30Apr

Generative AI: A Roadmap for Healthcare Leaders

Generative AI:

A Roadmap for Healthcare Leaders

The integration of Generative Artificial Intelligence (AI) in healthcare is more than an innovation; it’s a transformative journey that requires careful planning, execution, and leadership. As the capabilities of generative AI continue to expand, healthcare leaders are tasked with harnessing its potential while navigating the ethical, regulatory, and operational challenges it brings. This article offers a comprehensive roadmap for healthcare C-suite and senior leaders to incrementally adopt generative AI, emphasizing the strategic approach and expertise provided by Curate in healthcare consulting and technology modernization.

Understanding Generative AI

Generative AI refers to the class of artificial intelligence technologies capable of creating new content or data based on its training. In healthcare, this might manifest as creating synthetic medical data for research, aiding in personalized medicine, or generating predictive models for patient care. The first step for any healthcare leader is to understand the technology’s capabilities, limitations, and the opportunities it presents.

Understanding Generative AI

Setting the Vision and Strategy

Identify Organizational Goals: Understand how generative AI can align with and advance the organization’s mission, whether in improving patient outcomes, operational efficiency, or clinical research.
Establish Clear Objectives: Set specific, measurable objectives for what you want to achieve with AI, such as reducing diagnostic errors or enhancing patient engagement.

Assessing Readiness

Infrastructure Evaluation: Determine if the current technology infrastructure can support AI applications. This includes data storage, computing power, and network capabilities.
Skills Assessment: Assess whether the team has the necessary skills or if additional training or hiring is necessary.
Data Governance: Ensure robust data governance policies are in place to handle the data AI will use and generate, focusing on privacy, security, and ethics.

Assessing Readiness

Infrastructure Evaluation: Determine if the current technology infrastructure can support AI applications. This includes data storage, computing power, and network capabilities.
Skills Assessment: Assess whether the team has the necessary skills or if additional training or hiring is necessary.
Data Governance: Ensure robust data governance policies are in place to handle the data AI will use and generate, focusing on privacy, security, and ethics.

Ethical and Regulatory Compliance

Understanding AI Ethics: Develop a deep understanding of the ethical implications of using generative AI in healthcare, including biases, accountability, and transparency.
Regulatory Alignment: Ensure that AI applications comply with healthcare regulations such as HIPAA in the U.S., GDPR in Europe, and other relevant guidelines.

Planning and Execution

Pilot Projects: Start with small-scale pilot projects that can provide quick wins and valuable insights into the use of AI in your operations.
Stakeholder Engagement: Involve all stakeholders, including clinicians, IT staff, administrators, and patients, in the planning and implementation process.
Partnering with Experts: Consider partnering with technology providers and consulting firms like Curate to navigate the complexities of AI implementation.

Planning and Execution

Pilot Projects: Start with small-scale pilot projects that can provide quick wins and valuable insights into the use of AI in your operations.
Stakeholder Engagement: Involve all stakeholders, including clinicians, IT staff, administrators, and patients, in the planning and implementation process.
Partnering with Experts: Consider partnering with technology providers and consulting firms like Curate to navigate the complexities of AI implementation.

Measuring Impact and Scaling

Performance Metrics: Define and monitor performance metrics to assess the impact of AI initiatives on patient care, operational efficiency, and other key areas.
Scaling Strategy: Develop a strategy for scaling successful AI applications, ensuring that infrastructure, policies, and team capabilities can support expansion.

Continuous Learning and Adaptation

Stay Informed: Keep abreast of the latest developments in AI technology and healthcare applications.
Feedback Loops: Create mechanisms for continuous feedback and learning from AI applications, adjusting strategies as needed.
Innovation Culture: Foster a culture of innovation that encourages experimentation, adaptation, and learning.

Continuous Learning and Adaptation

Stay Informed: Keep abreast of the latest developments in AI technology and healthcare applications.
Feedback Loops: Create mechanisms for continuous feedback and learning from AI applications, adjusting strategies as needed.
Innovation Culture: Foster a culture of innovation that encourages experimentation, adaptation, and learning.

Addressing Challenges and Risks

Risk Management: Develop robust risk management strategies for AI, focusing on areas like data breaches, ethical mishaps, and operational disruptions.
Change Management: Effectively manage the change process, addressing concerns and resistance from staff and ensuring smooth integration of AI into workflows.

Conclusion

The journey to integrating generative AI in healthcare is complex and requires committed leadership, strategic planning, and continuous adaptation. By following the above points, healthcare leaders could try to navigate the challenges and capitalize on the opportunities AI presents.

Leveraging the expertise of partners like Curate, leaders can ensure that their organizations are at the forefront of healthcare innovation, delivering improved patient care, operational excellence, and a sustainable competitive advantage. As generative AI continues to evolve, healthcare organizations that take a strategic, informed approach to its adoption will be well-positioned to lead the way in the future of medicine.

Conclusion

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.

23Apr

The 2024 Customer Service Transformation: Generative AI’s Pivotal Role

The 2024 Customer Service Transformation:

Generative AI's Pivotal Role

In 2024, a significant evolution in customer service is anticipated, driven by advancements in Generative AI (GenAI). This shift is expected to notably improve customer experience, a first in three years. Through this article, we’ll explore the implications of this prediction, its pros and cons, and how Curate’s AI Advisory services can help businesses harness this technology effectively.

The GenAI Revolution in Customer Service

Generative AI is set to redefine how customer service operates, equipping agents with advanced tools that enhance their problem-solving abilities and interaction quality.

Pros

Enhanced Efficiency: AI-driven tools will significantly speed up response times and improve accuracy in handling customer inquiries.

Personalized Interactions: GenAI can provide tailored responses, creating a more personalized experience for customers.

Cons

Depersonalization Risk: Over-reliance on AI might lead to a lack of personal touch in customer interactions.

Technical Complexity: Implementing and maintaining GenAI solutions requires technical expertise and resources.

Impact: Elevating Customer Experiences

The integration of GenAI in customer service is expected to elevate the customer experience, offering quicker and more effective solutions.

Analogies and Examples:

AI as a Skilled Concierge: Just like a concierge knows guests’ preferences, GenAI can anticipate customer needs and offer personalized assistance.

The AI-Assisted Physician: Imagine a doctor (customer service agent) with an AI assistant providing instant information to diagnose and treat patients (solve customer issues) more effectively.

Impact: Elevating Customer Experiences

The integration of GenAI in customer service is expected to elevate the customer experience, offering quicker and more effective solutions.

Analogies and Examples:

AI as a Skilled Concierge: Just like a concierge knows guests’ preferences, GenAI can anticipate customer needs and offer personalized assistance.

The AI-Assisted Physician: Imagine a doctor (customer service agent) with an AI assistant providing instant information to diagnose and treat patients (solve customer issues) more effectively.

Curate's Role: Navigating the GenAI Wave

Curate’s AI Advisory services are crucial in guiding businesses through the adoption and optimization of GenAI in customer service.

Strategic AI Implementation: We help design strategies that integrate GenAI seamlessly into customer service models.
Balancing AI and Human Elements: Curate ensures that while AI enhances efficiency, the human element in customer service remains intact.

Conclusion: A New Era for Customer Service

The year 2024 marks a turning point for customer service, with GenAI significantly improving how businesses interact with their customers. Curate’s AI Advisory expertise is pivotal in helping companies adapt to this change, ensuring they leverage GenAI to enhance customer satisfaction while maintaining a human touch.

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.

23Apr

The Power of Measurement and Pilot Programs in Payment Integrity

In the world of healthcare payments, accuracy is everything. Lost revenue due to errors and improper claims can significantly impact an organization’s financial health. That’s why building a strong payment integrity program is crucial, and a key element of that program is measurement.

As a veteran in Payment Integrity, I’ve seen firsthand the power of data-driven decision making. Here’s why measurement is lesson number six on my list for successful program implementation:

Identify Areas for Improvement: Without measuring results, it’s difficult to know where your program is excelling and where it falls short.Metrics help pinpoint areas with the highest error rates or potential for improper payments. This allows you to focus your resources and refine your strategies for maximum impact.
Demonstrate Program Value: Leadership needs to see the program’s worth. Regularly measuring and reporting on recovered funds, identifying errors, and preventing improper payments provide concrete evidence of program effectiveness. This data becomes a powerful tool to secure continued support and resources.
Fuel Continuous Improvement: The healthcare landscape is constantly evolving. What works today might not be optimal tomorrow. Measurement allows you to track program performance over time and identify areas for improvement. This iterative process keeps your program agile and adaptable to changing regulations and industry trends.
Boost Staff Morale: When staff sees the program making a tangible difference, it boosts morale and fosters a sense of accomplishment. Sharing metrics around recovered funds or prevented errors can motivate staff and inspire them to continue their efforts.

Explore our Payment Integrity Program Implementation Solutions

Curate Partners: Experts in Extracting Payment Insights

Our team goes beyond basic metrics. We use advanced data visualization to uncover hidden patterns in your payment data, helping you identify high-potential areas for recovery.

Scalable Measurement for Your Program

We understand your needs are unique. We will work with you to build a customized measurement plan, starting with core metrics and seamlessly integrating more data points as your program matures.

Partner with us to leverage our expertise and advanced tools. Transform data into actionable insights and achieve long-term financial success.

Meet the Author

Chad Roswick, VP of Healthcare Consulting

Link to bio

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.

18Apr

Unlocking Efficiency: A Guide to Automation Technologies for Healthcare Payers

Unlocking Efficiency:

A Guide to Automation Technologies for Healthcare Payers

Executive Summary:

Embracing automation is becoming a standard for operational excellence in the healthcare payer landscape. In this primer for payers, we break down the five core automation technologies: robotic process automation (RPA), smart workflows, computer vision, natural language processing (NLP), and cognitive agents. As healthcare payers navigate digital transformations and a competitive market, embracing this suite of automation technologies becomes not merely a technological evolution but a strategic imperative for sustained growth and operational sustainability.

There’s no way around it. The automation revolution has come for healthcare—and payers are no exception.

The more you look around, the fewer payers remain who haven’t implemented some form of AI-enabled automation in their business. These technologies are helping next-generation healthcare payers operate more efficiently and offer effortless white-glove service to their members and network.

However, much like healthcare, automation is not one-size-fits-all. Which automation technology you implement—and where in your business it fits best—is a very individual choice. To understand what automation upgrades would work best for your payer business, you need to feel confident with your knowledge of the automation landscape.

Whether you’re just getting started with automation for payers or looking to refine your toolkit, you’ve come to the right place.

At Curate Partners, we’ve worked with a range of payer organizations to refine a wide variety of business operations using automation. Now, we’re boiling down our automation experience for you, all in one accessible place. Consider this your crash course on the core automation technologies payers need to know.

The core automation technologies for payers:

Robotic process automation (RPA)
Smart workflows
Computer vision
Natural language processing (NLP)
Cognitive agents

RPA for payers: Start your automation journey here

Robotic process automation (RPA) is one of the most powerful and relevant automation technologies for healthcare payers. It’s a game-changer for organizations seeking to streamline routine, rule-based tasks.

At a fundamental level, RPA works like this: Software robots mimic human interactions with digital systems. The result is a win-win—staff can redirect their attention to areas where their input is more necessary, and the business lowers their risk of administrative errors. Plus, because RPA relies on existing interfaces, implementing it doesn’t require a costly IT infrastructure overhaul.

In healthcare, RPA improves functions ranging from billing accuracy to regulatory compliance and credentialing. RPA can be so nimble because of how it can work with or without supervision. Attended RPA bots are activated by employees on workstations or private servers, giving organizations a high level of control over how the bot functions in collaboration. In comparison, unattended RPA bots ease automation at scale, working independently by relying on a preset schedule and meticulously constructed logic.

Expert estimates predict that up to 60 percent of the healthcare value chain can be automated with attended and unattended RPA.

McKinsey: Where machines could replace humans—and where they can’t (yet) UiPath: Robotic Process Automation (RPA) in the Healthcare Sector

UiPath also projects that automation with both attended and unattended bots gives healthcare organizations, on average, a 5.3-month ROI after a 5.2-week implementation time.

Supercharging claims processing with RPA

For healthcare payers, RPA can especially help speed up claims processing. Software robots can efficiently extract relevant information from incoming claims, validate data accuracy, and update records without human intervention.
This accelerates the claims adjudication process and frees up human resources to focus on more complex tasks that require critical thinking and decision-making.

When paired with other automation—like smart workflows—payers can leverage RPA to significantly increase work intake while decreasing errors and adjudication time. For instance, a national U.S. payer saved $30 million in administrative costs while decreasing manual downstream processing. This further opened a door to digitizing 15 additional business operations.

From our experience, we’ve found RPA is the best place for payers interested in automation upgrades to start. We’ve worked with many payers implementing RPA across different business areas. If you’re wondering where RPA might improve your payer organization, we’d love to weigh in. Let’s start the automation conversation.

Smart workflows for payers: Creating integrated experiences

Imagine you’re a healthcare plan member. You’ve gotten used to having your digital health experiences operate like many of your favorite apps and lifestyle subscription services. Think sleek interfaces and seamless personalization. Why wouldn’t you expect your interactions with your health plan to be the same?

Creating an elevated digital experience takes more than one step of automation. Don’t miss our specialized recommendations for digital transformation.

One of the first steps toward creating that seamless digital experience is implementing smart workflows. Smart workflows leverage intelligent automation to streamline end-to-end processes.

As a payer, you can take advantage of smart workflows to optimize the entire healthcare management lifecycle—from member enrollment to claims processing. For instance, when a member submits a claim, a smart workflow can automatically trigger the necessary approvals, track the progress, and update stakeholders in real-time. Your overall member experience elevates with reduced processing times and increased transparency.

When it comes to updating business workflows, your payer business needs a rigorous and sensitive approach. That’s why our approach to change management pairs smart workflow design with stakeholder alignment and comprehensive change management education.

Computer vision: Leveraging payers’ unstructured data

From our years of working with payer businesses, we understand that one of the biggest headaches is coordinating and integrating unstructured data.

Healthcare as an industry manages so many forms of unstructured data—from discharge summaries to medical imaging. And that data is only growing. In fact, the rate of data generated across the industry has been rising at a rate of 47 percent per year.

Payers are no exception when it comes to the pains of handling all of that unstructured data. That unstructured data especially comes into play with document processing and fraud detection.

That’s where computer vision becomes a healthcare payer’s secret weapon.

If you’re already using this form of visual information processing automation, you’re likely using optical character recognition (OCR). This application of computer vision is most useful for tasks like verifying member identity documents. The days of manually inputting names from driver’s licenses are long behind us.

If you’re not yet using computer vision and OCR, now is the best time to get on board, as advances in artificial intelligence have made this automation technology much more accurate at pulling information from visual media.

And as natural language processing (NLP) techniques work with computer vision to improve OCR—especially when it comes to handwriting and lower image quality—the technology will continue to power how payers integrate unstructured data into their business operations.

NLP for enhanced healthcare payer communication

As we’ve covered, NLP pairs well with computer vision to help payers manage their unstructured data.

Of course, NLP is about more than powering the word-detection aspect of OCR.

NLP consists of the following automated tasks:

Text classification
Sentiment analysis
Language translation
Speech recognition

To put it most broadly: NLP is a form of AI that helps computers to interact with human language by breaking it down into its foundational parts.

Payers can take advantage of NLP to, for example, automate and error-proof diagnosis coding reviews and loop unstructured, free-text data into claims decision support.

In healthcare, organizations also use NLP to revolutionize how they communicate—with each other and with consumers. This is, of course, where generative AI chatbots come into play.

For payers, the customer-facing application of NLP is where we see the most momentum. An effective chatbot can lower the pressure on a payer’s customer service department by answering members’ common questions, guiding them through the enrollment process, or providing information on coverage options. After all, IBM has found that three out of four times, answers to customer service questions can be easily found on the company’s website. Even the most rudimentary NLP algorithm could remedy this source of waste.

Plus, when leveraging sentiment analysis, NLP could help payers better understand prospective and current members’ common frustrations, turning customer service into valuable customer experience (CX) research.

The result: A more focused customer service department and a more seamless, personalized digital experience for prospective and existing members alike.

Cognitive agents for personalized payer decision-making

As we’ve been mentioning, automation can be useful to organizations looking to dedicate their human resources to more critical evaluations. Even so, not every complex decision necessarily requires an entirely human touch.

This is where cognitive agents come in. This automation technology bridges NLP with machine learning, creating virtual entities—agents—that perform tasks typically requiring human intelligence.

In healthcare, we commonly see this automation technology in AI-enabled clinical decision software. For healthcare payers, cognitive agents can especially come in handy for eligibility assessments and prior authorization.

Cognitive agents can analyze historical data, take into account the member’s medical history, and provide recommendations based on predefined eligibility criteria. Automating this process not only speeds up decision-making but also ensures that recommendations are consistent and aligned with clinical guidelines.

The difference in efficiency can be staggering. When Elevance Health began employing cognitive agents in its preauthorization processes, they were able to cut down urgent care authorizations from 72 hours to a few seconds. When it came to elective procedures, preauthorizations that previously took three to five days also came down to a few seconds with the cognitive technology.

Takeaways: How your payer business can get up to speed with automation technologies

The choice to automate processes in your payer business is a personal one. Your operation is unique in its mission, workflows, populations, and business plan.

The automation technology that is right for your business may not be what has brought other payers success. At the same time, with the rise of intelligent automation and advancements in AI, even the simplest of automation technologies—RPA—is growing further intertwined with the other core automation technologies. The most automation-savvy healthcare businesses are embracing this multi-faceted approach.

Overall, you must keep in mind that the journey toward greater automation is not just a technological upgrade—or a fad. It’s a strategic move aimed at keeping up and excelling in an increasingly digital and personalized healthcare landscape.

Embracing these automation technologies will not only drive operational excellence but also empower you to focus on your core mission of providing quality care to your members.

Let’s discuss how automation can future-proof your payer business. Get in touch.

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.

16Apr

Accelerating Payment Integrity: The Power of Internal Resources in Healthcare Operations

Accelerating Payment Integrity:

The Power of Internal Resources in Healthcare Operations

In the dynamic landscape of healthcare operations, the pursuit of payment integrity stands as a crucial imperative. At the heart of this endeavor lies the strategic utilization of internal resources, whose expertise and advocacy can significantly accelerate progress. In this article I detail how leveraging internal assets can drive success in payment integrity initiatives within healthcare organizations.

Maximizing Expertise

Experienced professionals in payment integrity bring a wealth of knowledge to the table, offering invaluable insights that propel programs forward. Their seasoned perspective allows for a deeper understanding of industry nuances and challenges, ultimately accelerating the pace of progress.

Advocating for the Health Plan's Interests

While vendor solutions play a vital role in expanding payment integrity capabilities, internal resources serve as staunch advocates for the health plan’s interests. Their ability to evaluate vendor opportunities while balancing potential provider abrasion ensures alignment with organizational objectives and priorities.

Explore our Payment Integrity Program Implementation Solutions

Navigating Data Limitations

Internal resources possess a keen understanding of data limitations, recognizing potential pitfalls that may lead to high false positive rates for vendor solutions. By leveraging this insight, organizations can mitigate risks and optimize data utilization, enhancing the effectiveness of payment integrity initiatives.

Building Internal Processes

Successful implementation of vendor solutions hinges upon the establishment of robust internal processes. Internal resources play a pivotal role in this endeavor, leveraging their expertise to design and implement workflows that support the integration of external innovations. This ensures seamless collaboration between internal teams and vendors, driving efficiency and effectiveness.

In conclusion, the strategic utilization of internal resources is paramount in accelerating payment integrity initiatives within healthcare operations. By maximizing expertise, advocating for organizational interests, and navigating data limitations, organizations can drive meaningful progress towards achieving payment integrity goals. With internal resources at the helm, healthcare organizations can unlock new levels of efficiency and effectiveness in their pursuit of payment integrity excellence.

Reach out to us to explore how we can support your organization’s Payment Integrity transformation!

Meet the Author

Chad Roswick, VP of Healthcare Consulting

Link to bio

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.

09Apr

Navigating the Path to Payment Integrity: Crafting a Clear Roadmap for Success

Navigating the Path to Payment Integrity:

Crafting a Clear Roadmap for Success

In healthcare operations and finance, establishing a robust Payment Integrity (PI) program is imperative for optimizing financial health and ensuring quality care delivery. However, embarking on this journey requires a clear roadmap and execution focus to navigate the complexities effectively. Drawing from insights learned from my article “Navigating the Landscape: 10 Lessons Learned while Implementing a Payment Integrity Office in Healthcare Operations,” In this article I aim to explore how crafting a comprehensive roadmap can pave the way for success in PI initiatives.

Developing a roadmap is the cornerstone of any successful PI endeavor. It serves as a guiding framework, outlining key milestones, objectives, and strategies to achieve desired outcomes. In my experience, aligning this roadmap with organizational goals and priorities is crucial to ensure its relevance and effectiveness.

One of the key decisions in crafting this roadmap is determining the optimal mix of internal capabilities and external vendor solutions. Leveraging both internal expertise and external resources can enhance efficiency and effectiveness in addressing payment integrity challenges. Moreover, this approach allows for flexibility, enabling organizations to bring vendor activity in-house over time as the PI organization becomes more established.

The components of a robust PI roadmap are diverse and encompass various capabilities aimed at identifying and mitigating payment inaccuracies, fraud, and waste. These components include:

Coordination of Benefits (COB): Streamlining processes to ensure accurate coordination of benefits across multiple payers, reducing overpayments and inappropriate claim reimbursements.
Payment Integrity Platform: Implementing a comprehensive platformto centralize data, streamline workflows, and enhance decision-making capabilities in identifying and resolving payment discrepancies.
Data Mining: Harnessing advanced analytics and data mining techniques to uncover patterns, trends, and anomalies indicative of potential payment errors or fraudulent activities.
Claims Editing: Implementing automated claims editing solutions to flag and correct inaccuracies, ensuring adherence to billing guidelines and regulatory requirements.
Fraud & Abuse Program (SIU): Establishing a robust Fraud & Abuse program with a specialized investigative unit (SIU) to detect, investigate, and mitigate instances of fraudulent billing practices.
Clinical Reviews: Conducting thorough clinical reviews to validate the medical necessity and appropriateness of billed services, minimizing overutilization and unnecessary healthcare expenditures.

By integrating these components into a cohesive PI strategy, organizations can enhance their ability to identify, prevent, and recover improper payments effectively. Moreover, a clear roadmap enables stakeholders to align efforts, allocate resources efficiently, and monitor progress towards achieving overarching PI goals.

Explore our Payment Integrity Program Implementation Solutions

In conclusion, crafting a clear roadmap and execution focus is paramount in driving success in Payment Integrity initiatives within healthcare operations and finance. By developing a comprehensive roadmap that aligns with organizational objectives and leverages internal and external resources effectively, we can navigate the complexities of PI and optimize financial outcomes while ensuring quality care delivery.

Reach out to us to explore how we can support your organization’s Payment Integrity transformation!

Meet the Author

Chad Roswick, VP of Healthcare Consulting

Link to bio

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.

04Apr

Breaking New Ground in Medicare CX

Introduction: The Evolution of a Revolution

Welcome to part three of our series exploring the transformative power of CRM and specialized consultancy in healthcare. Having explored the conceptual landscape and dived into a specific case study, we now journey into the inner workings of the CX track for this effort, where a cross-functional team from the healthcare payer organization and Curate Partners came together to revolutionize the Medicare experience through Human-Centered Design.

Setting the Stage

Imagine a vibrant, dynamic space buzzing with the electricity of new ideas—welcome to the payer organization’s Innovation Center. Here, a multidisciplinary team of Curate Partners Purple Squirrels, payer organization employees, UX designers, Salesforce experts, Business and Technology Leaders, Patients, and project managers came together to ideate, experiment, and transform the customer experience (CX) for Medicare business.

The Human-Centered Design Approach

Human-Centered Design (HCD) served as the guiding philosophy. Unlike traditional approaches that focus on system needs, HCD revolves around the end-user—patients in this case—and aims to understand their journey deeply.

Research: Interviews and Surveys

The team conducted one-on-one interviews and developed surveys aimed at capturing the ‘Voice of the Customer.’ This initial research was pivotal in understanding what the patients truly valued and where their pain points lay.

Journey Mapping

Armed with qualitative and quantitative data, the team moved to journey mapping. This exercise revealed the entire patient lifecycle, from becoming aware of the Medicare plans available to post-treatment engagement.

Buyer Persona and Segmentation

Data coalesced into distinct buyer personas, which were then segmented based on several parameters like age, healthcare needs, and digital savviness. This segmentation helped in tailoring different services to different user groups.

Service Design and Workshops

Service Design workshops were held to align all touch points a patient would encounter. Workshops were highly interactive, featuring storyboarding sessions that visualized the entire patient experience.

UX Concepts and Designs

The UX team, enriched by the research and workshop findings, produced wireframes and prototypes, transforming conceptual ideas into actionable designs.

Outcome: An Exemplary Model for Medicare CX

The combined efforts materialized into a comprehensive CX strategy, tailor-made for Medicare patients. The innovation center, once just a space, became a crucible where ideas turned into solutions.

Metrics Speak: KPIs and Success

Improving Net Promoter Score (NPS)
Growing Customer Retention
Increasing Employee Satisfaction

Linking it All Together: The Trilogy in Perspective

If parts one and two were about setting the stage and introducing the characters, part three is the triumphant climax. Where CRM systems provided the foundation and specialized teams built upon it, Human-Centered Design offered the finishing touches that transformed a service into an experience.

Conclusion: The Big Win

The journey through the Innovation CX track wasn’t just a win for the Medicare business team; it was a leap forward for patients and the healthcare industry at large. By focusing on Human-Centered Design, we didn’t just solve problems; we anticipated them, turning challenges into opportunities and skeptics into believers.

As the age wave continues to rise, this triad—of CRM, specialized consultancy, and Human-Centered Design—shows us that with the right approach and tools, we can ride this wave, not just with survival in mind, but with a vision to thrive. And in doing so, we redefine the journey of aging itself.

Ready to redefine your customer experience strategy? Contact Curate Partners to discover how we can transform your challenges into unprecedented opportunities.

Through Human-Centered Design, Curate Partners and the payer organization have proven that innovation is not a one-time event but an ongoing journey. As we continue to explore and expand, we’re paving the way for a healthcare experience that is not just efficient but empathetic, not just business-savvy but deeply human. And this is just the beginning.

Delve further into this three-part series for deeper insights:

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.

02Apr

Overcome Data Challenges: Building a Strong Payment Integrity Program for Health Plans

Building a Strong Payment Integrity Program: Challenges and Solutions for Health Plans

WEBINAR RECAP

Unraveling Payment Integrity Challenges: Tactics for Sustainable Success

Speakers:

Chad Roswick, VP Healthcare Consulting, Curate Partners
Dennis Rossi, Data & Analytics Solutions Partner, Curate Insights
Emily O’Brien, VP Healthcare Solution, Curate Partners

Healthcare costs are a major concern, and health plans are constantly seeking ways to optimize their spending. Payment integrity (PI) programs play a crucial role in this effort by identifying and preventing improper payments. However, building a successful PI program can be challenging. This blog post dives into the key takeaways from our recent webinar on this topic, exploring the common hurdles health plans face and outlining best practices to overcome them.

1. Data: The Foundation and the Challenge

At the heart of any PI program lies data. Unfortunately, accessing the right data can be a significant obstacle. Data is often scattered across various systems, requiring close collaboration with IT to ensure its quality and completeness. Additionally, platform migrations can further disrupt data access for PI initiatives.

2. Data Analytics: The Engine that Drives Results

A robust PI program goes beyond simply having data. It requires a certain level of data analytics maturity within the organization. This involves having a dedicated data platform, robust data quality processes, and skilled personnel who can manage and analyze the information effectively.

3. Governance: Setting the Course for Success

For an in-sourced PI program to thrive, establishing a formal governance structure is essential. This typically involves an executive committee that provides strategic direction and allocates resources. Additionally, a working group with representatives from various departments is crucial for evaluating and approving new opportunities.

4. Internal Capabilities: Building a Scalable Solution

Many health plans have internally developed PI tools. While these tools may have served initial needs, they can often lack scalability and rely heavily on manual processes. Regularly evaluating internal processes and technology is crucial to ensure they can support the program’s growth and future needs.

5. The Future of Payment Integrity: Shifting to a Prepay Model

Traditionally, PI programs reviewed claims after payment (retroactive approach). However, there’s a growing focus on shifting to a prepayment model (proactive approach) to identify and prevent improper payments upfront. This can improve provider relationships by reducing claim denials later and streamline processes for both health plans and providers.

Beyond the Basics: Additional Tips for Success

The webinar also offered valuable insights beyond the core challenges:

Engage IT Early: Involving IT from the outset ensures a smoother implementation process and facilitates access to the necessary data.
Prioritize Independence: Avoid piggybacking PI initiatives onto other large programs. This can lead to resource allocation issues and hinder the effectiveness of both programs.
Collaboration is Key: Partnering with the business side is crucial for defining data quality standards. Clear communication and collaboration will ensure the program focuses on identifying and preventing the most impactful improper payments.

Building a strong PI program requires careful planning and ongoing evaluation. By addressing the challenges discussed above and implementing the suggested best practices, health plans can leverage PI programs to optimize their spending and ensure they are delivering the best possible value for their members.

View Full Webinar:

02Apr

Unlocking Payment Integrity Success: Why Claims Leaders Need Dedicated Support

Unlocking Payment Integrity Success:

Why Claims Leaders Need Dedicated Support

In my experience navigating the intricate world of healthcare operations and finance, I’ve come to recognize a crucial aspect that can make or break Payment Integrity (PI) initiatives: the need for dedicated support. Let me share why expecting claims leaders to manage PI efforts alongside their existing responsibilities can hinder progress rather than propel it forward.

As someone entrenched in healthcare operations, I understand the conflicting incentives claims leaders face when it comes to PI. Their objectives often revolve around reducing provider abrasion, improving auto-adjudication rates, and minimizing provider disputes. However, the implementation and management of incremental PI solutions demand a significant amount of time and resources, which claims leaders may not always have at their disposal. From my vantage point, it’s clear expecting claims leaders to juggle these competing priorities can lead to fragmented efforts and suboptimal outcomes. That’s why I firmly believe in the necessity of establishing a separate PI organization with a distinct focus and clear accountability.

Explore our Payment Integrity Program Implementation Solutions

By carving out a dedicated team for PI initiatives, organizations can ensure these critical efforts receive the attention and resources they deserve. This approach allows for concentrated efforts on identifying and addressing payment inaccuracies, ultimately leading to improved financial outcomes and stronger relationships with providers.

Moreover, a dedicated PI organization fosters collaboration across departments, harnessing expertise from various stakeholders to drive meaningful results. With clearly defined goals and accountability structures in place, organizations can streamline processes, implement targeted interventions, and measure outcomes more effectively.

In conclusion, my journey in healthcare has taught me the importance of providing dedicated support for Payment Integrity initiatives. By establishing a separate PI team, organizations can accelerate their PI program, optimize financial health, and ensure quality care.

Let’s make Payment Integrity a strategic focus and commit the necessary resources and support to achieve success.

Meet the Author

Chad Roswick, VP of Healthcare Consulting

Link to bio

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.

01Apr

The Future of Medicare: Advancing Interoperability and Streamlining Prior Authorization

The Future of Medicare:

Advancing Interoperability and Streamlining Prior Authorization

Executive Summary:

We delve into the evolving and intersecting landscapes of prior authorization and healthcare interoperability for payers. Amidst increasing scrutiny related to AI-enabled denial decisions, CMS continues to waver on prior authorization rulings. We urge payers to stay ahead, navigating regulatory changes, optimizing workflows through automation, and investing in interoperability for enhanced trust and efficiency in the healthcare ecosystem.

Prior authorization (PA) has been in the news a lot lately. And more often than not, the coverage has been unflattering.

The cost-saving measure that helps plans save on unnecessary care has come under scrutiny. Partially due to the government’s slow-moving regulation process regarding PA—more on that in a moment.

However, the most damning coverage has been about Medicare Advantage (MA) plans using AI to deny coverage.

Of course, the use of algorithms in itself is not a problem. When used carefully, we think automation can improve authorization processes for plans and patients. The problem is that investigations of the denials found widespread issues and inconsistencies.

Given these headlines, payers need to be especially confident and mindful of how they proceed with their updates and messaging around PA. Of course, compliance is always important, but heightened media scrutiny increases the pressure.

At Curate Partners, we’re used to guiding our payer clients through business transformations for a variety of strategic reasons—regulatory compliance included. In this evolving regulatory landscape, we want to ensure payers stay up to date with best practices around making the most of the latest regulatory moves.

Today, we’re diving into what payers need to know about the future of Medicare policy, including:

A timeline of recent CMS rulemaking regarding PA
A check-in on how payers fit into the healthcare interoperability landscape
Action steps for payers ready to level-up their PA processes and interoperability

What is the new CMS rule on prior authorization?

Prior authorization is increasingly common. A KFF analysis of Medicare Advantage plans found 35 million requests in 2021 alone.

Over the past few years, the federal government has been studying and ruling on the future of PA. They’ve been doing the same with healthcare interoperability. We wouldn’t blame you if the slew of PA and interoperability rulings from the past few years have made your head spin.

A timeline of the latest CMS moves regarding Prior Authorization and/or interoperability:

May 2020 CMS Interoperability and Patient Access Final Rule: This rulerequired certain payers to give patients direct electronic access to their own
claims and encounter data through astandardized portal—aPatient Access API.
December 2020 Interoperability and Prior Authorization ProposedRule(Withdrawn): Building on the policies in the previous rule, this proposed rule emphasized the need to improve health information exchange. This rulespecifically focused on improving PA processes through technology.
December 2022 Advancing Interoperability and Improving Prior AuthorizationProcesses Proposed Rule: The proposed rule emphasizes CMS’ continued commitment to increasing efficiency while keeping health information point of care availability as a central priority. The rule emphasizes leveraging FHIR standards for improved interoperability.
April 2023 CY 2024 Medicare Advantage Final Rule: This rule prohibits MA plans from denying patients care they would otherwise receive under a traditional Medicare plan. It also required PA validity to be upheld throughout an entire course of treatment and a 90-day transition period if a patient switches to a new MA plan.

Policymakers hope that the proposed and final regulation will shorten PA wait times for Medicare Advantage, Medicaid managed care, and Affordable Care Act exchange plan patients. They also hope to quell tension regarding Medicare Advantage and traditional Medicare patients receiving different standards of care due to PA.

In the meantime, several states have passed or proposed legislation to give providers “gold cards” to bypass prior authorization. Statements by figures like Surgeon General Vivek Murthy blame PA for provider burden, adding pressure to get the rule finalized.

What payers can anticipate from CMS on these issues soon:

Another CMS move on the horizon is the expected 2024 release of the HHS Medicare managed care organization compliance audits. The Office of Inspector General (OIG) has conducted audits regarding denials of requested care that required PA.

We’re also awaiting rulemaking regarding MA plans’ use of algorithms to reject PA requests. In Congress, House Democrats are especially pushing for further regulation specifically regarding this issue.

The Ecosystem: Payers’ role in healthcare interoperability

As intended, electronic PA intends to improve patients’ access to care, keeping the flow of information moving between facilities, payers, and patients.

The ideal of interoperability is similar—it evokes an ethos of a harmonious healthcare ecosystem. In this ideal, providers and payers each equitably share data—and health information is always available when it’s needed, where it’s needed.

In reality, there’s a bit more friction. These delineated payer and provider roles have blurred as payer-provider relationships grow closer with more emphasis on value-based care. And communication between different sources of health data has improved with HL7 and FHIR standards—but there is still room for improvement.

The CMS requirement for a patient access, provider access, and payer-to-payer APIs and metrics reporting increases the urgency for payer interoperability improvements. But there’s a long way to go.

While payers have made great strides with ADT and CCDA data ingestion, FHIR data exchange is still “in its infancy,” per Gartner’s 2Q23 research report on U.S. Healthcare Payer Interoperability Benchmarks.

Of course, in a competitive payer marketplace, working toward interoperability is not just about compliance. It’s about providing greater value to providers and retaining a high-quality network.

What are the benefits of automating Prior Authorization?

In case you missed it, read our primer on automation technologies for healthcare payers.

Despite the challenges in these early forays into PA automation, we still see opportunity in pursuing these innovations. PA will benefit from automation—especially given the requirements around PA status reporting in the FHIR API.

The typical PA workflow is ripe for disruption with AI-enabled automation. Per McKinsey’s analysis, we foresee the most AI disruption along the initial three steps of the eight-step standard PA workflow.

However, to even be able to implement these kinds of automations, payers first need to make their PA process electronic.

Ernst & Young estimates that even just digitization can significantly improve PA processes, bringing the time from submission to decision down to seven days for standard requests and 72 hours for expedited.

With the addition of automated PA triage, the CAQH estimates the entire healthcare industry could save $437 million a year from the benefits of digitized, near-real-time PA processes.

As we await movement from the government on possible regulation of PA algorithms, we urge impacted payers to familiarize themselves with how they may optimize their PA workflows—whether it’s sooner or later.

Building trust through data availability

Proposed CMS policy is forcing impacted payers to up their interoperability game, creating compliant FHIR APIs for patient, provider, and payers-to-payer access.

At the moment the interoperability ROI is simple: Compliance helps payers avoid penalties and negative payment adjustments. However, the financial opportunity does not end there.

Investment in FHIR APIs and associated data integration processes will also further reduce administrative friction for payers with respect to prior authorization. Seamless claims and encounter data flow will reduce time spent searching for relevant data and improve payers’ ability to meet regulatory requirements.

And in the end, giving providers greater access to real-time data—especially during transitions of care—helps reduce the utilization of high-cost care and increases the use of in-network providers. Plus, quick care gap identification boosts plan quality scores (such as MA Star ratings).

More than just meeting compliance thresholds, investing in interoperability builds goodwill in the broader healthcare ecosystem. As you seek to maintain a high-quality provider network and maintain a stellar reputation, your ability to “play nice” with the greater healthcare landscape will make your plans a more attractive choice.

Perhaps nothing will be more of a marker of this reputation than how well your patient and provider access APIs work. We recommend intentional investment in these data resources.

Takeaways: Teamwork for improved interoperability and prior authorization

Given our guidance on this page, we don’t recommend payers go about upgrading their PA and data-sharing processes and systems themselves. One of the best reasons to consult experts on these issues is that legacy system mindsets will hold you back from seeing the potential of strategic change.

Whether we’re building a comprehensive data strategy or mapping out how to align stakeholders through a period of organizational change, working with Curate Partners reduces time and headaches for payers in getting solutions like these operational.

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The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.

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