Reviewing  the drivers, restraints, challenges and opportunities for healthcare payer technology in 2020.

You’ve made plans, met for countless hours to strategize on the coming year and finally it’s here: 2020. A new year and a new decade promise big changes for the industry. And much like we did last year, we are looking at industry drivers, restraints, challenges and opportunities to ensure payers are on the right track for the coming year. 

We didn’t have to look far. Thanks to 2019, much of the writing is on the wall regarding expectations of health plans for 2020 and beyond. We’ve followed these trends throughout the year. Look for our guide below to explore articles we’ve published on key topics impacting health plans. 

Drivers: Top Motivators for Health Plans in 2020

Last year, we predicted that “2019 will be the year that health organizations will need to make real upgrades in technology if they haven’t already, or face issues meeting government regulations.” We didn’t know then how prescient that statement would be. By February, CMS and HHS had issued the proposed Final Rules (expected to be final in early 2020) to promote freer sharing of healthcare data. This initiative is driven in part by value-based care directives, the need to reduce provider abrasion, and the emergence of industry disruptors. The far-reaching implications dominated the news cycle throughout the year and will continue to do so in 2020. 

“2019 was a year of acceleration in digital health with several foundational advancements.”


The ultimate goal of technology is to break down barriers and allow information to empower a better healthcare system. This is termed “cognitive collaboration.” With interoperability and information blocking as a focus, health plans will naturally evolve to start questioning any process within their organization that inhibits information sharing.

Health plans understand with greater clarity now that their members, who are tasked with owning their own healthcare experience, will expect their relationship with their health payer to be frictionless and intuitive. This expectation (and the risk that not meeting consumer demand will open payers up to disruption) will lead health plans down a path that, if navigated correctly, can open up numerous opportunities to improve claims recovery processes and program integrity efforts. As a result, plans will look more closely at social determinants of health and healthcare data as primary drivers of consumer experience. 

Health plan workforces are and will continue to be impacted by technology as well. Lean as the industry may seem, health plans are adapting to the “do more with less” credo unofficially adopted by all healthcare stakeholders. 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. 

To that end, in 2020 health plans will be tasked with separating the wheat from the chaff when it comes to technology claims by third-party vendors, particularly firms looking to leverage experience with other industries into similar successes in the healthcare sector. Understanding that technology can help rapidly improve ROI on the claims recovery process, health plans will need to become more sophisticated consumers of tech products and solutions in the coming year. 

With great change comes the need for health plans to keep up with more sophisticated schemes and improper payment incidences. The SIU, which often operates as a disparate island within health plans, will feel the pressure to become more integrated with other departments. Many health plans have invested heavily in technology to combat fraud, waste and abuse but are growing weary of the lack of sophistication found in most solutions on the market. But health plan departments are all realizing that in every case, advanced technology is only as good as the data. These struggles will unveil a new focus on the need for better data collection practices across the healthcare continuum. 

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Planning for the unknown: A guide for health plans making strategic plans for 2020.

Restraints: Navigating the Roadblocks Health Plans Face

What’s information blocking, exactly? Many health plans, industry experts and health organizations are asking this as the proposed Final Rules move through final stages. The Rules, which many feel did not properly define information blocking, were not revised despite broad calls for them to be. Still, a decent portion of surveyed healthcare executives (43%) have indicated they plan to go above and beyond any interoperability and information blocking measures put in place by the Final Rules. The majority of health plans, however, will have to react quickly to interpret these terms, according to a survey. 

It’s an election year and federally regulated changes to the healthcare system will be mired in politics in 2020. Health plans will have to plan for all outcomes. One factor that transcends partisan politics, however, is transparency. Consumer-driven and value-based care is a certainty and transparency (fueled by interoperability) will be the aim. This transition has proven difficult for health plans due to complex regulatory environments, data security requirements, shortages in skilled workers, and struggles to shift old processes into new practices at a speedy rate. 

Dealing with large amounts of patient data makes health plans a prime target for security breaches. Health plans are moving methodically with technology adoption to mitigate risks, thereby delaying the realization of benefits from improved technology. Additionally, health plans will have to overcome learning curves, fear of change and other employee challenges as they navigate business and look for increased returns. Plans face challenges and limitations when it comes to combating fraud, waste and abuse due to a lack of relational data on the most-likely group to commit FWA: providers. 

Challenges: Factors for 2020

Let’s look at the specific factors that will challenge health plans in 2020: 

  • Proposed Final Rules
    • The proposed rules on information blocking and interoperability were submitted to the Office of Management and Budget at the end of October. OMB typically has 90 days to review a rule and make final, but they did not identify a deadline. The rule is expected to go into effect in 2020 but many questions remain. 
  • Big Tech Cynicism
    • Big Tech (think Google, Apple, Amazon) have circled around healthcare in recent years, but insiders doubt the technology giants can truly solve healthcare’s biggest problems. Robert Pearl, MD, former CEO of the Permanente Medical Group, outlines some of the biggest hurdles these outsiders face in healthcare:
      • Deciphering consumer wants versus medical needs
      • Medical liability
      • Growing data ownership and privacy issues
  • ACA
    • Short Term Health Plans were made legal in 2019, and according to CMS they can be used for 12 months and renewed for up to 3 years
    • Consumers have more options
    • Risk adjustments payment program implemented under ACA was upheld in court at the end of 2019. Reuters reports that the “decision by the 10th U.S. Circuit Court of Appeals in Denver is a victory for insurers that feared the Feb. 2018 lower court ruling and payments suspension could drive up premium costs and cause market turmoil.” 
  • Value-Based Care
    • CMS released their Value-Based Purchasing Program results for 2020, stating “in FY 2020, more hospitals will receive positive payment adjustments than will receive negative payment adjustments.” This is a rise of about 5%, according to FierceHealthcare which reported that 55% of hospitals got a payment bonus in 2019. CMS is looking to boost value-based care adoption rates which waned in 2019. Health plans look to diversify benefits and meet SDOH tenets as care perspectives shift to whole patient health. 
  • Mandated Transparency 
    • A large push to promote healthcare cost transparency, termed the “price transparency rule” which was released in November of 2019 via executive order has met with roadblocks including a lawsuit questioning the validity of requiring hospitals to disclose negotiated prices with insurers, which would take effect in 2021. The other component of the rule, if finalized, would “give patients access to their insurers’ cost-sharing liability and disclose the insurers’ negotiated rates for in-network providers and allowed amounts paid for out-of-network physicians,” reports Medical Economics
  • Election Year
    • Political candidates are running on healthcare reform, with more liberal Democratic candidates promoting “Medicare for All.” Big changes are unlikely during an election year, but payers will have to buckle up for what could be historic overhauls to the healthcare system in coming years. 

Opportunities: Chances to Excel in 2020

Health plans have the opportunity to be 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.  Health plans may breathe a sigh of relief that the “Cadillac tax” was repealed, which was slated to take effect in 2022 after multiple delays. 

Payers have caught on to the fact that providing improved member services is a differentiator in a consumer-driven market. By addressing all 6 social determinants of health, plans can offer broader benefits with perceived higher values (even if costs are lower). CMS has made it easier for health plans to offer supplemental benefits, another incentive for offering them. Digital health adoption continues to grow with some plans even covering personal health devices and offering increased telehealth capabilities. 

“According to Deloitte’s 2018 “Global State of AI in the Enterprise, 2nd Edition” survey, 80% of the respondents said their AI investments had already led to ROIs of 10% or more.”


Technology advancements continue, as API becomes more accepted and blockchain 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. 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 and empower users to break down barriers within their organization to drive efficiencies and improve the care continuum. 


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