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Driving Technology Innovation for Healthcare Payers

The payer marketplace, like the overall healthcare industry, is undergoing a digital transformation journey. The focus of payers continues to be to improve the health outcomes of its members by providing accessibility to the best and the most affordable care possible.

To deliver on these objectives there is significant transformation, of both business models and technology capabilities, that is occurring. Payers are focusing on the continued move from fee-for-service models to value-based care models. This is happening across segments - commercial, individual, and government business. There continues to be Payer - Provider - PBM convergence in the marketplace, to integrate capabilities, improve efficiencies and ultimately reduce overall costs. Payers are also continuing to engage in innovative Digital Healthcare Technology. From experimenting with new technologies to significant investments in digital health startups, they are looking to adopt technologies that can provide business value. The healthcare marketplace is also continuing to see an explosive number of vendors attempting to provide solutions for the connected customer experience.

Virtusa is working with the largest payers in the nation to navigate through these challenges and to deliver on their vision for enterprise transformations, digital health innovations, and improving care delivery for its membership.

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Virtusa has partnered with IBM® Watson Health to lead digital transformation in healthcare.

 

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Frequently Asked Questions
What is a healthcare payer?

A healthcare payer or insurance provider manages the cost of healthcare by setting the price of provider services. Payers collect fees from premium healthcare plans or taxes through government-sponsored programs and process the provider claims.

The collected revenue pays for the provider's healthcare services. Examples: United Health Groups, Anthem, and Aetna; Government payers include Medicaid and Medicare.

Yes. Payers manage resources to ensure health plans are optimized for cost and quality health outcomes. Payers organize programs that align with patient needs and can include the management of high-risk cases, chronic pain, and transitional care.

Payers obtain a lot of patient healthcare information to improve current care models. Payers can use this data to build new business models that enhance provider health management and create new avenues of care for patients. Payers can give providers increased access to information incurred from claims data and EHR management, helping them make more informed healthcare decisions that can improve patient health while lowering service costs.

Digital technology can help payers direct or convey appropriate points of care throughout a patient’s health journey by improving patient services and creating more market share. Digital transformation of payer technology can improve the success rate of managed care models. Modernized core systems and integrated delivery networks improve payer strategy, risk, and business position.

A fee-for-service model is when providers are paid for each test or treatment performed on a patient. Providers bill payers for every service and patient visitation. This model reimburses providers based on the number of reported services, not quality health outcomes.

Value-based care models allow payers to ensure that patients receive the correct treatments that enable quality health improvements. In this model, payers require patients undergoing treatment or surgeries to recover successfully.

Payers pay providers a set amount for the services and recovery period, holding a percentage until the patient has a positive health outcome. Providers lose money if patients have adverse effects or need additional treatments.

New healthcare technology solutions allow payers and providers to work together to improve healthcare and deliver better business value for all stakeholders. In combination with telemedicine, providers can use remote patient monitoring devices like biosensors, smartwatches, and wearables to receive real-time analytics of a patient’s heart rate, blood sugar, and blood pressure.

Artificial intelligence can power advanced insights from healthcare data, helping providers make more informed healthcare decisions. Patients use digital therapeutics through computer software or digital apps to assist with medical monitoring, symptom management, and training exercises.

The healthcare industry can also improve care with the Internet of Medical Things (IoMT). IoMT can provide real-time data on workflow efficiencies within hospitals and connected to patients’ smart medical devices. Providers have data-driven healthcare analytics that helps improve treatment options, advance symptom management, monitor health patterns, and facilitate optimized health outcomes.

Healthcare technology solutions for payers can help maintain compliance, improve data integration, and streamline operations. With the digital transformation of core systems, payers can improve member experience with advanced systems that ease billing, simplify claims processing, enhance internal collaboration, and address payer and provider data exchange gaps.

Digital technology like advanced analytics, AI/ML, robotic process automation, voice interfaces, and the cloud improve data management and help payers better understand provider needs. Modern data platforms increase flexibility and allow for real-time data exchange with customers, assisting payers to gain access to valuable data that can improve member experience and health delivery.

 

Medical billing and reimbursements require healthcare technology solutions for payers. Automating healthcare reimbursement systems can help payers minimize human errors when managing claim coding and payment collections, lowering costs and reducing claim denials. Data interoperability improves access to electronic health records (EHRs), helping payers manage patient files and speed up reimbursement. Integrated EHR systems make it easier for payers to exchange health information across different healthcare systems.

Revenue cycle management streamlines payment and billing operations, helping payers monitor key performance indicators to ensure healthcare groups receive payments on time. Real-time processing of claims improves the efficiency of the billing cycle by monitoring duplicate claims and managing filing operations. Payers can also preconfigure the claims process to achieve better adjudication rates.

Yes. Virtusa has many healthcare payer technology solutions that can help payers address problems like provider management, financial transparency, claims denials, gaps in patient care, and unstructured data. Virtusa’s solutions help payers transform the customer experience, drive innovation, and increase utilization. Payers can provide meaningful services and simplify healthcare delivery at a reduced cost. Example solutions include:

  • Healthcare AnalyticsToAction: Payers can leverage data-driven insights to evaluate physician performance, improve care management, and deliver accurate information to employers. 
  • Pega Smart Claims Engine (SCE): Payers can replace legacy claims platforms and make the claims process more efficient with advanced analytics, microservices, cognitive computing, blockchain, and machine learning. 
  • Reimagining Omni-Channel Communication Experience for Payers: Payers can optimize payer-provider communication with machine learning and conversational AI for fast, accurate, and consistent customer service across channels. 
  • Simplify Appeals & Grievances Processing: Payers have simplified case management of the appeals and grievance process with guided workflows powered by machine learning. 
  • InsightsToCare: Payers have access to a commercial database of de-identified patient medical data that lists provider performance across cost and utilization. Cloud analytics deliver advanced insights into care management programs, clinical outcomes, cost of care plans, and claims fraud. 
  • CMS Interoperability and Patient Access Solution: Payers gain CMS interoperability, improving real-time access to claims information. Fast Healthcare Interoperability Resources (FHIR) and HL7 formats modernize healthcare IT systems for quicker access to healthcare records and advanced data exchange, giving payers a holistic view of provider information.
  • HealthConnect: Payers can create better health plans with improved access to patient health statusPatient health can be monitored with decision aids, digital health platforms, and wearables. Providers can track patient symptoms and health measurements using connected devices, assisting payers in collecting essential health data. 

Healthcare technology solutions for payers consist of advanced analytics that builds strategic frameworks for meeting the rising demands of market competition, limited resources, and increased risk. Payer analytics leverage data on claims operations and health plans, offering new insights on how payers can make better decisions when providing services.

Patient medical data is easily shared across systems that allow payers to customize health plans that align with patient health requirements, improving the quality of reimbursements. Payers can also use predictive analytics that provides real-time data to analyze health and behavior changes, forecasting new medical requirements to individual health plans.

The healthcare sector is facing increased technology-driven disruption. Payers can gain a competitive edge with digital solutions that automate the sale process for quicker case resolution, modernize core systems for better data integration, and apply machine learning to handle claims risks and fraud.

Payers need to invest in targeted approaches to implement digital transformation that breaks through information silos in claims management. This can include building cross-functional teams between technology and business, nurturing digital talent with superior management, and embracing new technology that can help cross-department operations. Successful digital transformation campaigns are run by business leaders prioritizing delivery through a step-by-step approach, balancing IT investments with existing infrastructure capabilities and value propositions. Agile approaches to payer digital transformation can include design thinking, dynamic partnership, and prioritizing investment in new healthcare trends.

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