THE 'EDGE REPORT BLOG

In Today’s World, Health Plans Must Be Agile

Changes to the health insurance industry have been traditionally very slow. However, the global pandemic has forced health plans to move forward with decisions and initiatives at full speed. There was no opportunity to analyze every aspect of a benefit plan and take months to implement it, changes needed to happen immediately.

At the beginning of COVID-19, it seemed that state and federal authorities introduced or changed regulations every day. It was challenging to sift through the noise and keep up. Everyone experienced hiccups along the way. Payers and providers alike had to fix errors, re-submit and reprocess claims, and course correct.

The pandemic has demonstrated the need for health plans to be agile, flexible, and methodical; it all comes down to configuration. Behind-the-scenes, successful configuration comes down to two things: sound business processes and consistency.

The HIPAA electronic data interchange introduced standards for the communications for payers. It forced the industry to standardize business processes to ensure that the correct data is required and used throughout the lifecycle. Sound business processes guarantee the data continues to maintain accuracy; consistency is key for clean data.

For example, as a result of the pandemic, specific benefits were rapidly mandated and changed “on the fly,” but the value of having consistent data requires that there are minimal variations or outliers to ensure accurate data analysis.  Certain information and fields must be uniform so health plans can easily look at claims experience, identify all of the claims that fall into specific buckets, and understand the historical data and what it means.

The truth is, many claims processing systems are not as agile as they need to be. Now that payers have experienced the pressure and expedited timelines around COVID-19, no one wants to go through that again. That is why consistency, business processes, and agility are all very crucial for success. 

Maggie Brown

Maggie Brown, Regulatory Compliance Manager
LinkedIn
mbrown@healthedge.com

Maggie Brown has over 30 years of leadership experience in healthcare and insurance marketplace. Maggie transitioned from health plan management roles to implementing core business solutions for numerous health plans around the country. With the enactment of HIPAA, the Balanced Budget Act, and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 she focused on how to ensure a health plan could implement key technology solutions, meeting the needs of their members, while being compliant in a rapidly changing regulatory environment. Maggie has led implementations for government programs at both new and established managed care companies. Maggie holds a Doctor of Religious Arts degree with a major in Pastoral Psychology.

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