Keeping Up with 2021 Healthcare Payer Technology Trends

Keeping Up with 2021 Healthcare Payer Technology Trends

Reviewing the drivers, restraints, challenges and opportunities for healthcare payer technology in 2021.

Those organizations that kept pace with healthcare payer technology trends weathered the uncertainty of this year relatively unscathed. In fact, 2020 made the strongest case yet for health plans succeeding with technology. If your health plan felt less prepared, you may have increased the intensity of your strategic planning efforts to ensure your health plan is on the right track. To that end, let’s explore the industry drivers, restraints, challenges and opportunities impacting these strategies as we look to 2021.

Drivers: Top Motivators for Health Plans in 2020

We can’t reflect on the past year and look forward to 2021 without addressing the novel coronavirus pandemic. It stands to have an outsized impact on the industry for years to come. And even though it didn’t uncover any unknown issues, it accelerated the need for solutions practically overnight.

Because COVID-19 so efficiently highlighted known gaps in the healthcare system – including how far behind many stakeholders are digitally – it is the source of the primary drivers for healthcare payer technology. Health plans must take care of these in the coming year or risk falling even further behind.

Calls for increased transparency

In 2019, we predicted that "health organizations will need to make real upgrades in technology if they haven’t already, or face issues meeting government regulations.” And in 2020, two rules brought this prediction to the forefront.

First, the rules against information blocking were finalized. Though deadlines for compliance have been delayed, the need for healthcare data interoperability has never been greater. This initiative is poised to solve several of the issues worsened by the pandemic, and health plans will continue to push for increased data sharing. Improvements in care quality and decision-making and progress on value-based care programs should result.

The administration also finalized a price transparency rule. It calls for first posting online documents that include prices for healthcare services and medications. A “shoppable” experience for consumers will follow.

The ultimate goal of technology is to break down barriers and allow information to empower a better healthcare system. Health plans have realized advanced technology is only as good as the data that fuels it. With interoperability, data accessibility and transparency as a focus, health plans will naturally evolve to start questioning any process within their organization that inhibits information sharing.

“Health plans that are able to adapt to these changing trends are far better positioned for long-term success.” FierceHealthcare

Work-from-anywhere environment

Improving data accessibility extends to internal operations at payers as well. The modern work-from-anywhere environment has arrived. The technology that supports it must follow. Health plans have adapted to the “do more with less” credo that pervades most industries, but manual and labor-intensive processes only contribute to the administrative burden.

By adopting integrative technology platforms, health plans can eliminate data silos and improve collaboration and oversight. As payers start to experience the big picture benefits of advanced technology, health plans will be able to work towards becoming more proactive and less reactive.

Changes in membership mix

Health plans have started to experience shifts in their lines of business. This year has brought an influx of members into Medicare Advantage, Medicaid and ACA plans. While severe impacts to employer-sponsored plans have not yet materialized, how consumers think about healthcare coverage has changed for good.

Members are tasked with owning their own healthcare experience and expect the relationship with their health payer to be frictionless and intuitive. Not meeting consumer demand will open payers up to disruption. But if health plans make technology decisions with their eye firmly on the member, they will also find numerous opportunities to improve program integrity efforts.

Changing competitive landscape

Increasing consolidation among health systems and payers is also motivating health plans to innovate. They understand that relying on legacy technology and paper-intensive processes minimizes the ability to scale. Health plans are taking steps now to upgrade their position.

And not a moment too soon. The long-predicted disruption to healthcare has arrived as top retailers have made bigger inroads in the industry. In an increasingly consumer-driven environment, demonstrating value to members and employers is key. Payers with a tech-first mindset – and the ecosystem to match – will have the strategic advantage in these situations.

At the same time, health plans will see more technology vendors looking to leverage experience with other industries into similar successes in the healthcare sector. Technology can help rapidly improve ROI on the claims recovery process. But health plans will need to shrewdly evaluate these solutions to ensure a good fit.

Restraints: Navigating the Roadblocks Health Plans Face

Health plans have long known the advantages of advanced healthcare payer technology. But the usual suspects continue to block progress. Slim margins, data security concerns and shortages in skilled workers could prevent health plans from making headway on their goals this year.

Uncertain medical loss ratios

The uncertainty around how the ongoing pandemic will affect medical loss ratios has some health plans putting strategic technology investments on hold. Profits at most insurers have risen this year, but many industry leaders predict a forthcoming correction. Combined with the historic struggles to efficiently and effectively transition to digital processes, taking on new technology projects may feel too risky in the short-term.

Health plans can overcome this perceived risk by seeking out solutions that surface quick wins and set them up for long-term advantages. Look for speed to value. Enterprise healthcare payer technology that is easy to implement, builds empathy with stakeholders, improves efficiency and reduces team frustration will pay dividends.

Concerns about data security

Dealing with large amounts of patient data makes health plans a prime target for security breaches. And the entire industry trying to quickly integrate numerous data sources has the potential to create vulnerabilities in the system. But health plans moving too slowly with technology adoption can lead to irreparable harm as well.

Current manual approaches to PHI – locally stored data, paper faxes, etc. – are even more vulnerable than secure digital processes. Modern technology, on the other hand, can grant you more control. It allows you to be more granular with granting access to PHI, for one. It also creates a digital log of access. For even greater peace of mind, seek out HIPAA-compliant technology vendors that pursue HITRUST CSF and SOC 2 certifications.

Unexpected costs of outsourcing

The data sharing and transparency regulations and other technology initiatives have payers concerned about how they will pay for and staff these projects. Additionally, health plans will have to overcome learning curves, fear of change and other internal challenges as they select solutions and look for increased returns. The vast majority – 79% – will look to outside vendors to cover these gaps.

Predictable costs will make these burdens easier to bear. Off-the-shelf solutions that are easily configurable will prove more cost-effective than custom-built technology. And a strategic combination of insourcing and outsourcing activity based on health plan core competencies will also optimize spend. A partner and technology that allows you the flexibility to decide – service by service – whether to outsource or insource based on your cost-benefit analysis will better poise your health plan to scale effectively.

Challenges: Factors for 2021

Internal restraints aren’t the only barrier to success with healthcare payer technology. Let’s look at the broader industry factors that could challenge health plans in 2021.

Provider financial instability

So far, providers have borne the brunt of the pandemic financially, and their survival is at risk. Healthcare payer technology strategies will need to support this valuable group. Without a broad network of providers, health plans will find it difficult to advance on engaging members and lowering healthcare costs. Health plans that use technology to focus on this relationship can overcome this challenge. Consider solutions that ease providers’ claims payment administrative burden and support real-time communication.

Slow adoption of value-based care

Value-based care continues its slow adoption among providers. Those participating in alternative payment models performed better than their fee-for-service counterparts in 2020. They also are more likely to pursue population health improvements that stand to keep their patients healthier during the pandemic. But other providers may hesitate to take on more risk.

Health plans can support providers in this transition with healthcare payer technology that overcomes trust and abrasion issues. Increase data transparency so both sides of the relationship are working from the same playbook. Come to agreement on interpretations of value and quality. And measure everything: clinical quality, consumer experience, return on investment, and more. Then share those data insights and work together on continuous improvements and innovations.

Considerations for selection to participate in CMS’ largest bet on value-based care to date “will include an entity's risk-sharing experience, IT infrastructure, compliance and beneficiary engagement.” Healthcare Dive

Uncertain political landscape

A new administration will be in place this coming year, including new leaders at government healthcare agencies. Stabilizing the coronavirus response will likely be the focus of any short-term action, which most healthcare stakeholders should welcome. Whether or not additional burdensome regulations or market changes will be introduced is currently unknown. Agile, tech-forward health plans will be positioned to succeed no matter what happens on this front.

Opportunities: Chances to Excel with Healthcare Payer Technology

While challenges abound in an uncertain healthcare environment, so does opportunity. Changing member behavior and technology advancements may both offer health plans the chance to succeed with their digital transformation goals.

Members open to engagement

One unexpected benefit of this year is how it has opened up avenues for member engagement. People want to hear more from those responsible for their care. They have embraced home health. And they have welcomed technology into their healthcare unlike ever before.

Payers have caught on to the fact that providing improved member services is a differentiator in a consumer-driven market. By offering convenience and addressing social determinants of health, plans can offer broader benefits with perceived higher values while lowering costs. CMS has made it easier for health plans to offer supplemental benefits, another incentive for offering them. With health plans expanding coverage in this area, digital health adoption will continue to grow.

"Leveraging the power of your lifestyle and combining it with research and technology will enable people to take full control in their health journey. With the cost of healthcare rising, providing tools to prevent or reverse diseases that could be costly for patients and the system is a win-win.” Health plan Chief Innovation Officer

Advancements in technology

Technology advancements continue, as API standards are enacted and artificial intelligence capabilities improve. Plans can leverage the mountains of data they collect through improved data analytics technology, reducing time to reports and empowering real-time decision making. And these updates come just in time. Expansion of digital healthcare may prompt more incidents of improper payments and bad actors. But A.I. has also pushed forward opportunities to proactively combat fraud, waste and abuse. By going deeper and wider into the data to push likely leads to you, new schemes won’t pass you by. This improved technology can better integrate the SIU with overall payment integrity as well.

Through secure integrations, data sharing could be a hurdle that health plans finally surpass. Cognitive collaboration capabilities will emerge for health plans if they utilize the right technology solutions. Empowering users to break down barriers within their organization will drive efficiencies and improve the care continuum.

Partner to Make 2021 the Best Year Yet

Health plans can stay ahead of the curve by making strategic investments in change, particularly surrounding transparency. Integrative technology and shifts in program integrity approaches will allow payers to continue to gain ground and focus on proactive efforts, particularly when it comes to claims recovery and payment integrity.

Extending your competitive advantage transcends trends. Fortunately, a comprehensive technology platform like Pareo allows health plans to scale and improve processes, harness the power of A.I., increase medical savings, and accelerate ROI. Talk to ClarisHealth about how Pareo can keep you a step ahead of healthcare payer technology trends – no matter what the future brings.


See the ClarisHealth 360-degree solution for total payment integrity in action:

“The Great Pause” Brings Unyielding Uncertainty to Medical Loss Ratios but Also Opportunity

“The Great Pause” Brings Unyielding Uncertainty to Medical Loss Ratios but Also Opportunity

Are better-than-expected medical loss ratios in 2020 setting up payers to take a severe hit on profit margins in 2021? Go on offense by making moves that feature these 4 risk-mitigating hallmarks.

Six months into the novel coronavirus pandemic in the U.S., the crisis has affected the healthcare industry unevenly. While providers have been hit hard financially, health plans have experienced record profits due to a significant drop in medical expenses. But while they come under scrutiny for the current medical loss ratios, health plans argue this is a situation that cannot last. They expect a pent-up demand for healthcare coming in 2021 that will more than make up for this year’s health plan profit margins.

None of us can predict the future. But we can still find a path forward for payers. One that helps you successfully navigate the short-term uncertainty around healthcare claims costs and poises you for long-term success. The “great pause”– as the initial lockdown period of 2020 is sometimes referred to – has changed our economy and the way health plans think about business operations for the long term.

Will COVID-19 Delay the Payer Financial Impact?

The Affordable Care Act mandated health plans spend at a minimum 80-85% of premiums on healthcare or quality improvements. The result is a medical loss ratio (MLR) calculated as follows:

MLR = Healthcare Claims + Quality Improvement Expenses / Premiums – Taxes, Licensing & Regulatory Fees

With the onset of the COVID-19 pandemic, as consumers avoided or deferred care, the “healthcare claims” portion of that equation shifted dramatically. This downward trend was most significant in the second quarter. A recent study found that in April 2020, total hospital admissions declined 34%, including COVID admissions. At the same time, visits to ambulatory practices declined 60%, and emergency room visits dropped off 42%.

This lower-than-expected use of healthcare services has reduced medical expenses billions of dollars across commercial health plans leading to, in some cases, doubling of profits. But, what does the future bring?

The “bad”

Especially at the onset of the pandemic, several experts predicted catastrophic healthcare costs would accompany COVID-19 and severely hit payers’ bottom lines. That worst-case scenario hasn’t materialized, though some worry that higher costs are on the horizon as a result of early care delays.

Of particular concern are decreased rates of screenings, vaccinations and other preventive care. At least 40% of individuals surveyed reported delaying care due to COVID-19 through the end of June. This article cites studies that note a 46% decline in cancer diagnoses and an 85% drop in common cancer screenings. CMS data revealed 22% fewer vaccinations administered, 44% fewer screenings for physical and cognitive development, and 69% fewer dental procedures among children between March and May of 2020.

A predicted future spike in elective procedures is also worrisome. By some estimates, they make up 37% of health plans’ hospital admissions spending. Some of those 40% mentioned above who delayed care undoubtedly fall into this category. As of July, though, procedures had rebounded to 16% below baseline levels. And a September survey found 60% of patients are open to rescheduling their elective procedures this year, a figure that jumps to 71% among those whose needs are more urgent.

The “good”

When COVID-19 forced consumers and providers to re-think healthcare encounters, it yielded a few moves that may lower costs in the short-term and the long-term:

Embrace of telehealth and virtual care: The adoption of remote patient monitoring, virtual visits and more has jumped forward and may help better manage chronic conditions, including behavioral health. By improving access to care, it might also help redirect the non-emergent visits that have historically ended up in the emergency department. As a PwC report noted, “Even if telehealth increases utilization, many payers see the platform as an opportunity to get members the right care at the right time in the right place while also saving the member and the employer money.”

Creative healthcare solutions: From at-home dialysis and other home health treatments to reassessing the usual cancer treatment protocols, the hyper-focus on effectiveness has started to chip away at the “more equals better” healthcare idea.

Alternative payment models: Those providers participating in contracts that prioritize value fared better financially than their fee-for-service counterparts – and achieve improved outcomes for their patients. Combined with modern payer initiatives that focus on social determinants of health, coordinated care, population health and the transparent data sharing that supports these moves, the current environment might signal a sea change in this shift.

The “wait and see”

Because we are still very much in the middle of this healthcare crisis, these outcomes – the “bad” and the “good” – are far from a foregone conclusion. In fact, the latest estimates – from the Willis Towers Watson actuarial analysis of employer healthcare cost – project 2020 totals to come in 3.3 - 9.9% lower and 0.5 - 5% higher in 2021 for a combined cost reduction of 2.8 - 3.8% from non-pandemic levels. Even still, the analysts warn about volatility around these costs.

With this uncertainty comes risk for health plans. Uncertainty around when and where elective procedures will resume, the total COVID-19 testing and treatment costs, and how ongoing unemployment will affect insurance coverage rates all make it difficult to act with conviction. In response to this lack of assuredness in the market, some health plans have gambled on suspending long-planned strategic projects.

However, while the novel coronavirus is our collective reality for the time being, it will pass eventually. With that in mind, does it make sense to make relatively short-term moves that may prove costly in the long run?

4 Hallmarks of Win-Win Strategic Moves for Payers to Implement Now

We might feel the impact of COVID-19 on healthcare through 2022. And especially in the face of potential healthcare cost volatility in 2021, health plans have to extend their long-term visioning. What strategic moves both mitigate risk now and move the needle on your competitive advantage in the future?

Consider decisions that make sense, no matter what the future brings regarding medical loss ratios. Look for these four characteristics of moves that promise to propel your health plan past the risk-averse reactive mode that can result in inaction and unwanted setbacks.

1. Easy to implement

When you think of plans that are easy to implement, policies and processes that are already in place may come to mind. For instance, when CMS provided payers flexibility on medical loss ratio reporting and rebates this year, health plans didn’t hesitate to exercise their options. Many had already taken it on themselves to provide direct support to consumers. This relief came in the form of waiving COVID-19 cost sharing, extending premium payment grace periods, and offering premium rebates and discounts.

By the same turn, if your health plan is already in the process of pursuing an enterprise technology platform, consider how quickly you could realize savings from that decision. And how difficult it would be to get back on track if you abandoned that process. Emphasize your potential speed-to-value when you encounter these roadblocks, and it won’t steer you wrong.

2. Build empathy with stakeholders

As COVID-19 ravages your consumers, network providers and employer clients, any strategic move that shores up these relationships holds promise for long-term benefit. For example, extending telehealth benefits and continuing member engagement campaigns for consumer satisfaction. Evolving provider engagement programs to further ease their claims burden. And offering creative solutions to keep employer healthcare costs down.

Some of these strategies build on the positive outcomes realized thus far into the pandemic, which also make them easy to implement. And they include policies that mitigate healthcare delays and may even lower healthcare costs, making them a good match for today’s challenges and tomorrow’s opportunities.

3. Improve efficiency

No matter how healthcare costs impact medical loss ratios next year and the next, it pales in comparison to one perennial challenge. Administrative complexity makes up at least 10% of annual healthcare spending in the U.S. Reducing your administrative burden holds the greatest potential to increasing your profit margins.

For that reason, prioritize decisions that will yield the greatest return on investment. Times like these increase the stakes greatly. And you simply can’t afford not to invest in solutions that could double or triple your recoveries while improving efficiency.

4. Reduce team frustrations

What issues did the pandemic bring to the forefront for your team’s day-to-day? For most of us, work flexibility and communication have become more important than ever. Work cultures that depend largely on face-to-face interactions have had to adapt quickly to maintain productivity. And your email inboxes may have taken a hit as their limitations as workflow tools have been tested.

As a result, teams across all industries have quickly adopted virtual meeting solutions that may already have been in place. You may also consider secure, cloud-based collaborative technology platforms. Especially ones developed specifically for the healthcare industry can help you extend a work-from-anywhere posture and invite key external stakeholders into the workflow.

Set Yourself Up for Success – No Matter What Medical Loss Ratios Bring

While there continues to be talk about “getting back to normal,” we may have to recognize that the new normal equals uncertainty. We have to become agile enough to succeed under those circumstances. Take this opportunity to implement solutions that address inefficient processes. Innovate your way through broken relationships with stakeholders. A scalable technology platform like Pareo can help you transform your payment integrity function, which better positions you to successfully navigate unpredictable medical loss ratios and their impact on profit margins.


See the ClarisHealth 360-degree solution for total payment integrity in action:

Health Plans Launch Innovative Solutions to Respond to Mental Health Crisis

Health Plans Launch Innovative Solutions to Respond to Mental Health Crisis

Transparent data sharing supports seamless care coordination, relevant outreach that mitigates effects of chronic conditions.

The novel coronavirus pandemic continues its near-perfect record as a harsh but effective teacher for the healthcare industry as it efficiently evolves systemic weaknesses into full-blown crises. Patient and procedure volume-based reimbursement structures? Check. Primary care access? Check. Healthcare coverage? Check. Now we can add the mental health status of Americans to that list. But, even with these issues, the ability to steer through the challenges and find our way to an appropriate solution is still within reach. And payers, with their increasing focus on whole-person care, are particularly suited to drive these changes.

How can health plans promote improved access and outcomes in mental health while controlling costs associated with this expensive chronic condition during the pandemic and beyond? And what are the implications to health plan payment integrity operations? Let’s explore the landscape and potential solutions.

Challenges: Access and Expense

It’s estimated that 1 in 5 Americans suffer from mental health issues. It’s a problem that’s already been increasing in severity across our population, especially among teens and young adults. But with the onset of the pandemic, there are signs that figure may be increasing dramatically.

Increased isolation, grief, job losses, pressures from juggling home/work/childcare responsibilities, extended uncertainty and more are creating and worsening anxiety and depressive disorders. And, among frontline healthcare workers and other essential employees, in particular, there are concerns with potential long-term PTSD-akin effects. Experts predict an associated increase in suicides, overdose deaths and substance use disorders as well.

Why are these rising cases such a concern? There are two big perennial challenges associated with mental healthcare.

Limited access to care

Without proper intervention and maintenance, there is risk of situational mental health issues becoming chronic and existing mental health conditions becoming increasingly severe. But while 20% of Americans experience mental illness, historically less than half receive treatment. This limited access to appropriate care has a variety of causes. While there are cultural barriers – concern about perceived stigma, for instance – structural barriers are just as restrictive.

At least 60% of U.S. counties don’t have a single practicing psychiatrist, so even for those patients covered by insurance, access is an issue. They struggle to find in-network mental health providers that will take their insurance. One study found that these patients with commercial insurance were up to 15% more likely to receive out-of-network care than other chronic disease patients, and their cost burden was almost 4 times higher.

And, for those who have managed to get treatment, the pandemic has limited their in-person visits and put their providers in a precarious financial position. Already vastly underfunded, fragmented and difficult to access, mental health providers have been just as impacted financially as other healthcare providers. But because relief funding is largely based on Medicare rates, rather than Medicaid, community behavioral health centers were less likely to pursue and receive support.

Mental health and addiction providers estimate they will lose $38.5 billion in revenue in 2020, and more than 60% of providers had already been forced to close at least one program before the end of April. Close to half of mental health and addiction providers report their chances of survival at 6 months or less in the current fiscal climate, minimizing their ability to act as a safety net when they are needed most.

Expensive to manage

Mental health conditions negatively impact quality of life and economic productivity, which are grave enough consequences. But in addition to the healthcare industry lacking sufficient mental health resources, it is also one of the more expensive chronic conditions to manage. In 2019, the U.S. spent over $225 billion on mental health services, or 5.5% of total healthcare spending, and that dollar amount has increased over 50% in the last 10 years.

Direct spending on mental health services doesn’t paint the full picture. Mental illness is disproportionately associated with physical chronic conditions as well – cardiac, pulmonary and obesity comorbidities. In fact, depression quadruples the risk of a heart attack. And taken together, these issues create a much bigger impact. According to the CDC, 90% of national healthcare spending goes towards managing chronic conditions and mental health.

Approximately 75% of those with severe mental illness (SMI) have at least one chronic physical ailment, and the number increases among vulnerable populations. One 14[study] of Medicare beneficiaries found 12.7% of spending was associated with mental health disorders, but mental health services only made up 4.2%. In fact, patients with an SMI reflected a 37% increase in physical healthcare costs, and an 18.4% increase for those with other common mental health disorders.

Opportunities: Telehealth and Whole-Person Care

Even with these systemic challenges associated with mental healthcare, promising signs have emerged that hold the potential to mitigate their effects, including rapid adoption of telehealth and payers increasingly focused on whole-person care.

Accelerated virtual care adoption

Telehealth use already found its niche in behavioral healthcare, especially in underserved areas. But with the stay-at-home orders, telehealth claim lines increased more than 8,335% from April 2019 to April 2020. Mental healthcare was a big driver of those visits, but chronic condition management made big gains in virtual care adoption as well.

Teletherapy offers distinct advantages for mental health patients, not the least of which is extending access to mental health providers when availability or convenience is an issue. It also eliminates the need for travelling to an appointment, allows for a familiar environment and may even mitigate concerns of stigma. Mental health providers, too, see benefits by gaining insights into the home environment and allowing patients to more easily maintain valuable therapeutic visits.

Even though many patients had little to no experience with telemedicine or other forms of virtual care, most have been pleased with the encounters and want to see it continue indefinitely. And, in the same way payers have seen success with virtual care for monitoring and managing physical chronic conditions – and creating patient trust in the process – there is reason to expect similar results with mental health conditions.

Increasing focus on whole-person care

Health plan models are increasingly centered around improving the delivery of person-centered care. How can you treat the whole person and engage provider, patient and other stakeholders after the encounter? Two different models of coordinated care for better integrating mental health are common.

Co-location of services – where mental health and primary care providers physically exist in the same place – offer economies of scale, efficiency and improved outcomes that benefit health plans. Looser collaboration agreements don’t require a provider organization to deliver the full array of services, provided they work closely with others across the service delivery ecosystem to ensure coordinated access to care, but does necessitate a technology infrastructure that supports true data interoperability.

For health plans, both models see the full array of services – for mental health and physical healthcare – covered under a single agreement with a goal of positively impacting utilization and health outcomes. And new clarity on privacy regulations makes it more straightforward for providers to coordinate care for those patients suffering through a crisis.

Innovative approaches to coordinated care promise to unlock value for payers, providers and consumers by supporting alternative reimbursement models; offering leeway on care modalities to include telehealth, remote patient monitoring technologies, and care management home visits; and providing real-time care integration. Many health plans are relying on integrative technology solutions as a backbone to power a seamless patient care experience, and these benefits extend to behavioral health.

Advanced Technology Enables Relevant and Sustainable Solutions

While the challenges – and opportunities – are significant, health plans don’t have to pioneer entirely new programs in order to improve systems for mental healthcare maintenance and intervention. Engaging members and providers via current advanced technology initiatives can strategically extend this function.

Member engagement

A new poll confirmed what we already feel to be true as consumers: the healthcare industry is simply too complex to navigate effectively. Respondents overwhelmingly cited every aspect of healthcare – care access, management, and payment – as needing to be streamlined and simplified. “They want health plans and providers to end the fragmentation, simplify the experience, and deliver a fully connected encounter that makes healthcare as seamless as any other online endeavor.”

Arguably, the system proves to be even more unnecessarily opaque for those experiencing mental health issues and their support system. And those with mental health disorders are at higher risk during the pandemic. Many health plans already prioritize seamless member engagement opportunities, supported by modern communication modalities. But, as we wrote in a previous article, consumers want to hear from their health plans more, especially with relevant information. One payer program of this type is already seeing the benefits.

Additionally, more advanced solutions like population health management platforms, such as that offered through Pareo, allow you to proactively assess disease risk among your membership. Taking this opportunity to reach out to members about their telehealth options, the importance of medication adherence, information about prescription assistance, wellness options, chronic disease management, checking in with a primary care provider, how to better protect themselves from COVID-19 and more promises to yield significant dividends.

Provider engagement

Many behavioral health providers and facilities still receive most of their revenue from fee-for-service reimbursement, but from there member experience can unravel. Some payers will not give reimbursement checks to a facility directly, but rather to the plan member. This can create abrasion between the patient and provider as well as the provider and the payer, but that risk can be mitigated through strategies like prospective cost avoidance and coordination of benefits.

However, in order for mental health providers to shift revenue management strategies, health plans need to be in a place where they can support prepay. Pareo is a seamless payment integrity solution that can power retrospective and prospective claims recovery. It does this in part through automated workflows and by housing relevant medical claims data, enabling plans to hold up their end of prospective cost avoidance.

Related to mutually beneficial payment structures, a survey conducted in March 2020 indicated 74% of primary care organizations and 61% of behavioral health organizations participate in some form of value-based reimbursement. But, only 16% of those organizations have 20% or more of their revenue in such an agreement. With health plans looking to accelerate adoption of alternate payment models, it’s important to keep in mind what’s essential to their acceptance and ultimate success.

Extending clinical data interoperability, integrated workflows, proactively identifying gaps in care, and real-time metrics are key components of modern value-based contracts. When health plans better engage with mental health providers, those providers are empowered to better support members. And transparent data sharing – like that supported by the integrative platform Pareo – extends health plans’ abilities to do exactly that.

Pareo Provider is a seamless technology platform for real-time engagement with providers, including specialty providers. Not only for the purposes of payment integrity – though Pareo effortlessly accommodates complex reimbursement contracts and supports two-way communication on claims. But also new information on virtual care allowances, sharing quality metrics, getting credit for SDOH assessments and more – without increasing the provider or payer administrative burden.

Pareo is a Single-source Solution for Payment Integrity Operations

Understanding trends in behavioral health management is vital to health plans, and payment integrity teams must take note of the implication of mental healthcare utilization on their operations. With only half of those who suffer from mental health conditions receiving care, and many members eligible for care struggling to find access to providers, complexities abound. Further, many mental health providers and facilities are using outdated payment models, because before the Affordable Care Act, mental health was often not a covered health insurance benefit.

Pareo is a single-source payment integrity solution that can integrate with myriad data systems to power even the most nuanced retrospective and prospective claims recovery efforts. Within Pareo, features that support provider engagement, population health management and prepay can facilitate (and automate) facets of behavioral health claims management to create a better experience for payers, providers and most importantly – patients.


See the ClarisHealth 360-degree solution for total payment integrity in action:

Healthcare Interoperability Poised to Solve COVID-19’s Big Data Crisis

Healthcare Interoperability Poised to Solve COVID-19’s Big Data Crisis

Coronavirus highlights power of big data and the need for interoperability to improve population health. How can health plans lead the way?

What’s the single biggest weapon used by government, pharma, academic researchers, healthcare systems, and health insurers alike to combat the novel coronavirus pandemic? It’s data. Massive amounts of data. Unfortunately, we’ve said it before, and it bears repeating: healthcare has a data problem. And, like many things in healthcare, the current crisis has brought this deficiency into focus.

In this article we’re exploring the many uses of big data for the coronavirus and beyond and how health plans can overcome the obstacles to ingesting and processing data from a myriad of sources to achieve interoperability, positively impact population health and secure their competitive advantage.

Big Data and the Coronavirus: A Unique Use Case

Already, work involving advanced analytics applied to real-world data is seeing success in combating COVID-19. By analyzing publicly available datasets, scientific literature, social media information and their own data, progress of a sort has been made by different groups: from predicting adverse events in coronavirus patients to rapidly developing potential vaccines. But the propensity for healthcare, academics and industry to stick to their silos – and their information right along with them – has limited their potential for reliable successes.

Challenges to leveraging healthcare data

Despite generating a ton of healthcare data – most of it now digital – much of that data is still incomplete, irrelevant, inaccessible or a combination of these. And the sheer volume makes it difficult to overcome these deficiencies. By some estimates, we’re generating over 2,300 exabytes per year (one exabyte = one billion gigabytes), which is expected to grow at least 36% year over year through 2025.

While compute power has evolved to handle the sheer amount of information, this data is locked in silos. In the absence of clinical trial data – the gold standard – real-world clinical information from COVID-19 patients is the most useful in guiding medical decisions. Thanks to a decades-long push to digitize healthcare information, this data exists inside electronic health records. Despite the promise of digitization, EHRs have not made it easy to retrieve this crucial data.

Built as they were with billing efficiency in mind, most of the useful clinical data is stored as unstructured free text. And without a common architecture, labels are inconsistent, which makes sharing difficult – even in rare cases where data is complete. There are reports of providers unable to deliver detailed clinical data on coronavirus cases, largely because it would have to be printed or tediously copied from EHRs, then sent by fax or email, or manually entered into CDC forms.

Interoperability and collaboration offer keys to success

The new rules against information blocking have been delayed to free up resources devoted to the pandemic response, but the need for data interoperability has never been greater. When health data is shared, front-line providers are informed in real time on patient movement, health changes and diagnoses, allowing them to respond smartly.

According to the Office of the National Coordinator for Health IT's Don Rucker, M.D., the current COVID-19 pandemic is a clear example of why the data sharing regulations are so critical. "Ironically, if we had this rule several years ago, we would be in a far better spot for knowing what’s going on with this pandemic. There are fundamental things about the biology of this virus that we don’t know, such as latency, duration of disease and how immunity is built up. It would be easier if we had richer clinical information streams."

One success story demonstrates just how essential data interoperability is to identifying vulnerable populations and performing targeted outreach. The regional data network had already taken the steps to integrate health information from numerous providers in the area, so they were well positioned to respond quickly during the COVID-19 pandemic. But they were still limited to barely more than a third of the county’s population in this initiative, which shows there’s still plenty of work to be done.

Other successes tell a similar story. Working together, sharing information – even among competitors and others that don’t traditionally collaborate – accelerates the path toward viable coronavirus solutions. Making quality data more readily available should be the goal. As one expert in public health research puts it, “How can we continue to work together and invest in these infrastructures so that we can collect data, share that data, and analyze that data rapidly in pandemic situations? Or even in smaller-scale situations, like a localized outbreak of food poisoning or salmonella?”

Where is all this data coming from?

In 1950, the doubling time of healthcare data was 50 years; in 1980, 7 years; and in 2010, 3.5 years. Today, that rate is 0.2 years—just 73 days. These increasingly varied sources of digital data all offer value, though few health plans are able to ingest and parse all of them.


  • EHR
  • Claims systems
  • CRM
  • Rx data
  • PACs
  • Lab data
  • Clinical Trial Management systems
  • ACOs/HIEs
  • Genomics and research registries
  • Wearables
  • Apps
  • IoT
  • Chatbots
  • Medical devices and sensors
  • Social media
  • Machine logs
  • PHR systems

How Health Plans Can Push Data Interoperability Forward

Now that the pandemic has reinforced the need for improved sharing of healthcare information, what comes next? Like the push for EHRs to streamline healthcare billing, it’s likely health plans will again have to lead the charge in the journey to healthcare data interoperability. We outlined before 4 steps health plans can take to comply with the new information blocking rules. In addition to technical compliance, there are 3 things health plans can do to promote interoperability more broadly in the industry.

1. Adopt modern technology with interoperability in mind

The assortment of fragmented technology and manual systems currently in use at many health plans will no longer cut it. Every internal operations system – the claims adjudication system, CRM, fraud detection, payment integrity, provider outreach tools, member service chatbots and everything in between – must be able to “talk” to each other. Moreover, two-way interaction between external provider systems like EHRs and members’ apps of choice also will be required. Advanced integrative technology platforms like Pareo leverage modern APIs built on the FHIR standard to support interoperability.

2. Use A.I. to process data

Once health plans have ingested data from myriad sources, processing that information into real-time insights is the next logical step. But even with data interoperability standards in place, healthcare information is still likely to be largely inconsistent and unstructured. Applications of A.I. like supervised and unsupervised machine learning, natural language processing and more can help overcome these challenges, turning raw data into visualized business insights.

3. Share insights

Once a health plan has done the dirty work of ingesting and analyzing healthcare data, that’s where the real value of promoting interoperability comes in. Sharing insights with relevant stakeholders – providers, members, even other health plans – builds trust and the ability to realize the benefits of big data across the healthcare continuum.

Benefits of Big Data Interoperability

While healthcare data interoperability promises many benefits during a pandemic, innovations pursued now promise to pay dividends long into the future. We’ve written about a few of these during our recent series of articles covering long- and short-term effects of COVID-19.

For one, without data interoperability, the transition to value-based care is a non-starter. Sharing mutually beneficial information with providers is the foundation of fostering these valuable relationships. It’s up to health plans to take the reins on opening the lines of communication with providers, and supporting them with relevant clinical information can help them reduce costs while improving care.

The coronavirus pandemic has unfortunately affected members as well, particularly their healthcare coverage and finances. As a result, they have been more likely to delay needed care – even for chronic conditions that make them more vulnerable. At the same time, they are signaling they are more open than ever before to receiving communications from their health plan. This convergence provides an ideal opportunity for health plans to leverage big data insights for population health management efforts. Advanced technology like Pareo surfaces lists of those members most likely to need engagement and care to improve healthcare access, outcomes and quality.

Finally, greater information sharing allows health plans to make more informed decisions faster. Where are the errors, areas of high-risk and opportunities for driving changes? Access to the “big picture” ensures strategic planning that secures a health plan’s competitive advantage.

Health Plans Find Success with Tech-Forward Strategies

COVID-19 has thus far proved to be a harsh but effective teacher, not least by emphasizing the need for an interoperability record that helps to provide comprehensive clinical insights with a 360-degree view of members and patients. This initiative is only feasible through advanced technology. Those health plans with digital-first strategies already in place are better set up for success, but payers that lag can still make progress and secure their competitive advantage.

By adopting scalable comprehensive technology and leveraging modern interoperability standards, health plans can position themselves to excel at payment integrity, coordinated communication and population health efforts alike. As the COVID-19 crisis evolves – and in readiness for when the next healthcare crisis presents itself – payers will be able to lead the way in identifying those at risk based on their clinical predisposition, genetics, social determinants of health, and other factors as well as coordinating member and provider engagement.


See the ClarisHealth 360-degree solution for total payment integrity in action:

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.


See the ClarisHealth 360-degree solution for total payment integrity in action: