Health plans are processing more payments than ever, often with outdated technology and workflows. According to the “2023 CAQH Index Report,” the volume of medical administrative transactions, including claim payment and associated tasks, reached just over 55 billion in 2023, increasing by over 200% compared to nearly a decade ago.
Yet, health plans paid about a quarter of claim payments through fully manual methods (i.e., phone, mail, fax, or email) last year, CAQH reports. The remaining payments went through the electronic ACH and EFT channels. However, technology solutions need to more efficiently consolidate the wide range of modalities used and support providers in this shift to digital transformation.
Outdated technology and manual processes drive complexities in medical billing, which already contains many steps to get to final payment. These challenges not only drive operating costs up but also create friction between health plans, providers and members. A significant portion of healthcare members expect enhanced experiences from their health plans, and many are willing to switch plans to get it. According to a survey, nearly 40% of consumers indicated that they would switch their provider to one that offers a better digital experience
“An evolving industry that’s over 20% of the GDP may be using great technology, but the solutions are not generally designed to keep up with the velocity and the change in demand that providers and members are asking for today,” says Dylan Papa, senior vice president of growth & transformation at Zelis.
There’s a cost to not doing anything. The status quo will not lead to the efficiencies payers need to manage increasing claim volumes while delivering a better experience for payers, providers and members.
Payers are uniquely positioned to pioneer modernization with investments and strategies that enable them to be more efficient and focus on payments innovation and provider and member experiences. Here are five of those.
Build a consolidated payments environment
The healthcare payments experience includes a complex network of administrative transactions, from eligibility and benefit verification to claim payment and remittance advice. Yet, payers often work in siloes and different systems to complete each step to claim payment.
Implementing a unified platform that integrates various payment systems can streamline processes. This ecosystem approach reduces complexity and fosters a more cohesive operational environment, consolidating multiple functions and improving overall business efficiency.
“The key question is how a modern healthcare payments platform can streamline operations and enhance business efficiencies across the board,” says Papa.
Consolidating processes under a single platform can also alleviate a major source of friction between payers and providers. Being able to manage a claim from start to finish in a single platform can increase turnaround times and minimize the administrative burden of submitting and paying a claim.
Prioritize integrated, intelligent compliance management
With ever-changing healthcare regulations, maintaining compliance is crucial. Payers are under a microscope as federal and state regulators look to rein in healthcare spending. New rules and regulations, and even updates to existing ones like the No Surprises Act, create complex compliance requirements that are increasingly intricate and demanding.
"The increasing number of legislative changes, such as the No Surprises Act, and the complex compliance requirements imposed by regulatory bodies highlight the need for a reliable partner,” asserts Papa. “This partnership is essential as regulations continue to evolve, becoming more intricate and demanding over time."
Modern payment solutions can offer built-in compliance tools, like rules-based engines, that help health plans adapt to new laws and regulations efficiently, ensuring that they are compliant and proactively responding to the latest requirements.
Align with consumer demands for digital transformation
Providers and members want more digital methods of payment to streamline and unify the experience.
"Payees, whether it be providers or members, are looking for advancement. They want evolution. They want modernization,” says Leah Silver, vice president of business solutions at Zelis. “Today’s modern consumer wants to take advantage of all the new technology features and digital disbursement offerings that will create efficiency in process and free up time to focus on other priorities.”
For providers, payers need to offer digital payment solutions like ACH and EFT payments and new virtual credit card options to alleviate the time-consuming, inefficient tasks that cut margins and slow growth for payers and providers. These digital payment options also streamline the payments process, getting billing information back to consumers quicker and in ways they want to receive communications from their health plans.
In particular, many payers have an opportunity to improve the digital member payments experience. “The goal should be to evolve to a point where you're creating sustainable satisfaction levels for both providers and members, staying a step ahead of their changing needs and expectations,” Silver said.
A recent survey found that nearly a third of health plan members are dissatisfied with their plan’s website, and a fifth are dissatisfied with their plan’s emailing strategy. What members do want, according to a majority of survey respondents, includes connections between a member’s touchpoints with their plan, better claims processes and personalization of communications.
Technology platforms need to accommodate what payers need to manage claims and what providers and members want from their experience with health plans.
Use data analytics and AI integration
Digital transformation is key to modernizing the healthcare payments experience and driving better engagement and satisfaction among providers and members. However, this digital transformation can also transform the payer’s experience through data analytics and AI.
Leveraging data analytics and AI can help plans understand and predict needs and behaviors. By analyzing data, plans can identify inefficiencies, forecast trends and provide more personalized services to their members and providers. These technologies also enable health plans to optimize their offerings and improve decision-making processes.
"Utilizing AI and related emerging technologies within a modern healthcare payments platform enhances the ability to effectively gather and analyze data,” adds Papa. “Advanced analytical capabilities allow organizations to better understand and tailor their offerings to the distinct needs and behaviors of various user groups while simultaneously serving as another driver of improved efficiencies.”
Take it step by step
Modernization does not happen overnight. Digital transformation takes time as payers evaluate their systems, understand provider and member needs and implement the technologies or capabilities they need to improve the healthcare payments experience. As payers look to evolve the way they manage payments, any step toward digitization and more modern means of communication will enhance the experience for all involved.
"Modular technology supports step-by-step enhancements in healthcare payment systems,” states Papa. “This approach enables organizations to tackle specific needs progressively without a total system overhaul. Initially, the technology can address a particular requirement, then expand as the health plan's needs grow.”
“This flexibility is vital for adapting to the constantly evolving healthcare landscape without overwhelming the system or the staff,” Papa emphasizes.
The traditional way of doing business is hindering provider efficiencies and the improvement of patient care. Paper-based payments and siloed systems increase payer spending and reduce efficiency. This outdated system isn't working for payers, providers, or members — we are all interconnected. Incremental modernization can unlock a better experience for all constituents and let care flow smoothly, enhancing efficiency and satisfaction across the healthcare ecosystem.
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Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts. To learn more about how Zelis is modernizing payments and communications, click here.
