Tuesday Jul 29, 2014

What Providers Should Consider Before Jumping into the Payer Market

The evolution of ACOs in the market has led to an increase in provider based payer organizations, the addition of some 400 this year require a new level of data sharing and analytics. The ability to analyze impacts of changing payment models and care guidelines on healthcare delivery and payment will define the stability and growth of the integrated organization.

Kathy McCarthy, Director of Sales Consulting for Oracle Health Insurance, discusses the topic in today’s post:

With the ACO model, healthcare organizations will continue to acquire groups and services within a specific demography.  Using integrated analytics to predict the impacts when entering new markets where different services and payment models overlap will be a key for accelerated expansion.

Providers need to consider several criteria before entering the payer market. The provider organizations needs to:

  • Understand the complexity of the market
  • Have clear goals
  • Conduct the necessary research
  • Evaluate delivery systems

Research has shown that there is no correlation between success and market share, location or deep pockets.

Providers need to:

  • Have positive relationships with other health systems in your area.
  • Have existing risk-based contracts with your providers.
  • Look at your market.
  • Have a relationship with a  payer organization

Providers will require systems that can:

  • Respond to rapid changes in policy
  • Merge clinical and financial data
  • Provide quality cost-efficient care
  • Support HIPAA PHI requirements
  • Create new sustainable payment and delivery models

Operational efficiency will be a key to success. Payers will need to have IT and analytics that will play an important role .Being able to merge clinical and financial data will be crucial to success. They need to improve the overall IT efficiency and gain more predictable costs and outcomes.

IT needs providers should consider:

  • Be prepared to implement changes required to improve performance.
  • Need for analytic capabilities.
  • Need for alternate payment arrangements.
  • Need to quickly introduce new plans, support efforts to reduce operating costs and take advantage of the emerging opportunities.
  • Many legacy systems are decades old and require costly and time-consuming hard coding to make even simple changes.
  • Seek and require rules-based systems.
  • Seek new payment models.
  • Provide quality care for a reasonable cost.

Oracle Health Insurance components help address these issues by providing:

  • Rules-based componentized products allow plans the agility and flexibility needed for success.
  • SOA-based components allow plans to purchase solutions that do not require an entire new system.
  • Scalability and reliability are built into all Oracle products.
  • Solutions can be delivered in multiple ways.

Learn more by watching the recent webcast, How to Navigate the Emerging Trend of Providers Shifting Focus to Healthcare Financing.

Don’t forget to keep up with us year-round:

Thursday Jun 06, 2013

Conquering Healthcare Reform and Rating Complexity with a Simple, Single System

We all know about the Patient Protection and Affordable Care Act that was upheld by the US Supreme Court in 2012.  Now, how do we respond and react to embrace this legislation while also providing quality service to our customers and maintaining an edge over our competition?  While states debate whether to expand Medicaid, launch health insurance exchanges, or both, payers have less than 18 months to plan their strategies, change their infrastructure and launch new products to capture market share. Payers must now learn to interface directly with end users. And they must learn the nuances of local markets. Flexible IT systems that enable unprecedented business agility will be critical to their success.

In executing on the individual mandate, payers need to take a hard look at their underlying rating infrastructure.

  • Is it flexible enough to accommodate new customers and roll out new products quickly?
  • Are the rating systems configurable so they do not require custom coding when the business needs change? 
[Read More]

Thursday Oct 06, 2011

Harvard Pilgrim Health Care Launches Claims Adjudication Solution from Oracle

This year, more than ever, Oracle OpenWorld is the place to be for insurance companies. More than insurance attendees were on hand to share experiences, network, and learn from each other. But even as the gathering wraps up, one healthcare payer is putting in long hours at its head offices to launch an ambitious transformation project.

Harvard Pilgrim Health Care will go live this month with its new claims adjudication system built on Oracle technology. Harvard Pilgrim is known for delivering consistently outstanding service in the areas of clinical quality and customer service. For eight years running, the payer has been ranked the number one private health plan in America by the National Committee for Quality Assurance. With its new Oracle Health Insurance claims engine, Harvard Pilgrim hopes to push its reputation for excellence to the next level.

Harvard Pilgrim seeks to put in place flexible, adaptive technologies that help the payer respond to the needs of the marketplace. Harvard Pilgrim also aims to reduce expenses , all while processing millions of yearly transactions consistently, accurately and effectively and maintaining an outstanding level of customer service to plan members.

“Our objective at Oracle Insurance is to provide flexible, rules-driven systems that help insurers meet their business goals: rapid introduction of new products, efficient customer service, compliance with industry regulations, and effective performance management,” said Don Russo, Senior Vice President and General Manager, Oracle Insurance. “We’re very proud to be part of helping Harvard Pilgrim Health Care achieve these business goals. With our new claims application expected to be widely available in the coming calendar year, we look forward to helping other healthcare payers achieve similar success.”

To learn more about the project and Oracle’s new claims engine for healthcare payers, read the press release on Oracle.com.

Lynne Sampson is senior marketer for Oracle Insurance.
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Oracle's flexible solutions can help insurers navigate the change necessary to meet today’s challenges and have the business agility to be prepared for the future.

For mor information, visit oracle.com/insurance.

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