce administrative waste and increase collaboration and engagement between payers and providers. 

Strategic shift to prepay 

With as few as 15 days to make a pay/deny decision on a claim, many health plans choose “pay and chase.” But is this a risk that payers want to take during the COVID-19 crisis compounded by a stressed economy? For some health plans, the pandemic serves as a catalyst to grow prepay effortsAlready a long-term goal for many, the commitment to reducing provider abrasion has prioritized this shift 

This risk of delayed income could be reduced if health plans had a robust prepay operation that could quickly identify and respond to overpayment trends before claim payment. Prepay efforts – while not frictionless – create less abrasion among the provider community and can be continued in extraordinary times like the one we find ourselves in now. In addition, a shift to prepay reduces administrative burdens for health plans and providers while reducing improper payment risk.

What codes should providers use for COVID-19 testing and diagnosis? 

New codes have been published to designate healthcare encounters
related to the novel coronavirus:

  • ICD-10 
    • Pneumonia: J12.89 and B97.29 
    • Bronchitis: J20.8 and B97.29, or J40 and B97.29 
    • Respiratory infection: J22 and B97.29, or J98.8 and B97.29 
    • ARDS: J80 and B97.29  
    • Exposure: ruled out Z03.818, confirmed Z20.828 
  • HCPCS 
    • CDC laboratory test: U0001 
    • Non-CDC laboratory test: U0002 
  • CPT 
    • Test: 87635 

For current Pareo clients, it’s easy to move more claims work prepay. The integrative platform allows a health plan to ingest data from multiple sources (such as CMS, states, claims, etc.), apply successful post-pay concepts prepay, configure workflows to effectively stack internal and vendor efforts – including fraud, waste and abuse mitigation – and make fast payment decisions. 

Engage providers 

Some suggest that health plans cannot move swiftly enough on urgent care coordination responses, like prior authorizations, that have left patients without COVID-19 taking up valuable hospital beds as they await discharge. And, strategically shifting the payment integrity mix to include more prepay internal efforts won’t do much on their own to support valuable network providers and decrease abrasion. Solution? Real-time engagement and communication. 

Some health plans already use tools like portals to push messages to providers, like sending prepay information to providers along with education on how to correct incorrect billing issues. While that is a starttrue engagement is a more encompassing initiative, one that mutually beneficial advanced technology can help support. Think of dashboards that highlight key performance indicators of the payer-provider relationship, integration with the EHR to streamline clinical documentation requests, and the ability to automate underpayment and denials inventory management.  

Proactively and continuously opening the lines of communication with providers eases their administrative burden at a time they need it most. This initiative will pay dividends for health plans and providers alike, long after the threat of the pandemic has passed, paving the way for needed innovations that will transform the industry and set us up to weather future challenges. 


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

Your health plan’s best crisis response strategy? Innovation.

Your health plan’s best crisis response strategy? Innovation.

Health plans set themselves up for success – during a pandemic and beyond – by pursuing advanced technology to engage providers, satisfy members, and improve population health initiatives.

The healthcare system is on the front lines of the novel Coronavirus pandemic, working tirelessly day after day to heal the sick and comfort the anxious. Health plans, in understanding the potential impact to members, are taking unprecedented steps in waiving copays and cost-sharing for testing and treatment. What stands before all of us is both crisis and opportunity. How you respond has the potential to cement your place in history as a visionary.

A recent Best’s Special Report lauded healthcare payers’ steps towards innovation in technology and partnerships, noting that these leaps are often prompted by times of change and urgency. Challenging situations often exacerbate whatever is not working as well as it should be, evolving annoyances into major problems that need to be fixed pronto. If necessity is the mother of invention, we should expect accelerated adoption of technology and other innovations intended to alleviate pain points during this “black swan” event.

In particular, health plans are likely to push payer-provider relationships, member service, and population health initiatives dramatically forward, moves that hold the potential to change the healthcare landscape permanently for the better. Let’s explore those three drivers in depth.

Improve Payer-Provider Collaboration While Moving to Prepay

We’ve written at length on the need for health plans and their network providers to open the lines of communication and work together to improve broken processes. During the pandemic, that engagement becomes even more essential. Many providers are on the front lines combatting the COVID-19 crisis, adjusting to new care delivery models overnight, losing revenue, or some combination of these. How is your health plan delivering updates to your providers on changes to telehealth coverage, adjusted reimbursement for novel Coronavirus testing and treatment, and select prior authorization waivers?

Health plans are understandably holding off on aggressive payment integrity pursuits at this time, instead focusing on issuing payment as fast as possible, recognizing that over-taxed provider teams don’t need another stressor to contend with. But even before this crisis came to be, the transition to value-based care and an overall shift from payers denying payment to more guiding of care were impacting the payer-provider relationship. Immediate solutions to ease burdens on providers are great in the short-term, but payers will have to think long-term about shifting more claims work to prepay to avoid pay and chase activities.

Shifting to prepay has long been a challenge for health plans because payment decisions on claims must be made quickly, often within two weeks. With numerous disparate data streams and systems at play, payers have not been able to be as agile in prepay as they would prefer. But advanced technology facilitates more seamless coordination with providers, which is required for frictionless payment integrity strategies, including prepay, as well as advanced payment models.

Pareo enables users to easily apply post-pay concepts to prepay and access the information they need to make payment decisions in real-time, which supports your most ambitious internalization strategies. And because Pareo offers a Provider portal to facilitate communication between plans, third-party suppliers and providers, Pareo clients can shift more work prepay while avoiding provider abrasion.

Focus on Members

While health plans have put member service upgrades at the top of their investment lists for a while now, the pandemic has fast-tracked a few of the most crucial. Primarily, technology initiatives that make healthcare available from anywhere, both for convenience and safety reasons.

Providers rely on wearables and remote monitoring devices to manage chronic diseases and detect infections earlier – early evidence shows wearables can even be used to monitor Covid symptoms. Changes in acceptable parameters for telehealth reimbursement by CMS combined with patients embracing the interface promise to change that encounter mix long-term. A recent survey illustrates consumers’ changing mindset around telehealth visits, due to the novel Coronavirus. Though only 25% have ever had a remote health visit, 59% said they are more likely to use telehealth services now than in the past, and 36% would switch their physician in order to have access to virtual care.

Health plans are also embracing technology for streamlined and relevant communications with their members, including chatbots and responsive risk-assessment tools. As one leader of a tech-forward health plan puts it, “It’s all of our digital engagement channels that are required to come together in order to help guide our members through this anxious and uncertain time.”

Make Strides in Population Health Management

One shortcoming this pandemic has highlighted is that the drive towards value-based care is warranted. Value-based care contributes to improved rates of preventive care, leading to a healthier population. This is important, because pandemics like the coronavirus have been shown to prey on those who have certain pre-existing conditions at greater rates than those who do not. Yet addressing population health at a national level requires a great level of coordination among all stakeholders to identify, treat, evaluate and quantify investments in population health management.

Interoperability and the ability to process big data take outsize importance, too. During a disease outbreak, early mapping data could help healthcare organizations and government agencies identify areas where there’s a concentration of people with likely symptoms and therefore higher needs. Testing and disease tracing have proved more effective at containment. Even HIPAA recognizes the advantages of sharing health information during a pandemic and announced a temporary, narrow relaxation of enforcement during this time. “Granting HIPAA business associates greater freedom to cooperate and exchange information with public health and oversight agencies can help flatten the curve and potentially save lives.”

Pareo can assist in care management for health plans by identifying populations at risk, engaging patients and optimizing the care pathway:

  • Predictive modeling that analyzes the patient population from millions of data points helps identify risk factors of early disease.
  • Data modeling delivers lists of current patients and non-patients at risk so they can be engaged, leading to earlier diagnosis and treatment.
  • Care pathways are optimized to provide better, more affordable patient care while increasing the efficiency of your provider network.

Many health plans have already piloted initiatives that address social determinants of health and otherwise target vulnerable segments of the membership for early intervention that promises to improve outcomes and lower costs. A global public health issue like the novel coronavirus prioritizes exactly this sort of useful application of big data analytics.

Technology for the Win

Health plans have been increasingly turning to advanced technology as it evolves to better address a number of operational challenges. Platforms like Pareo that bring together disparate systems and stakeholders, allow for secure remote access, and leverage modern analytics and applications of A.I. to harness the power of big data offer payers a competitive advantage during the best of times and less predictable situations alike. By controlling more of your payment integrity continuum, you are in a better position to optimize your medical spend and drive improvements in the industry as a whole.

Health plans have long been bracing for disruption in an outdated industry. And like all innovators, they’re likely realizing that a global pandemic creates an opportunity to improve on processes and technologies quickly. Improving provider-payer engagement, moving more claims work to prepay, and leveraging technology to improve member satisfaction as well as health plan operations all contribute to broader goals like value-based care and interoperability.


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

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 how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies.

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.  

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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 how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies.