The challenges of today’s evolving health care climate will not be resolved with yesterday’s technology. For a payer organization to effectively compete and thrive in the current environment, it must replace outdated legacy platforms, aging ancillary systems and expensive, error-prone manual processes. Payers need next-generation, business-transforming technology that radically innovates and efficiently addresses business imperatives.
Business transformation rests on meeting five key challenges currently facing payers. We’ve outlined solutions below that center on the role technology plays in transforming these challenges into opportunities.
Streamline operations. Cut administrative costs, streamline processes and improve efficiencies.
The solution: Plans should strive to improve auto-adjudication, driven by data cleanliness across members, providers and benefit plans. Automation across processes and application configuration will improve efficiencies and empower business users to make changes quickly and easily.
Engage members and providers. Today’s consumer-centric approach to health care has created higher customer service expectations among members and providers.
The solution: New technology allows payers to facilitate consistent, accurate and timely communication via contact centers, portals and mobile applications. It’s easier to identify at-risk members for enhanced medical management, thereby reducing medical spend.
Increase transparency. When stakeholders have the right information, they become empowered decision makers. Improved data capture processes, and real-time interaction with members and provider, is critical.
The solution: Business transformation only works if outdated systems are upgraded. Improved processes allow plans to make integrated, enhanced data available to internal and external stakeholders.
Support new business models. Health care is no longer one-size-fits-all. Payers must be able to adapt as models evolve.
The solution: Payers need flexible and responsive systems to enable current and future business models, such as accountable care organizations, pay-for-performance, health insurance exchanges and value-based reimbursement/value-based benefits.
Achieve regulatory compliance. The concept of “remediate once and then you are done” is no longer an option. Payers must be able to adapt repeatedly with reliable approaches as standards continue to change.
The solution: By investing in modern, agile technology designed to adapt to regulatory changes cost effectively, payers will be better prepared to respond rapidly to future compliance and regulatory changes, and further differentiate themselves as a market leader.
To read more about the role technology plays in business transformation, download our white paper, “Using technology to drive business transformation.”
About the authors
Dean Farley, Vice President of Provider Reimbursement, Optum Payer Consulting
Dr. Farley is a health economist with more than 30 years of experience managing and conducting research on health care financing and reimbursement. He currently manages a consulting practice focusing on payment reform and payment analytics within our Networks and Population Health business. Dr. Farley is a nationally recognized health economist specialized in hospital finance, case-mix measurement and severity adjustment.
Shaun Flanagan, Senior Vice President of Consulting, Optum Payer Consulting
Shaun Flanagan has 20+ years of experience in Health care business transformation and complex systems integration. He is a key leader in Optum system integration consulting and leads the HealthEdge practice. His teams focus on delivering consulting services, technology, and product solutions that enable health plans to reduce administrative cost and inefficiencies, streamline business processes, improve customer acquisition and retention and build technology based business solutions to drive our clients’ strategic growth objectives.
Donna Holmes, Vice President, Optum
Donna leads the operational consulting and ICD-10 practice at Optum. She brings over 30 years commitment to helping health plans transform themselves through measurable performance improvements. Donna works with U.S. health plans providing executive leadership in business and IT strategic planning, business performance optimization and organizational alignment to drive higher performance of people, processes and technologies within client organizations.