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Technology Helps Payers Transition for the Future

By Craig Kasten

SKYGENUSA Powering Healthcare for the Digital Age


Despite all the advances in technology over the last three decades, many large health payers are still conducting aspects of their business the way they did in the pre-Internet days of the 1980s, relying on manual processes and interactions with members and providers.

That mindset can no longer continue. Between the huge influx of individual members that resulted from the Affordable Care Act (ACA) and the expectations of the customer experience members have based on their interactions with retail, telco and other industries, payers must make significant changes to prepare themselves for success in the 21st century – and beyond.

The days of sprawling campuses housing thousands of employees, acres of call centers and a labyrinth of file rooms archiving mountains of incoming paper documents are going away. Following are some of the key adjustments health plans will start making in 2016.

  • Deploy robust web portals. The use of self-service web portals has become common in many industries. Consumers can go online to obtain information or complete transactions whenever they want from wherever they are using whatever device they prefer. Health plans will start making this same level of self-service available to their members and providers rather than relying solely on phone, email or snail mail. By providing more answers through online self-service portals, payers can focus call center personnel on answering more difficult, complex questions that provide higher value to members and payers while reducing their costs to deliver that level of service.
  • Implement 24/7 online claims administration. Most health plans cannot afford the high level of overhead required to staff claims processing or authorization department around the clock. By implementing online claims administration technology, payers will be able to offer continuous, 24/7 processing of incoming claims and authorizations, removing delays and delivering resolution faster. They can also use these technologies to identify exceptions and pass them to the appropriate personnel for immediate review, ensuring they receive the proper attention rather than getting “lost in the shuffle” of paperwork.
  • Automate the claims process. Despite advances in technology such as electronic data interchange (EDI), processing claims and authorizations still requires a great deal of manual work. By replacing manual processes with automated, rules-based technology, payers will be able to quickly and accurately process 100 percent of all claims edits, and provide immediate authorization for certain agreed-upon services. New technology will enable providers to process a prospective benefit claim to determine both the reimbursement levels and corresponding patient responsibilities in real time. Automation technologies will not only help with today’s fee-for-service claims, but also prepare payers for the future by enabling the administration of the new bundled payment formulas.
  • Enable paperless claims administration. New imaging technology and database designs will eliminate the need for massive file rooms, replacing them with electronic files that can be securely stored in a fraction of the space – either on-premise or in the cloud. Moving from paper to electronic files makes the data easily accessible 24/7 from anywhere in the world as well, improving member and provider service.
  • Promote operational transparency through performance dashboards. Filterable, online access to real-time dashboards will deliver greater visibility into financial operations. This information will help payers monitor key performance indicators to improve business efficiency, solve problems and streamline the delivery of benefits. All which help payers stay ahead of competitive pressures.

The world of healthcare is changing rapidly. What worked in 1986 will be woefully insufficient in the coming years.

Payers must resolve to make 2016 the year they begin replacing manual processes with technologies that will improve efficiency while delivering a better customer experience to members and providers.

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Craig Kasten

About Craig Kasten

Craig Kasten leads SKYGEN USA in creating next-generation technology-enabled solutions that power the business of healthcare through the digital age. Through his visionary leadership, SKYGEN USA leads the market with transformational technology and service offerings that reinvent healthcare benefits.

Mr. Kasten is an accomplished leader whose career in the managed healthcare industry spans 30 years. He is the founder and co-founder of several organizations which have evolved to become part of SKYGEN USA’s suite of world-class solutions. He also co-founded Doral Dental USA and grew the company to a market-dominant position before its sale to DentaQuest Ventures. Mr. Kasten continues to provide vision, strategic direction and creative support for functional design innovations to the Enterprise System, SKYGEN USA’s proprietary software platform.

Prior to launching his entrepreneurial career, Mr. Kasten served concurrently as the Chief Operating Officer and Chief Financial Officer of CareNetwork, Inc., a publicly traded regional health plan later acquired by Humana. Mr. Kasten holds a Bachelor’s Degree from Marquette University and an MBA from the University of Wisconsin-Milwaukee. He has been licensed as a Certified Public Accountant in the State of Wisconsin.

Mr. Kasten was honored as Entrepreneur of the Year by Ernst & Young in 2003. In 2005, he was named a Distinguished Alumnus by the Marquette University School of Business Administration.

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