Claims Platform Modernization: A New Competitive Edge for Regional Health Payers

The trend toward consolidation is a challenge for regional health plans. When national payers keep getting bigger, how do you stay competitive? Especially when it comes to digital transformation—what can you offer that your larger competitors can’t?

The answer is: trust. You know your local providers better. You’ve worked with them for years. You’re part of their communities. 

So while your competitors can throw excessive resources at acquiring chronic conditions management apps, you can build something even better—a platform that offers transparency, ease of use, and answers providers’ questions with relevant insights at the point of need.

Read on to learn why platform modernization + trust offers a competitive edge that only you can provide.

On the surface, there’s tension between providers and health plans. Every claim submitted is revenue for the provider. Every claim paid is a cost for the health plan.

So provider groups and health systems have come to expect friction submitting claims and prior authorization requests:

• Abrasive user interfaces on payer platforms
• No transparency into claims acceptance/denial logic
• Varying paths to clean claims among various payers, all of which are technically documented but the insights aren’t retrievable at the point of need

When it comes to building trust among providers, the bar is literally on the floor. As a payer, if you can offer a transparent, modern  experience to submit clean claims, receive reimbursement quickly, and provide real-time guidance on prior authorization, it’ll go a long way toward distinguishing you from all the other health plans out there. That allows you to build a wider, less expensive network. 

The status quo of manual processes and abrasive tech experiences doesn’t just make providers’ lives more difficult. These inefficiencies hurt health plans as well, since each inefficiency is a cost: 

• Working through provider and member questions
• Managing claims denials—most of which will get paid anyway
• Delaying patient care that will lead to more expensive care within the same financial year

High administrative costs also prevent you from securing competitively priced contracts with health systems. An example of this is from Transcarent CEO Glen Tullman, who’s provided discounts for surgery bundles from top surgery centers by promising to pay for them the same day they occur, rather than Net 90 or some other payment term. 

Unfortunately, most payers—regional or national—aren’t set up to take advantage of complex, irregular, or value-based contracts. That’s why technology modernization for claims processing, pricing, and editing is a top priority among health plan CIOs:

• Investing in tighter integrations and real-time capabilities
• Leveraging modular, cloud native and API-first platforms
• Using RPA, AI, and ML to surface critical insights at the point of need
• Deploying low-code/no-code solutions to accelerate platform development

This is easier said than done. There’s a significant amount of technical debt and inertia around legacy solutions, namely due to rolling contract renewals and lack of proactive engagement to seek out new platforms and capabilities. 

What’s more, technology alone can’t fix a broken process. What is needed is a more fundamental transformation of the administrative processes surrounding claims processes. Platform modernization, then, is about more than just upgrading your technology. It’s about a more holistic approach to how you approach claims management.

So what does all this look like in reality? I’ll walk through an example from the provider and member side to illustrate. 

By making your claims acceptance/denial logic transparent and offering seamless, interoperable technologies, you can make it easier for providers to integrate that logic throughout their entire health system. Far from being limited to the back office, these benefits can trickle up to mid-cycle and front office:

• Providers can create RPA-based applications and workflow prompts to address potential billing issues in advance
• Autocomplete and co-pilot billing to pull historical data from EMR and slotting them to relevant fields
• Ambient listening & real-time questions to address concerns in real-time, including information about approximate costs
• Build a quality UI into your RCM system to capture relevant payment information upfront so the clinician isn’t prescribing treatment in a vacuum
• Go beyond verifying active coverage and retrieve deeper information about secondary coverage, usage, etc.
• Incorporate insights from the health plan to achieve greater price transparency and even collect payment at the POS

One way to accomplish this is to create a developer API portal that enables providers and their vendors direct access to data relevant to the claims submission process. This is far more efficient than directing them to a PDF that’s never updated and too unwieldy to manage. 

This is becoming increasingly important as value-based payments become the norm. Often these result in highly complex provider schedules, as well as nuanced, self-funded employer contracts. Addressing these challenges and complexities will only make you more competitive as larger, less agile payers struggle to keep up.

As I alluded to in the previous section, clinicians rarely understand the financial implications of a given course of treatment. The safe assumption used to be that patients would have a copay, and the confusing details of billing would be negotiated between providers and health plans.

That assumption is not so safe anymore. Deductible plans are the norm, which means members are far more interested in where to go for care, cost, and the accuracy of their bills. As such, members engage more frequently with health plans, as your policies and rules govern this process. This is where demands for modern, easily accessible provider directories to identify in-network care come from.

What’s more, there’s the added wrinkle of Medicare Advantage, which empowers members to choose their plans upon retirement. The experience you provide when a member is 35 will go a long way to guide their decision when they turn 65. The better the experience, the more likely they’ll stick with a health plan into retirement. 

Health plans, then, have an opportunity to differentiate themselves in the commercial market—namely among HR purchasers—by distinguishing themselves as the concierge advocate for the member. The easier you make it to provide value to members through modern data platforms, conversational AI, and other modern solutions, the better.

If you aren’t looking at modernizing your claims platforms, processes, and systems, you’re missing an opportunity to get ahead of the curve. Wait too long, and you’ll end up behind the curve when everyone else starts implementing AI, ML, RPA, etc. to provide that concierge service to providers and members.

Thankfully, you don’t have to wait to get started. 3Pillar has extensive experience with building modern platforms for health plans—and we’re leading the charge on offering a more efficient, seamless, and interoperable approach to revenue cycle management.

To see what this approach entails, download our RCM playbook here.

Steve Rowe

Industry Leader, Healthcare Portfolio

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