Navigating current health plan roadblocks  

Even the most innovative health plan can hit a pothole or two. Sometimes it’s a lack of strategy, and sometimes it’s just bad luck. As 2023 blazes on, it seems the typical suspects continue to hinder progress. Thanks to slim margins, data security concerns, and outsourcing costs, many health plans could fail to make headway on their goals. But not on our watch. 

Let’s take a look at a few of the bandits roaming around the wild west of healthcare these days.

Increased transparency requirements   

Market shifts, including legislative efforts, aren’t going anywhere anytime soon. And as more regulations come into play (like the machine-readable files mandate), and members become more knowledgeable and financially savvy, transparency in healthcare is critical.  

So is technology.

According to a recent report from Ernst & Young, CMS regulations on price transparency demonstrate that investing in tech can help payers and providers reduce costs and much more.   

However, even though payers have implemented tools like consumer portals, mobile apps, phone contact centers, and concierge navigation services, these features only play a small part.

In order to meet transparency requirements, each and every health plan needs to make more room for innovative vendor partnerships to build a robust, interoperable technology architecture that leverages data analytics and other tech-related capabilities to provide visibility into network adequacy, patient experience, contract management information, claims efficiency and more. 

The ultimate goal of transparency is to break down barriers and allow information to fuel a better healthcare system. But the issue isn’t a lack of knowledge; rather, it’s the use of outdated processes. Consider technology as an oil change. Then, turn your focus to interoperability, data accessibility, and transparency.

Tight labor market 

Nearly half of health systems in the U.S. fell behind on their 2022 revenue goals. And the reasoning is simple: if you don’t have enough people, you can’t do the work, and if you don’t do the work, you won’t get paid.

Likewise for payers. Due to modern challenges sparked by the pandemic, like the great resignation and quiet quitting, health plans have adopted a “do more with less” mindset. But that doesn’t have to be the case.

With less available talent and resources to draw on, many payers are now turning to vendor partnerships to leverage cutting-edge technology and help cut costs.

By outsourcing tasks to well-equipped vendor partners, TPAs and health plans have been able to automate some processes and transform the shape of their businesses to conform to the current environment. Bringing in a partner that fits seamlessly into your workflow allows you to extend your team, despite hiring challenges.

Leveraging technology to do traditionally manual work saves time, increases productivity, and improves staff satisfaction. Just by automating manual tasks, you can speed up requests and decrease denials, errors, wasted time, and soaked labor costs.

Health plans can also greatly benefit by gaining greater insight into business operations and performance. This leads to better business decisions and greater interoperability while reducing workflow issues, and preventing denials. (Hello, savings.)

But that’s not all.

When staff is allowed to work where they excel, staff dissatisfaction, productivity loss, and lacking employee morale decreases. Meaning: staff is more engaged, and staff retention increases.

As a result, you no longer bear the brunt of certain costs associated with employee attrition (e.g., recruitment, onboarding, orientation, staff overtime, temp pay) and can now focus your attention on the bigger picture.

Changes in membership 

At the end of 2022, CMS announced that ACA Marketplace enrollment was up 18% from the year prior. The Biden-Harris Administration has made expanding access to health insurance and lowering healthcare costs a top priority, leading to the national uninsured rate reaching an all-time low at the end of 2022.

And due to the ending of the public health emergency and loss of Medicaid coverage for millions, there are now more health insurance members going into 2024 than ever before.

And we all know what that means: more members, more unique member needs. 

Understanding the challenges members face allows you to create solutions to reduce member abrasion. Of course, that’s often easier said than done. Especially, when cost of care is at the top of the list. But by prioritizing members and making technology decisions with their needs in mind, health plans can discover numerous opportunities to support and enable member satisfaction.

The wrap up 

Empowering your organization to break down barriers within your current workflows will drive efficiencies and advancements along the cost containment journey, despite the roadblocks we all must face.

To see how Zelis can help you navigate recent market challenges, boost your technology portfolio, and ensure accurate payments, connect with us.