Healthcare companies and managed healthcare groups are under tremendous pressure. They must lower costs while raising the quality of care their customers receive. Rising medical prices, new companies joining the industry, and demands for more convenience force these groups to innovate with the latest technologies.
What are Healthcare Payer Solutions?
Healthcare payer solutions are the tools, services, and technologies used by various stakeholders, such as insurance companies, government health schemes, and managed healthcare facilitators, which run plans and policies smoothly. These solutions cover a wide range of activities, such as claims processing, member enrolment, billing, and many more customer relations. Healthcare payers are involved in funding healthcare services, implementing policies, taking action, determining provider fees and practices, and developing general strategies to control the cost of healthcare services. Healthcare payer solutions employ advanced technologies such as artificial intelligence, data analytics, and automation to enhance member efficiency, reduce burdens, and promote quality care delivery. Current trends in payer solution development focus on transitioning to VBC models, optimizing processes, and adapting to changing demands for innovative technologies in healthcare service provision.
This article will examine five ways technology gives healthcare payers more vital abilities to save money and work better. It will explore how insurance companies and medical managers use innovations to handle rising costs and competition while improving customer service.
1. Automation and Efficiency
Automation is one of the best ways technology can assist payers. Drones, robotics, and artificial intelligence do routine paperwork like processing claims, checking if someone can get care, asking doctors for permission to treat something, and answering questions about bills. For example, chatbots and virtual assistants can now handle 85% of customer questions without a natural person. This lets staff focus on more complex problems that need understanding feelings and making sound judgments. Automation also expedites work by integrating various outdated computer systems.
In addition to assisting with customer service, payers utilize AI and robots to input medical data into computer files, ensuring the accurate use of codes for illnesses and treatments. By seeing electronic health records, bots can find important health details and fill out claims with the proper diagnosis and procedure codes.
This reduces bill mistakes and ensures they follow the rules for how insurers pay. Using intelligent automation also allows for early problem detection and spending based on how sick people are. Healthcare payer solutions like these help payers work better and faster and give better care by learning about people's health.
2. Data Analytics
Payers have a lot of medical information stored. Consequently, they save information like insurance claims, who can get care, lists of doctors, notes on managing health, test results, and more. Furthermore, using complex analysis, technology helps payers learn from all this data. For example, payers can use predictive analysis to find members who might get expensive conditions later. Similarly, this allows payers to reach out early and help manage their health to avoid costly emergency room visits and repeat hospital stays.
Additionally, analysis assists payers in accurately setting prices, evaluating how well doctors perform their jobs, detecting fraud and incorrect bills, choosing the best doctor networks, and working with customers who use healthcare the most. Similarly, the insights found guide programs to prevent disease and pay doctors based on the quality of care, not just the number of patients seen. As more payers agree to share data through computer connections and sharing agreements, their ability to analyze complete medical histories over time will likely increase.
3. Telehealth Integration
The pandemic accelerated telehealth adoption as patients sought virtual care options. Technology allows payers to facilitate and reimburse telehealth services on par with in-person visits. Integrating telehealth preserves the continuity of care while expanding access to specialists, behavioral health providers, and other services in remote/underserved areas. Some payers now cover 100% of telehealth claims with no copays.
Advanced analytics help payers identify which diagnoses and specialties produce the best outcomes through virtual care. In the future, payers will see telehealth lowering overall costs by reducing unnecessary emergency room visits and travel expenses for patients and providers.
Telehealth also helps payers address social health determinants. Secure messaging and remote patient monitoring allow providers to communicate with patients in their homes regularly.
4. Blockchain for Security
Blockchain and distributed ledger technology can improve healthcare security, tracking, and trust. As a result, payers use blockchain to ensure that sensitive eligibility and claims data shared industry-wide remain safe. Similarly, smart contracts automatically enforce rules for financial transactions between payers and providers quickly and securely.
In addition, blockchain prevents fraudulent billing by keeping tamper-proof records of all actions. For instance, one primary payer partnered with IBM to design a blockchain network that guarantees providers' requests for care approval are real and accurate. Furthermore, payers will expand blockchain use over time to allow the sharing of medical records between systems, prove where drugs and medical devices come from, and conduct distributed clinical trials.
Similarly, blockchain demonstrates the potential to address the opioid crisis and track prescription drug supply chains. As a result, pharmaceutical companies and regulatory bodies can gain transparency into how opioids and other controlled medications move from manufacturers to distributors to pharmacies.
5. AI and Machine Learning
Payers deploy AI/ML algorithms to create virtual assistants, automate choices, and provide predictive information. For example, AI helps payers automatically decide on claims by comparing insurance details, healthcare plans, and medical codes. Deep learning models also look for possible fraud or wrongdoing patterns when examining extensive claim records.
Additionally, payers can use AI to adjust risks and predict future medical costs in complex ways. Likewise, AI improves community health by giving custom suggestions for interventions based on each member's specific health risks and social factors impacting their health.
Final Thoughts
New technology means both beneficial and bad things for health insurance plans. When used right, automation, analysis, telehealth, blockchain, AI, and other tech can help plans better serve customers while still making money. Plans must also protect customers' private information, make healthcare fair for all, collaborate with doctors, and improve care through technology.
Technology also enhances the efficiency of plans, facilitates the coordination of care across all treatment locations, anticipates and prevents illness, and adapts to industry disruptions. Plans that creatively use new tools to make healthcare cheaper, improve results, and give better service will do the best job of caring for groups in a world where digital things are essential.
