Tips to Transform Your Health Plan in 2024

The health insurance landscape is changing faster than ever. New regulations, evolving technologies, and shifting member expectations demand agility from health plans. 

But plans still rely on outdated core administration systems that are rigid, inflexible, and unable to keep pace. Or, their technology teams have fallen behind and lack the skills necessary to succeed using modern technology. Or they don’t have an AI or API strategy to set them up for success.

If you identify with any of these statements, here’s how to transform your health plan in 2024:

Reconsider Your Core Administration Solution

In 2025, Medicare Part D plan sponsors will need to implement the Medicare Prescription Payment Plan that requires, among other things:

  1. A unique monthly billing rule/cap
  2. Required delinquency and termination communications
  3. Defined invoice data elements

For many insurers, complying with these regulatory requirements may leave them scrambling. Insurers have long purchased or built core admin solutions that combine claims administration, enrollment management, and billing. These core administration solutions can’t manage Medicare Prescription Payment Plan requirements. Complying with the prescription plan requirements can be problematic and time-consuming.

The Medicare Prescription Payment Plan regulations highlight the limitations of legacy core administration systems: Insurers can’t quickly modify them to comply with regulatory change. Most don’t include basic billing functionality, like configurable invoices, integrated payment portals, and automated delinquency communications, to maximize revenue and streamline processes.

Steps to Take

CIOs should proactively review their core admin capabilities. Start by discussing workflows with billing, enrollment, and claims management teams. Be attentive to workarounds resulting from system limitations. These workarounds likely impact efficiency and limit team productivity.

Then, analyze market offerings to determine best-in-class billing, claims administration, and enrollment solutions. Integrating these solutions takes time, but it’s becoming faster. It’s time well spent because you’ll deliver more functionality and significant time savings to your teams. 

Analyze and Improve Your Team’s Skills

As technologies evolve and change, so do the skills required to take advantage of those technologies. As you turn to emerging technologies – like cloud computing, artificial intelligence (AI), or low-code applications – to improve efficiency, the skills you seek on your technology teams will change.

In 2023, AI exploded. Health plans have dabbled with AI for a decade, but as the tools have improved, so have AI use cases. However, for many organizations, the skills necessary to develop and maintain AI projects require a software development skillset they may not have. 

Like AI, transitioning to cloud-based applications offers efficiencies and cost savings. Take the case of Sentara Health, which operates a not-for-profit health system and health plans. In 2018 the company launched an initiative to migrate to the cloud. By 2023, nearly 80% of its applications are cloud-based, leading to almost $6 million in annual savings while improving security.

But you need the internal knowledge and resources to make that transition possible, as anyone who’s transitioned internal applications to Amazon Web Services has experienced.

Steps to Take

Start by doing a SWOT analysis of your team. Identify how your team fits into your technology roadmap. What strengths will help you achieve that roadmap? Are there any weaknesses? What opportunities exist to exceed expectations? Are there threats that may prevent you from achieving your goals? 

Transform that analysis into actionable tasks you can execute to improve your team. That might include offering additional training opportunities, or you may need to hire talent adept at developing AI applications. Whatever the case, create a plan to ensure your team’s skills align with your technology roadmap. 

Consider the Implications of AI

AI was everywhere in 2023. Once generative AI applications like ChatGPT exploded in late 2022, money poured into AI applications. That results in both positive and negative implications for health plans. 

There are several use cases for AI – from member-facing chatbots to fraud analysis. But there are also negative impacts. For example, Medicare Advantage beneficiaries filed a class action lawsuit alleging that UnitedHealth Group used AI to deny care to Medicare Advantage patients. Members sued Humana for using the same nH Predict technology. 

Additionally, algorithmic bias can occur if health plans train AI models on biased data, leading to unfair outcomes for under or over-represented populations. Transparency can also be a concern because it may be difficult to understand how AI models make decisions.

But AI also offers significant benefits, like improved efficiency and cost reduction. It can enhance underwriting and risk assessment, help personalize care and engagement, and enhance fraud detection and prevention. As a result, health plans shouldn’t overlook AI as a technology that can propel a health plan forward. 

Steps to Take

For health plans, that means addressing ethical and practical challenges to ensure responsible AI usage. Regulatory and legal frameworks around AI in healthcare are still evolving, and health plans must stay up-to-date on the latest developments. Develop a clear strategy for using AI that includes data privacy, ethics, and transparency.

Think API-First

As health plans move toward modularity, embracing an API-first approach offers significant advantages for health plans. Among them:

  • APIs enable rapid integration with new technologies and services, allowing health plans to adapt to changing market demands and member needs. This agility leads to more innovative services, improving competitiveness.
  • APIs help disparate systems exchange data, breaking down information silos. Health plans can provide better care coordination, personalized offerings, and data-driven insights.
  • APIs can power self-service portals, personalized recommendations, and real-time health information access, putting members in control of their healthcare journey. 
  • APIs automate manual processes and eliminate data silos, streamlining workflows and reducing administrative costs. 
  • APIs provide a flexible and adaptable foundation for future technological advancements, ensuring health plans remain at the forefront of the digital healthcare revolution.

Examples of how health plans can leverage APIs:

  • Integrate with wearables and fitness trackers to personalize health programs and manage chronic conditions.
  • Connect with pharmacies to automate medication refills and track medication adherence.
  • Partner with telehealth providers to offer convenient care options.
  • Share data with public health agencies to improve population health initiatives.
  • Build better member experiences by integrating data from disparate sources in member portals.

Steps to Take

If it doesn’t exist, develop an API strategy. It can include goals and objectives, an inventory of existing APIs, a prioritization of API development, and guidelines for API development and deployment.

Consider industry API standards. Utilize established API frameworks like FHIR for greater adoption and compatibility. Make sure your APIs have clear documentation and intuitive design. Promote your internal APIs to developers, partners, and users. Finally, collect and analyze usage data so you can continuously iterate.

Certifi’s health insurance billing and payment solutions help payers improve member satisfaction while reducing administrative costs.


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