For healthcare payers, a strategically planned implementation journey for regulatory mandates encourages data flexibility, democratizes workflow, and enables innovation across the enterprise. Continue building your enterprise infrastructure, tempering the zeal to go at mandates one-at-a-time.
What's Important
- Establish an overall vision for data and workflow ecosystems, then modularly implement sections of the architecture using mandates to help sequence investments.
- Resist the temptation to “check the box” with minimally compliant implementations of mandated requirements.
- Allow requirements around mandates to be a driver to innovation instead of a necessary evil to be dispatched.
Introduction
Healthcare payers have implemented technology solutions to address state and federal mandates for over a decade. A timeline of mandated requirements during this period includes notable developments such as:
- 2010: Medical loss ratio
- 2011-17: Affordable Care Act
- 2017-24: Value-based reimbursement
- 2019-22: COVID-19-based telehealth regulations
- 2017-22: Directory accuracy and network adequacy
- 2020-24: API-based Interoperability
- 2021-24: Price transparency
- 2023-27: Interoperability and prior authorizations
Without a doubt, more mandates are forthcoming.
At the same time, the payer business model is in flux. Alignment and collaboration with healthcare providers, other payers, and nontraditional organizations is flourishing as payers attempt to address the cost of care.
Even as vendors demonstrate their ability to deliver enterprise-grade solutions that address both current and future mandated requirements, many payers continue to take a one-year, tactical approach for each project. To ensure operational excellence for members, providers, and internal constituents, payers instead need to evaluate individual mandates in the context of an overall vision.
Deploying technology to address mandates is not a linear destination but a multi-faceted journey. This journey takes into consideration costs and compliance, but more importantly, it can lead to the emergence of an ecosystem that encompasses comprehensively managed data and workflow enhancement for competitive advantage.
Standardization of data formats, consumerization, payer-provider organizational shifts, and whole-person approaches to healthcare require optimizing merged data as part of your integrated, less tactical mandate journey.