Navigating Healthcare Payer Challenges
As a healthcare payer, you face a multitude of challenges in today’s fast-paced industry. From navigating the ever-changing landscape of new regulations to managing enrollment crunches and resource gaps, all while reducing costs and improving patient outcomes, it can be tough to keep up. We recognize the importance of addressing these challenges head-on.
Our team of healthcare payer technology experts has decades of experience in successfully enabling health plans to streamline their operations, automate complex processes, and engage members and partners through digital services. We specialize in protecting critical assets and patient data to achieve compliance while innovating legacy systems to compete in today’s transformed healthcare environment.
Explore our Healthcare Payer Technology Solutions.
Revolutionize Healthcare Payer Compliance with FHIR-based Solutions
As healthcare payers continue to face new regulations and requirements, complying with prior authorization and data interoperability rules has become a growing challenge. Not only do these rules require significant resources, but non-compliance can lead to costly and negative consequences for payers and providers alike.
Our streamlined approach to sharing clinical and claims data in real-time using the FHIR (Fast Healthcare Data Interoperability) standard can help you meet compliance deadlines and enable better patient care, member care, and data processing. As major players adopt FHIR, it’s essential to act quickly to avoid being left behind. Let us help you stay ahead of the curve and achieve your healthcare goals.
How can System Soft help resolve the challenges?
To help healthcare payers navigate these challenges, System Soft has developed two solutions that are laser-focused on data interoperability, prior authorization rules and subsequent challenges.
- The Prior Authorization Automation Accelerator (PA3): Supported by a focused team of business and technology experts, the PA3 solution leverages robotic process automation, integration, analytics, and user experience skills to build required APIs to underpin internal workflow and external portals.
- FHIR Acceleration Team (FAT): This team is supported by intellectual property and repeatable methodology to design, develop, and implement the required APIs for payers and providers in rapid timeframes. The solutions are delivered to align with CMS’s requirements for Patient Access API, Provider Access API, and Payer-to-Payer API.
Other aspects of the solution include attestation for third-party application developers, reporting of quarterly use of the Patient Access API by patients, and robust security features.
INTELLIGENT AUTOMATION FOR HEALTHCARE PAYERS
Intelligent automation (iA) for health plans leverages robotic process automation (RPA), artificial intelligence (AI), machine learning (ML), hyperautomation and intelligent document processing (IDP) to increase efficiency, decrease costs and elevate member engagement and outcomes, so your organization can stay competitive.
- Reduce repetitive administrative tasks to streamline processes, enhance efficiency and lower costs with RPA
- Standardize and integrate data and workflows across multiple, disconnected and disparate systems
- Automate payer-provider collaboration through claims and appeals process automation that speeds payments and reduces redundancy
- Enhance the member experience and improve outcomes using automated chatbot technology and AI-powered automation
- Automate back-office revenue cycle management with RPA and intelligent document processing (IDP)
DIGITAL USER EXPERIENCE FOR HEALTHCARE PAYERS
Digital user experience enables payers to design member-centric experiences empowered by digital strategy, user experience design, artificial intelligence (AI) and data analytics, along with platform implementation for an omnichannel member experience. All of this enhances self-service care for increased member engagement, improved outcomes and increased member loyalty.
- Provide a seamless, omnichannel experience to help members easily access information, understand care options, update information, access or submit claims and research costs for improved care coordination
- Deliver personalized and contextualized communications with access to relevant education resources and services to support member wellness initiatives
- Automate customer engagement with analytics and models that help predict the next best actions for automating low-value or low-risk tasks, reducing time spent on manual processes and freeing up resources for more complex tasks
- Unlock valuable care insights and member journey information using AI and data analytics to drive intelligent member engagement, improve care effectiveness and identify and manage high-risk members
- Create an end-to-end member experience with the transparency and functionality members want and the integration and insights needed to enhance the member experience and deliver value-based care
INTEGRATION SERVICES FOR HEALTHCARE PAYERS
Integration services and solutions enable payers to modernize their platforms by assessing, architecting, transforming, executing and managing the transition from legacy applications and data environments, which are costly and complex, to cloud-based, agile and efficient environments, which are future-proof, cost-effective and align with modern healthcare.
System Soft’s integration services use innovative and effective middleware platforms to connect services, data and applications. By doing so, this creates a seamless environment supporting business users, such as providers, brokers, government entities, regulators, suppliers and PBMs and customer needs.
- Transition from costly and complex legacy applications and data environments to cloud-based, agile and efficient environments, which are future-proof, cost-effective and align with modern healthcare
- Use innovative and effective middleware platforms to connect services, data and applications
- Drive greater payer-provider collaboration for better care coordination with simplified workflows
- Comply with CMS interoperability and FHIR mandates by increasing automation and streamlining decision-making and communications between payers, providers and members, supporting efficient care coordination
- Consolidate member experience data from internal and external sources and across the member journey to build data-driven member engagement strategies, maximize engagement with personalized communications, improve outcomes and boost member satisfaction
- Eliminate data silos by consolidating disparate sources to enable a single source of truth for improving collaboration and increasing operational efficiency
SECURITY SOLUTIONS FOR HEALTHCARE PAYERS
Improve cyber resiliency, safeguard member data and protect your organization’s brand and reputation by implementing a multi-layered protection strategy against cyber-attacks for your networks, applications, devices and programs.
- Vulnerability Assessment and Penetration (PEN) testing to identify and remediate vulnerabilities and configuration issues with real-world attack simulations
- Application and Infrastructure Security Assessments to test critical applications’ security and assess high-risk transaction platforms
- Risk Assessments to identify threats, vulnerabilities, level of exposure and possible impact
- Controls Review to evaluate safeguards for confidentiality, integrity and availability of information systems
Maintain compliance with healthcare compliance services to include:
- Minimum Acceptable Risk Standards for Exchanges (MARS-E)
- Health Insurance Portability and Accountability Act (HIPAA)
- Health Information Trust Alliance (HITRUST)
DATA AND ANALYTICS FOR HEALTHCARE PAYERS
Turn data into insights by aggregating clinical, lab and pharmacy data across EMR systems and other sources. This better informs you of plan design and pricing, quality of care assessments and actuarial modeling, so you can best manage population risk, medical costs and member engagement metrics to enhance member engagement, increase quality of care and reduce costs.
- Automate a generation of data insights for more actionable decision-making with artificial intelligence (AI), machine learning (ML) and other advanced technologies
- Use member journey analytics to analyze engagement and deliver more personalized interactions with proactive care management recommendations
- Capture and analyze risk and outcome data to define member benefits packages, enable new services and products to improve member wellness and support value-based care initiatives