At Lateetud, we are acutely aware of the challenges our healthcare payer customers face, in the current public health crisis. We have been working closely with them to assess their needs and apply appropriate Intelligent Automation (IA) strategies to best solve their unique business problems.
In this series of two blog posts, I will cover the challenges healthcare payers are facing and the various automation opportunities - specifically in the claims processing area – available to them to navigate the pandemic successfully.
As COVID 19 continues to impact the healthcare ecosystem, payers will continue to face headwinds. In the post below, I highlight 8 challenges that payers must overcome, considering COVID 19, and the best way to be ready for an unpredictable future.
In the latest CAQH annual report, the cost to manually service a claim is the highest in the three areas that I previously identified - claim status enquiry, prior authorizations and eligibility and benefit verification.
The below graph by CAQH indicates the level of adoption of Fully Electronic Administrative Transactions in a typical payer workflow. The graph identifies the three areas most impacted by the challenges stated above. Evidently, these three areas that are impacted the most due to the above challenges will further encounter stress, due non-conformance with the electronic standards leading to more pends, adjustments, enquiries, pre-authorizations, and eligibility verifications.
Figure: Medical Plan Adoption of Fully Electronic Administrative Transactions.
Another functional area that will be significantly impacted is “Member Services,” where the payers communicate with the members via phone, emails, and mail. With the projected increase in individual subscribers due to unemployment (>11% as of this posting), this functional area will see increase in cost.
As is apparent from these challenges, the cost of servicing subscribers (relative to the revenue) will increase, which is somewhat impacted by new ways of delivering healthcare and new situations. These challenges are going to force payers to think differently to come out as winners – not only to survive but to save lives.
The pandemic is painful, but it is also a good lesson for all of us to stay alert and prepare for the worst as a disaster can come knocking at our doors anytime. Also, the aftereffects of COVID-19 are long-term that means patients remain at risk for lung disease, heart disease, frailty, and mental health disorders and to add more; with the way we humans are behaving irresponsibly to our environment, health issues may keep coming; therefore, a comprehensive plan for preventing and managing post-COVID-19 complications is becoming a necessity.
COVID-19 is already a medical, psychological, and economic burden on patients with lower income, the uninsured and underinsured, and individuals experiencing homelessness. To avoid further clinical, economic, and public health consequences and to support patients experiencing delayed morbidity and disability, policymakers and payers must look toward the future.
Telehealth is booming, and it may become the new normal post-pandemic as healthcare payers have now started segmenting telehealth visits into two categories: cost-related cases - which allows payers to reduce costs through telehealth, mainly by adjusting incentives to shift in-person care to digital visits and convenience-related cases - in which payers use telehealth services to generate loyalty even if the care is complementary and, therefore, increases costs.
One can also expect innovation in reimbursement post-pandemic. Healthcare payers are adjusting reimbursement policies to further encourage the use of lower-cost care settings. They are also seeking to shift reimbursement to value-based care.
Lastly, to survive in the postcrisis era, leading payers are making investments, building partnerships and exploring acquisitions that will further expand their business models. They have started to play more active roles in managing member relationships and making investments or acquisitions to compete with third parties and preserve their historic care management role. Many payers have started investing in a blend of navigation tools, disease-specific care management plays and digital engagement platforms due to the change COVID-19 has bought in the primary care market dynamics.
The only way to deal with all of this is to automate as much operational overhead as possible to free employees and to provide value to the providers and subscribers. In the next post of the blog series, I will cover the areas that are ripe for automation - the most pertinent and relevant being automation in claims processing.
In the meanwhile, check out why “Digital Operating Model” makes sense in the post pandemic world. Here, I talk about how this unexpected experiment has impacted all of us, what you should consider while creating a pandemic ready “Digital Operating Model” and also talk to Chief Innovation Office of AST Financial – Alan Eddie and CTO of Blueprism – Jon Walden.