When it comes to health plans, insurers and administrators are facing an era of rapid-fire change and many are struggling to keep up. Among the factors reshaping the healthcare landscape, outcome-based payment models take center stage, alongside startups with digital-first business models, changing regulatory headwinds, and a rapidly rising bar for patient experiences.
Overall, healthcare spending costs are projected to surge past $7 trillion by 2032 and that’s going to have a sizable impact on how payers and providers manage and deliver health services.
The concerns faced by healthcare leaders aren’t always particularly unique, but that doesn’t mean they’re easy to solve. Talent retention problems, difficulties in evolving their technology stack, and the ever-present budgetary concerns are always prevalent and smart leaders are attempting to predict just how the paradigm will shift in the next decade.
Healthcare plans under pressure: The core operational challenges
Over the past few years, the healthcare landscape has been peppered with some of the largest mergers in its history. Combined with a growing regulatory labyrinth and hamstrung growth prospects, insurers are being forced to map a hitherto uncharted set of ops challenges.
Fragmented, poorly organized data can have cascading negative consequences. When information is siloed across multiple systems, it becomes difficult to access and share. In turn, this can snowball into inaccurate patient data, limited clinician perspectives, increased costs, and diagnostic errors.
Additionally, maintaining data silos can be costly and time-consuming, draining resources that could be better spent elsewhere. To improve health plan outcomes and reduce operational costs, it is essential to break down data silos and establish a unified, interconnected system for sharing patient information across providers and insurers.
For healthcare plan providers, the compliance goalposts shift frequently. Federal and state regulations are constantly evolving, requiring insurers to stay informed and adapt quickly, because compliance failures can be expensive in terms of financial penalties, reputational damage, and operational disruptions.
The growing use of technology has also introduced new regulatory challenges. For example, the pandemic-induced rise of telemedicine has created new frameworks regarding patient privacy and provider licensing.
Managing claims in the healthcare industry is a complicated affair. Providers must cope with a diverse set of payer requirements and paperwork, address errors in claims submissions, and efficiently handle appeals to recover denied claims. To add fuel to the fire, the constant threat of fraudulent claims requires vigilant monitoring and prevention.
And on top of all that, walking the tightrope between increasing healthcare costs and ensuring that premiums stay affordable, adds another layer to the challenge. For many, the crux lies in orchestrating a claims management process that reduces fraud and provider abuse, while making sure that stakeholders with legitimate concerns don’t fall through the cracks.
The digital DNA of healthcare plan operations
Integrated digital tools and ecosystems offer a powerful framework to mitigate these challenges. By connecting various systems and applications, these solutions enable richer, more seamless data flow, automation of key processes, and lower operational expenses.
AI is streamlining health insurance processes by identifying errors and inconsistencies in data-intensive tasks. This is especially useful in areas like claims reconciliation and fraud detection, where accurately detecting errors is paramount to the insurer’s credibility.
IoT technology can empower health plans to promote preventive care and reduce costs by tracking members’ health data and rewarding healthy lifestyle choices. The data shows that this is a highly viable insurance model, with up to 54% of customers willing to share their data in return for cheaper insurance premiums and perks.
Robotic Process Automation (RPA) can significantly enhance operational efficiency in healthcare by effectively and accurately automating repetitive tasks, particularly within member onboarding, claims processing, and back-office operations. This creates more bandwidth for personnel to work on value-added activities like customer relationship management and complex claims reconciliation, driving greater member satisfaction and overall organizational performance.
Natural Language Processing (NLP) analyzes text-based data, including claims, patient records, medical charts, and historical medical data to improve decision-making at multiple organizational levels. This technology is particularly useful in customer service, where it can help summarize complex information and quickly address inquiries from all stakeholders. Given the high rate of insurer switching among consumers, NLP is becoming increasingly important for the insurance industry. In fact, NLP’s potential to transform the industry is widely recognized, as evidenced by the 75% of insurers that are planning to increase investment in AI for claims and underwriting, according to a 2024 survey.
Digitizing healthcare data, such as medical records and claims, can improve access, reduce costs, and enable data-driven decision-making. By integrating health platforms via digital tools, we can facilitate faster and enhance information sharing and collaboration, while limiting data-related expenses, and rapidly acquiring fresh insights.
The way forward Is paved with digital tech
With rising expectations from every stakeholder in the insurance ecosystem, the ability to quickly process data, automate key processes, and rapidly build and iterate on digitally supported health plans will be essential. To stay afloat, health plan providers need experienced partners who can implement strategic technology with powerful outcomes, as the landscape evolves.
What leaders must grasp is that highly integrated digital tools, once a prerogative of the most well-funded institutions, are now table stakes for all healthcare plan providers, especially in the US.
Photo: marchmeena29, Getty Images
John O’Day, Vice President of Citius Healthcare Consulting, has over 25 years of experience in the healthcare industry, much of that time spent consulting directly with health plan executives and teams to assess operational and vendor performance, as well as providing executive leadership for system/vendor replacement and implementation projects. John possesses an innovative strategic vision to provide strategies with measurable outcomes. His teams have successfully delivered end-to-end solutions, collaborating with payer organizations, partners and vendors. He has a proven record of on-time and on-budget delivery to aid health plans in achieving both current and future strategic and financial goals.
John has been engaged in managing key strategic programs and projects to successful completion. He has experience with multiple Core, Enrollment, CRM, Care Management and Portal platforms, as well as an in-depth knowledge of health plan operations and technology.
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