Flexible, Scalable Technology Solutions Can Position Payers For Long-Term Success in Post-Reform Healthcare Market, Says T

TriZetto Executives Available for Comment on Industry Trend

GREENWOOD VILLAGE, Colo.--(BUSINESS WIRE)-- According to The TriZetto Group, today’s challenging healthcare environment offers a unique opportunity for savvy payers to step up, take a leading role in complying with reform mandates, dramatically increase administrative efficiency, and improve the cost and quality of care. A winning strategy, however, requires that payers act quickly to leverage technology to comply with requirements beginning to take effect under the Patient Protection and Affordable Care Act. These requirements include free preventive care, a ban on rescissions and extended coverage of dependents. To be successful, payers must also improve patient-care processes and streamline administrative functions, placing a higher priority on managing health than on managing claims.

TriZetto’s Point of View

Payers can meet these challenges today with smart decisions regarding software and services. The best software and services are scalable and flexible for payers of all sizes, helping health plans increase administrative efficiency, improve the cost and quality of care, and seize the opportunities of reform to make enterprise-wide improvements and grow profitably.

In 2010, payers were challenged with integrating new costs into their economic models as a result of expanded coverage, restrictions on annual/lifetime limits and the elimination of rescissions. Significantly, flexible and scalable enterprise-wide administrative solutions helped health plans of all sizes respond quickly to implement required configuration changes. As the next wave of requirements takes effect through 2013, payers need to respond to new compliance challenges and opportunities. In particular, to meet the new medical-loss-ratio (MLR) requirements, payers should look for ways to:

  • Maximize efficiencies through greater system integration and automation.
  • Enable seamless interactions with providers, members and other constituents.
  • Drive increased healthcare value with automated, value-based programs.

The best claims administration, care management and constituent-engagement solutions offer flexibility, automation and integration that can position payers to address these challenges and comply with MLR requirements. Not to be forgotten, however, are the challenges of meeting HIPAA 5010 and ICD-10 requirements and embracing the larger opportunities that compliance brings.

Core Systems Can Leverage ICD-10 Compliance to Optimize Healthcare Management

As payers upgrade their core administration systems to comply with HIPAA 5010 and ICD-10 mandates, they have an opportunity to use the rich patient-care data within their systems to drive more sophisticated care- and incentive-management programs. The new diagnosis and treatment codes can help payers pivot from their traditional role as claims-management organizations to a new, greatly expanded role as service organizations.

In this emerging healthcare environment, ICD-10 coding can help payers place renewed emphasis on customer service, value-added products and operational efficiencies. Like any industry in the midst of change, the payer industry will find that pivoting requires additional IT investment. Investing in technologies that leverage ICD-10 coding to optimize healthcare management will help these organizations capitalize on new opportunities and gain long-term rewards. Compliance with the ICD-10 mandate presents payers with a larger opportunity to improve administrative efficiencies and:

  • Pursue avenues to increase Medicare and Medicaid reimbursement.
  • Refine payment policies for groups (e.g., diagnosis-related and ambulatory-patient).
  • Increase the amount of data used to help the underwriting team manage risk.
  • Support value-based benefit and value-based reimbursement programs. Such programs use software and service solutions to encourage proven, individually appropriate medical services and discourage unwarranted variations in care.
  • Improve claims subrogation.

Payers that leverage ICD-10 compliance to improve core administration will gain distinct competitive advantages. They’ll be able to identify and resolve issues faster and support more accurate trend, cost and reimbursement analyses -- all potentially leading to lower costs and better decision-making.

TriZetto keeps a close eye on reform mandates to ensure that its products are optimized to help health plans meet changing requirements and seize competitive advantages. TriZetto can support payers in effectively navigating new standards and regulations and positioning to take advantage of the many opportunities that lie ahead.

Health plans that act quickly to leverage technology to comply with mandates likely will be the first to improve patient-care processes and streamline administrative functions. They also will be best positioned to transform themselves into service organizations that manage member health and wellness as well as managing claims.

Reporters interested in speaking with TriZetto executives for further comment about this evolving trend in U.S. healthcare should contact Davida Dinerman at Schwartz Communications, [email protected] or 781-684-0770.

About TriZetto

TriZetto provides world-class healthcare IT software and service solutions, including patented and patent-pending innovations, that drive administrative efficiency, improve the cost and quality of care, and increase payer and provider collaboration and connectivity. TriZetto solutions, many of which are patented or patent-pending, touch half the U.S. insured population and reach more than 21,000 physician practices. TriZetto’s payer offerings include enterprise and component software, application hosting and management, business process outsourcing services and consulting. Provider offerings, delivered through TriZetto’s Gateway EDI wholly owned subsidiary, include tools and services that monitor, catch and fix claims issues before they can impact a practice. TriZetto’s integrated payer-provider platform will enable deployment of promising new models of post-reform healthcare. For information, visit www.trizetto.com.


Schwartz Communications
Davida Dinerman, 781-684-0770
[email protected]

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