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Health Plan Interfacing


It’s time for health plans to step up


Flexible, scalable technology solutions can position payers for long-term success in the post-reform healthcare market.


By Dan Spirek, TriZetto O


ne evening, novelist James Fenimore Cooper was reading aloud to his wife, who lay ill in bed. After a few chapters, though, he threw aside the book, saying, “I could write you a


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better book than that myself.” His wife, knowing that Coo- per hated even writing letters, challenged him on the spot to try, which he did with gusto. And so began his writing career, a success by any measure. Like Cooper, healthcare payer organizations have an opportunity to respond successfully to a challenge: In this post-reform market, health plans must step up, take a lead- ing role in complying with reform mandates, dramati- cally increase administrative


effi ciency and improve the cost and quality of care. To be successful, payers must act quickly to leverage technology to comply with requirements beginning to take effect under the Patient Protection and Affordable Care Act. These re- quirements include free preventive care, a ban on rescissions and extended coverage of dependents. Further, payers must improve patient-care processes and streamline administra- tive functions, placing a higher priority on managing health than on managing claims.


TriZetto’s point of view


Health plans can meet this challenge with smart decisions today regarding software and services. The best software and services are scalable and fl exible for payers of all sizes, help- ing health plans increase administrative effi ciency, improve the cost and quality of care, and seize the opportunities of reform to make enterprise-wide improvements and grow profi tably.


In 2010, payers were challenged with integrating new costs into their economic models as a result of expanded coverage, restrictions on annual/lifetime limits and the elimination of rescissions. Signifi cantly, fl exible and scalable enterprise-wide administrative solutions helped health plans of all sizes respond quickly to implement required confi gura- tion changes. As the next wave of requirements takes effect through 2013, payers need to respond to new compliance


20 December 2011


challenges and opportunities. In particular, to meet the new medical-loss-ratio (MLR) requirements, health plans should look for ways to: • Maximize effi ciencies through greater system integration and automation;


• Enable seamless interactions with providers, members and other constituents; and


• Drive increased healthcare value with automated, value- based programs.


As payers upgrade their core administration systems to comply with HIPAA 5010 and ICD-10 mandates, they have an opportunity to use the rich patient-care data within their systems to drive more sophisticated care- and incentive-management programs.


The best claims administration, care management and constituent-engagement solutions offer fl exibility, automa- tion and integration that can position payers to address these challenges and comply with MLR requirements. Not to be forgotten, however, are the challenges of meeting HIPAA 5010 and ICD-10 requirements and embracing the larger opportunities that compliance brings.


Core systems can leverage ICD-10 compliance As payers upgrade their core administration systems to comply with HIPAA 5010 and ICD-10 mandates, they have an opportunity to use the rich patient-care data within their systems to drive more sophisticated care- and incentive- management programs. The new diagnosis and treatment codes can help health plans pivot from their traditional role as claims-management organizations to a new, greatly expanded role as service organizations. In this emerging healthcare environment, ICD-10 cod-


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