The Critical Task of Assessing Healthcare Payment Infrastructure

March 20, 2023 - Health plans and third-party administrators (TPAs) face increasingly stiff competition in today’s payer marketplace. According to a recent American Medical Association study of health insurance markets, three-quarters of commercial markets are highly concentrated — and that figure shows little signs of dissipating.

To keep pace with their competition and improve their standing among purchasers and consumers, health plans and TPAs must identify areas of weakness to achieve new levels of efficiency and put their organizations in an advantageous position to succeed moving forward.

Capabilities gaps are salient in the area of healthcare payments as a result of how health plans and TPAs have adopted point solutions or integrated existing and new technologies due to mergers and acquisitions. The events led to unintended consequences: technology bloat, difficulty maintaining compliance, security risks, and a lack of interoperability.

Assessing healthcare payment infrastructure is a critical first step toward payers ensuring that continued digital transformation does not lead to fragmentation, inefficiency, and risk. However, an objective assessment cannot come from the inside. External resources are necessary to determine a health plan’s or TPA’s digital maturation.

“Benchmarking is key for a payer to understand its business,” says Zelis Vice President of Business Solutions Leah Silver. “Doing so internally doesn’t allow a health plan or TPA to measure itself against its competition, the market, and consumer perceptions. Looking externally gives a clearer and more streamlined view of where a payer has gaps and what a payer can do.”

Broadly, digital maturity describes an organization’s ability to use technology, improve its operations, and embrace innovation through the strategic use of people, process, and technology. A digitally mature organization is one that continually invests in digital infrastructure and provides technology that enhances its staff’s capabilities. But many payers find themselves pulled in multiple directions due to the composition of their technology stack.

“Digital maturity is something that is key within healthcare,” Silver explains. “We know much of healthcare is based on antiquated systems and processes. And while we’re trying to advance those forward today, some payers may be a little behind the curve. Assessing where a payer stands digitally is important to ensure that it is efficient, minimizing risk, and ultimately providing solutions that ensure stakeholders — payer, provider, members, and others — are satisfied with the outcomes.”

Compliance with operating rules and security and privacy regulations has become especially difficult for the healthcare industry, given its reliance on third parties. The more vendor relationships an organization maintains — the average organization manages more than ten vendor relationships for a single initiative — the greater its exposure to risks associated with third-party vendors and other external service providers.

Given the complexity of most healthcare payment infrastructure, taking a step outside a payer’s walls is crucial to charting a clear path forward. Doing so with a trusted partner offers a greater chance of success.

“An experienced vendor is going to come to the table with the appropriate tools and resources to be able to credibly tell the story as to whether a payer is on par with or behind today’s standards and give some suggestions on how to bring an organization forward. An objective view is important to understand an organization’s current position,” Silver maintains.

Following a thorough assessment of its digital maturity, efficiency, security, and provider and member satisfaction, a health plan or TPA can make more informed decisions about reducing inefficiency and mitigating risk relative to healthcare payments.

“The healthcare financial experience is complex, and the road from care to payment is riddled with burdensome tasks and confusion for all involved,” Silver emphasizes.

With the help of a proven strategic partner, payers can accurately assess its infrastructure and capabilities and implement solutions that address operational and technical gaps impacting healthcare payments.

“Strategic partnerships are important for payers to shift the dynamics of their business to drive efficiencies and lower costs. Ensuring that an organization has appropriate partnerships to do that with the right platform design solutions becomes integral to ensuring success across the board,” Silver concludes.

Payers need to reduce the complexity of their payment infrastructure to compete in today’s market. But many lack the resources and ability to assess and quantify the steps necessary to streamline people, process, and technology for healthcare payments. Leveraging an external resource can simplify the task and point their organizations in the right direction.

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Zelis harnesses data-driven insights and human expertise as scale to optimize every step of the healthcare payment cycle. They partner with more than 700 payers, including the top-5 national health plans, Blues plans, regional health plans, TPAs and self-insured employers, 1.5 million providers and millions of members, enabling the healthcare industry to pay for care, with care.