Four Key Challenges of Healthcare Reform

The First Challenge: Comply with Reform—Positioning your organization for long-term success

Today’s challenging healthcare environment offers a unique opportunity for savvy payers to step up, take a leading role in complying with reform mandates, dramatically increase administrative efficiency and improve the cost and quality of care.
A winning strategy, however, requires that payers act quickly to leverage technology in order to comply with requirements already beginning to take effect under the Patient Protection and Affordable Care Act (PPACA). These include free preventive care, a ban on rescissions, and extended coverage of dependents. To be successful, payers must also improve patient-care processes and streamline administrative functions, placing a higher priority on managing health than on managing claims.
TriZetto believes that there are four key challenges payers must address to be successful in today’s competitive healthcare insurance marketplace:

1. Comply with reform
2. Increase administrative efficiency
3. Improve cost and quality of care
4. Compete to win

Payers can address these challenges today with smart decisions regarding software and services. TriZetto’s industry-leading software and services are scalable and flexible for payers of all sizes, helping these organizations increase administrative efficiency, improve the cost and quality of care, and support them as they work to meet the challenges of reform. This paper, the first in a series addressing the four challenges, focuses on how payers can overcome critical compliance challenges.
TriZetto is a partner to help payers meet compliance requirements. In 2010, payers faced the challenges of integrating new costs into their economic models as a result of expanded coverage, restrictions on annual/lifetime limits, and the elimination of rescissions. To meet these challenges, TriZetto’s flexible and scalable enterprise-wide administrative solutions helped payers of all sizes respond quickly to implement required configuration changes.
As the next wave of requirements takes effect in 2011 through 2013, payers need to respond to new compliance challenges and opportunities. In particular, to meet the new medical loss ratio (MLR) requirements, payers will need to look for ways to:

• Maximize efficiencies through greater system integration and automation
• Enable seamless interactions with providers, members and other constituents
• Drive increased healthcare value with automated, value-based programs

Point of view

TriZetto’s claims administration, care management and constituent engagement solutions offer flexibility, automation and integration that can help payers address these challenges and be in a better position to comply with MLR requirements.
Not to be forgotten, however, are the challenges of meeting 5010 and ICD-10 requirements and embracing the opportunities they will bring.
Your Core Systems Can Capitalize on ICD-10 to Optimize Healthcare Management
As payers upgrade their core administration systems to comply with 5010 and ICD-10, they have an opportunity to utilize the rich patient-care data within their systems to drive more sophisticated care and incentive management programs. These new diagnosis and treatment codes can help payers pivot from their traditional role as claims-management organizations to a new role as service organizations. In this new healthcare environment, ICD-10 can help payers place renewed emphasis on customer service, value-added products, and operational efficiencies. Like any industry in the midst of change, the payer industry will find that pivoting requires additional IT investment. Investing in technologies that leverage ICD-10 in order to optimize healthcare management will help these organizations capitalize on new opportunities and gain long-term rewards.

Compliance with ICD-10 can help payers improve administrative efficiencies and:

• Gain opportunities to increase Medicare and Medicaid reimbursement
• Refine payment policies for groupers (DRGs, APGs, etc.)
• Increase the amount of data used in helping the underwriting team manage risk
• Support value-based benefit and value-based reimbursement programs
• Improve claims subrogation

Payers that leverage ICD-10 to improve core administration will gain distinct competitive advantages. They’ll be able to identify and resolve issues faster and support more accurate trend, cost and reimbursement analyses—all potentially leading to lower costs and better decision-making.
New Challenges. New Solutions. New TriZetto.

You’re facing new challenges in today’s rapidly evolving healthcare marketplace. To help you meet these challenges, we’ve enhanced our solutions and added new service capabilities to help you increase efficiency and productivity, enable payer-provider connectivity and collaboration, facilitate compliance and improve the cost and quality of care. That’s the power of a proven partner at work.
TriZetto is keeping a close eye on reform mandates to help ensure that all our products are optimized to help you meet the changing requirements and gain important competitive advantages. Act now to prepare for the future of healthcare. TriZetto can show you how your business can effectively navigate new standards and regulations, and how you can position your organization to take advantage of the many opportunities that lie ahead.
Payers that act quickly to leverage technology in order to comply with mandates can be the first to improve patient-care processes and streamline administrative functions. They also will be positioned to transform themselves into service organizations that manage member health and wellness rather than managing claims.