We’re in the age of big data, and one of the challenges healthcare payers have is to make sense of all the data they capture. From pulling actionable insights to identify and close care gaps to quickly providing the quality metrics and reports needed by state and federal regulatory bodies. For healthcare organizations, integrating data-driven insights into clinical and operational processes can help drive better health outcomes, make care teams more effective and efficient, lower healthcare costs through proactive care, and create better visibility into performance and productivity. Below we look at six ways healthcare payors and plans can improve...
How Can Payers Better Support Adults with Behavioral and Mental Health Needs?
Mental health and behavioral health support is a critical need for health plan members. This is especially true for payers handling commercial, individual, and Medicaid populations with members. As of 2024, the National Institutes of Health has found mental health conditions are common in 33.7% of adults aged 18 to 25 years, 28.1% of adults aged 26 to 49 years, and 15% of adults aged 50 years and older. And according to the National Alliance on Mental Illness (NAMI): 1 in 5 adults experience mental illness each year 75% of all lifetime mental illnesses begin by age 24 Data collected from...
Why a Good UX is Critical for Medical Management Platforms
A good UX (user experience) is a key player in how quickly a care management platform is adopted and how successfully it’s utilized. Adoption and usage are key concerns for healthcare organizations when choosing a medical management platform. This is especially true for those with large teams of care managers or case managers who need to support thousands of users and may also be leveraging portals for patients and providers. Making things easy to use, easy to understand, and easy to navigate and access can help boost platform adoption and usage. This often translates into better ROI, improved healthcare management...
How to Automate Care Management & Utilization Management with Configurable Workflows
Use industry-leading rules engines and intelligent workflows for efficiency gains Did you know that HELIOS already has built-in functionality that helps clients automate and streamline care management, utilization management, and case and disease management? This includes everything from automations for assigning tasks to the right staff member and triaging members to letters, risk flagging, and more. It’s why HELIOS can result in up to 93% increased efficiency for care management teams. Our tools to help automate care management and utilization management are available with HELIOS’ out-of-the-box platform. How is this possible? It’s thanks to the unmatched configurability (90%) and flexibility...
Why a Lack of Interoperability is Problematic in Healthcare
Interoperability is currently a big challenge for healthcare organizations using care management and population health technologies. To put it simply, these technologies lack interoperability (or sufficient interoperability). And it’s hurting member care and engagement. Interoperability is also lacking in utilization management solutions, which contributes to delays in authorizations and getting members the care they need. Moreover, many of today’s data interoperability solutions are just not interoperable enough. They’re not able to support seamless communications between healthcare payors and providers, and they’re not able to quickly exchange bi-directional feeds. Why Does Interoperability Matter for Care and Utilization Management? Interoperability means two...
VirtualHealth & AI: Harnessing AI in HELIOS to Accelerate CM and UM Value
Artificial intelligence (AI) is a trending thing in healthcare, and it’s why HELIOS already has built-in integrations powered by AI that clients can leverage. AI is threaded throughout the HELIOS platform in a variety of ways. Specifically for this blog, we’ll focus on how AI is leveraged to power predictive analytics for population health and help automate decisioning and authorizations. VirtualHealth is actively integrating Artificial Intelligence (AI) technologies into its HELIOS platform intending to accelerate outcomes its customers care most about, which are to enhance efficiencies, improve patient outcomes, and streamline operations. By leveraging machine learning models, secured LLMs (Large...
What to Know About CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F): Quick Facts & Next Steps
For healthcare organizations, CMS-0057-F outlines the modern healthcare system and offers opportunities to improve care and utilization management In the last couple of years, the Centers for Medicare & Medicaid Services (CMS) have been making strides to increase health data exchange, as well as improve and expand access to care. On January 17, CMS finalized its interoperability and prior authorization rule. The rule applies to Medicare Advantage (MA) organizations, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) offered on the Federally-Facilitated Exchanges...
How to Achieve Healthcare Data Interoperability Without Overtaxing IT Teams
For healthcare payors and organizations, the HL7® FHIR® (Fast Healthcare Interoperability Resources 1) standard is crucial to data interoperability efforts. This standard is designed to improve data interoperability by providing a standardized way to exchange and integrate health information from multiple sources stored in disparate systems. And as healthcare payors look for ways to enable or improve collaboration across different care teams and settings, interoperable data will be paramount. The key to accurate and expedient value-based care, data interoperability can make or break a payor’s ability to properly serve its population. Burdens on IT Team Make Data Interoperability a Challenge...
Understanding Whole-Person Care: What It Is, How to Deliver It
In the last few years, many payors have worked hard to implement a whole-person care approach or whole-person integrated care model. But what does that even mean? What is the definition of whole-person care? How is whole-person care delivered today? And what are the challenges in whole-person care today? Below we dive into all three for a quick understanding of modern-day whole-person care. What is Whole-Person Care? Whole-person care is a framework for care delivery. It involves an approach where healthcare payors and practitioners consider the well-being of a person collectively. This means a care model that focuses on optimal...
How Rule-Driven Assessments Help Streamline Care Management
Assessments are a critical component of care and case management programs. Assessments help care and case managers quickly identify the health and social needs of members, flag at-risk individuals, and help teams prioritize and effectively handle their caseloads When assessment response data is incorporated into member views and care management workflows, this can help automate the generation of the next best actions (task assignment, outreach, etc.). Below we quickly look at how assessments, that incorporate rules, can help streamline care management, reduce administrative burden, and prevent costly events such as hospital readmissions. Using Rule-Driven Assessment in Care and Case Management...