Advances in technology, aging technology infrastructure, shifting regulations, and increasing competition have made it difficult for payer CIOs to prioritize activities. Here are 5 key actions for health insurance CIOs in 2024 to improve their technology infrastructure, address regulatory change, react to competitive pressure, and improve the member experience:
Continue Technology Modernization Efforts
For many insurers, the act of modernizing their technology can be daunting. Purchasing and implementing large core admin solutions can take years. Building a solution can be expensive and require resources that may not exist in your organization. But modernizing technology can lead to massive productivity gains and transform your business model.
How do you prioritize those modernization efforts? Here are some tips:
Embrace the Cloud
The scalable infrastructure, enhanced data security, and flexibility lead to better, more cost-effective solutions. Take our premium billing solution: generating billing transactions often occurs at a specific time each month. Generating millions of transactions and the associated invoice generation takes significant computing resources. By leveraging dynamic cloud computing resources, we can scale up to create those transactions and down again once completed. By only using those computing resources for a short time, we reduce billing costs.
Consider the Member
Health insurance has transformed to focus more on the member experience. In individual markets like ACA exchanges or Medicare Advantage, a poor member experience leads to increased member churn. Technology that streamlines backend processes can improve productivity, but member experiences are the future of health insurance. Don’t just buy a billing solution that generates invoices. Buy one that enhances the member experience with integrated, configurable delinquency management and a payment portal.
We’ll discuss this in more detail later but in addition to interoperability requirements, building integrated systems can improve productivity and the member experience. Ensure systems and applications can seamlessly exchange data with other healthcare stakeholders, including providers, pharmacies, and government entities. Adopt industry standards, such as HL7 FHIR, to facilitate interoperability and enable secure data sharing for better care coordination.
Optimize Claims Processing
Processing claims is likely your most frequently completed process. Streamlining claims processing through automation, intelligent data extraction, and real-time adjudication can have significant business impacts. Implement rules-based systems and predictive analytics to improve accuracy, reduce manual intervention, and expedite claim settlement, leading to faster reimbursements for members and providers.
The Centers for Medicare and Medicaid Services has prioritized data interoperability among payers, providers, and consumers. The Interoperability and Patient Access Rule introduced regulations that required APIs that allow patients to access their health data electronically. Health plans must also supply a Patient Access API that enables patients to access health information.
Additionally, health plans must provide a Provider Directory API and support the secure transmission of patient health information to other health plans through payer-to-payer data exchange.
In addition to federal requirements, states may impose interoperability requirements for health plans. For example, New York introduced the Statewide Health Information Network for New York (SHIN-NY), which requires health plans to facilitate the secure exchange of patient health information.
As a result of these interoperability mandates, insurers have spent a considerable amount of time building interoperability assets. That work will continue in 2024. Among the strategic considerations to take in 2024 include:
- Prioritize interoperability use cases based on regulatory compliance while considering member, provider, and partner needs.
- Consider integrating data with popular consumer apps – like wearable device apps, appointment scheduling and reminder apps, pharmacy apps, and health and wellness apps – to deliver members insight into familiar apps.
- If you serve Medicare Advantage and Medicaid plans, work toward compliance with CMS’ prior authorization interoperability provisions in CMS-0057-P.
- Consider your provider contracts. As you renew, ensure contracts include language that requires interoperability standards in exchange for lower rates.
Is AI the new blockchain? A technology buzzword discussed even though little real-world application exists?
It doesn’t seem likely. Insurers have implemented AI use cases for years. As ChatGPT and other large language models (LLMs) have shown, significant advancements have been made that may lead to more practical applications of the technology.
AI will impact your organization over the next decade, so if you haven’t, start exploring use cases in 2024. Here are some tips for those exploring AI:
Determine How to Embed AI Knowledge in Your Organization
Your ability to execute relies in part on your AI organizational structure. Insurers beginning their AI journey usually embed those resources/knowledge in their IT teams or construct a separate AI unit within IT. Large insurers with mature AI teams often embed AI resources directly in departments, leading to more insight into daily AI needs. Other large organizations leverage a matrixed approach, embedding AI resources in specific departments – like member services – but still reporting to an AI unit. Determining which organizational structure best supports your needs should be an immediate priority.
Create an AI Framework
If you’re investing or planning to invest in AI, consider crafting a framework that defines how you use AI in your organization. Last year, we wrote about the US Department of Health and Human Services Trustworthy AI Playbook, which can be a guide for your AI framework. When creating an AI framework, consider:
- How do you ensure fairness?
- Is your use of AI transparent?
- Does your use of AI ensure privacy?
- Is your AI use secure?
- How do you develop AI solutions internally?
Prioritize Use Cases
Health insurance AI use cases abound. You won’t be able to tackle them all immediately, so begin by documenting and prioritizing them. Your prioritization process may include:
Does it meet your strategic objectives? If your strategic goal is to improve member engagement, you would prioritize AI use cases that help meet that goal above others.
Is it feasible? You’ll likely start the prioritization process with a brainstorming session where all ideas are welcome. Once you’ve generated a list, review each item to ensure it’s feasible given your resources and abilities.
How long will it take? If you’re just getting started, I’d focus on quick wins. AI use cases that may take years to complete may not be a priority given there is likely a lot of low-hanging fruit to attack first.
What’s the impact? In a perfect world, you want to prioritize AI use cases with the greatest impact – assuming they won’t take years to complete. Try to quantify the impact of each use case during the prioritization process.
Focus on the Member Experience
Payers have shifted their priorities in the past decade to prioritize the health insurance member experience. A member-centric approach has become the norm for health insurers looking to improve their member satisfaction. The customer experience includes many elements:
When investing in member experience technology, focus on solutions that solve member needs. Avoid solving edge cases. Focus on technology that improves high-volume member actions. Ensure that any software has a simple user interface for both members and your team. You should consider integration capabilities because most member experience solutions will likely need to talk with other internal and external systems.
Your members are used to Amazon’s one-click ordering process, Apple’s simplified phone interface, and hail Ubers. They expect the same level of process simplicity from you. So examine your processes from a member’s perspective and ensure they meet your standards. Member journey mapping can help pinpoint inefficient processes so you can improve them.
Great Customer Support
The member experience often starts with member support interactions. Ensure your member service team is well-trained and can access member information to deliver fast, accurate support. Many insurers have also begun using tools like generative AI and dedicated training to create more empathetic member communications.
Proactive, Personalized Experiences
Finally, look for technology that can deliver proactive, personalized experiences. Whether that’s tailored fitness activity advice, relevant content, or communication preferences, personal experiences based on member data can lead to a better member experience if properly constructed.
Prepare for Regulatory Change
Regulatory change is a constant in the health insurance industry. In the past decade, many health insurers have profited from Medicare Advantage plans. That may end as CMS has made it difficult to earn high Medicare Advantage Star Ratings and implemented rules, like the Medicare Advantage RADV Final Rule, that may decrease profits in Medicare Advantage plans.
Plus, throw in the new interoperability requirements, and health plans face an unpredictable regulatory environment. To ensure continued compliance and profitability:
Keep abreast of regulatory developments by regularly monitoring government websites, regulatory agencies, and industry publications.
Establish Regulatory Intelligence Processes
Develop processes and systems to capture, analyze, and disseminate regulatory information within the organization. Dedicated resources or teams should be responsible for monitoring and interpreting regulatory changes to ensure a timely and accurate understanding of requirements.
Conduct Impact Assessments
Assess the potential impact of regulatory changes on current operations, systems, policies, and procedures. Evaluate the need for adjustments, enhancements, or new initiatives to ensure compliance with the new regulations.
Engage in Regulatory Advocacy
Participate in industry associations, advocacy groups, and regulatory forums to contribute to the regulatory dialogue. Collaborate with peers, stakeholders, and regulatory authorities to provide input, share perspectives, and influence the regulatory process to align with health plan and member needs.
In a rapidly evolving healthcare landscape, health insurers must harness the power of technology to deliver exceptional member experiences. By embracing cloud infrastructure, prioritizing interoperability, optimizing claims processing, and exploring AI applications, insurers can modernize their technology and unlock new opportunities. However, technological advancements must align with regulatory requirements, underscoring the importance of staying informed, conducting impact assessments, and engaging in regulatory advocacy. By strategically addressing these areas, health insurers can navigate regulatory changes, enhance member experiences, and position themselves for long-term success in the dynamic world of health insurance.
Certifi’s health insurance premium billing and payment solutions help healthcare payers improve member engagement while reducing administrative costs.