Payers - gettectonic.com
ai arms race
05Dec

AI Arms Race

AI Arms Race: Providers Catching Up to Payers in Claims Review The healthcare sector is in the midst of an escalating AI arms race as providers adopt the same artificial intelligence technologies payers are leveraging for claims review. Insurers currently lead this race, using AI to streamline processes such as prior authorizations, but experts predict providers will soon narrow the gap. Insurers’ AI Advantage Leading payers, including UnitedHealth, Humana, and Cigna, have integrated algorithmic decision tools to assess claims and determine coverage eligibility. These technologies allow insurers to flag services that fall outside plan criteria, ostensibly increasing efficiency. This trend is expanding, as evidenced by Blue Shield of California’s announcement of a partnership with Salesforce to pilot claims automation technology in early 2025. The nonprofit insurer claims this initiative will reduce prior authorization decision times from weeks or days to mere seconds, benefiting providers and patients alike. However, provider experiences paint a more contentious picture. Reports from lawmakers and healthcare executives suggest AI-driven claims processes lead to a surge in denials. For example, Providence CFO Greg Hoffman revealed that AI adoption by payers resulted in a 50% increase in underpayments and initial denials over two years, forcing providers to significantly increase manual interventions to resolve claims. A Battle for Balance The imbalance in AI adoption has prompted providers to take action. Experts like Jeffrey Cribbs, a vice president analyst at Gartner, see this as a forced “arms race” in which both sides are continually refining their tools. While payers focus on flagging potential exceptions, providers are working to develop systems for more efficient claims submissions and dispute resolution. Providence’s strategy includes outsourcing revenue cycle management to R1, a 10-year partnership designed to quickly address rising claims denials. Hoffman explained that building equivalent AI systems internally would take years, making partnerships essential for staying competitive in the short term. Collaboration Among Providers On the provider side, executives like Sara Vaezy, EVP and Chief Strategy Officer at Providence, emphasize the need for collaboration. She advocates for coalitions to share data and establish AI standards, which would allow providers to compete more effectively. Panelists at HLTH echoed this sentiment. Amit Phull, Chief Physician Experience Officer at Doximity, argued that AI could eventually “level the playing field” for providers by reducing the time required for claims documentation. Deloitte principal consultant Bill Fera added that AI would allow providers to quickly analyze policies and determine whether a patient qualifies for coverage under plan terms. The Road Ahead Despite the current disparity, experts believe AI will eventually equalize the claims review process. Providers are beginning to invest in tools that will help them handle vast amounts of data efficiently, offering clarity in disputes and cutting down documentation time. “It’s still early innings,” Phull said, “but the technology is going to go a long way toward leveling that playing field.” For now, however, insurers maintain the upper hand. As providers navigate the complexities of AI adoption, partnerships and collaboration may prove critical in ensuring they remain competitive in this rapidly evolving landscape. Like Related Posts Salesforce OEM AppExchange Expanding its reach beyond CRM, Salesforce.com has launched a new service called AppExchange OEM Edition, aimed at non-CRM service providers. Read more The Salesforce Story In Marc Benioff’s own words How did salesforce.com grow from a start up in a rented apartment into the world’s Read more Salesforce Jigsaw Salesforce.com, a prominent figure in cloud computing, has finalized a deal to acquire Jigsaw, a wiki-style business contact database, for Read more Health Cloud Brings Healthcare Transformation Following swiftly after last week’s successful launch of Financial Services Cloud, Salesforce has announced the second installment in its series Read more

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December 5, 2024in Artificial Intelligence, Data, Salesforce, Technology0 Comments
Potential of GenAI in Healthcare
25Nov

Potential of GenAI in Healthcare

Clinicians spend about 28 hours per week on administrative tasks, mainly clinical documentation and communication. Medical and claims staff reported even higher administrative loads, with 34 and 36 hours spent weekly on tasks like documentation, communication, and prior authorization. Many respondents linked these demands directly to burnout, with 77% of claims staff, 81% of medical staff, and 82% of clinicians citing administrative burdens as significant contributors. Additionally, 78% of payer executives and 85% of provider executives noted that administrative work is a key driver of staffing shortages.

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November 25, 2024in Generative AI, Salesforce Data Cloud, Salesforce Health and Life Sciences Solutions, Salesforce Implementation Services0 Comments
Value-Based Care Technologies
22Nov

Value-Based Care Technologies

Essential Technologies for Value-Based Care Success As healthcare providers increasingly adopt value-based care, they must invest in the right technologies and resources to succeed in this model, which incentivizes high-quality, cost-effective care. Value-Based Care Technologies tie reimbursement to care quality, making providers accountable for patient outcomes while providing resources to enhance care. As of 2021, nearly 60% of healthcare payments were already tied to value-based models, according to the Health Care Payment Learning and Action Network (HCP LAN). While partnerships can initiate value-based care, providers must invest in the right technology to fully achieve the intended outcomes. Health Information Exchange (HIE) A robust health information exchange (HIE) is fundamental to value-based care, as it enables providers and payers to access high-quality data seamlessly. HIE allows healthcare professionals to share patients’ medical information electronically across organizations, promoting care coordination by giving providers a comprehensive view of patient needs. For patients, HIE enables more informed involvement in their care by making their health data accessible across specialists, labs, and pharmacies. While joining an HIE may involve new technology investments and workflow adjustments, it ultimately enhances provider access to critical health data. Population Health Management Tools Population health management tools help providers assess health outcomes within groups rather than focusing on individuals alone. These tools aggregate and analyze data, allowing practices to identify high-risk patients and create targeted interventions. This not only enhances health outcomes but can also reduce costs by avoiding expensive treatments. Patient engagement tools, such as telehealth and remote patient monitoring, are essential in population health management, especially for monitoring high-risk patients when in-person care is not feasible. Digital surveys integrated within patient portals can provide insights into social determinants of health, adding a broader context to patient needs. Data Analytics Data analytics transform healthcare data into actionable insights across four types: descriptive, diagnostic, predictive, and prescriptive. Providers can use these analytics to reduce hospital readmissions, predict diseases, and identify chronic illnesses. Data integration and risk stratification capabilities are especially valuable in value-based care, enabling providers to track patient health outcomes effectively and prioritize high-risk cases. Artificial Intelligence & Machine Learning AI and machine learning support many data analytics functions, helping identify patient needs and easing administrative burdens. Given staffing shortages and burnout—reported by 63% of physicians in 2021, according to the American Medical Association (AMA)—AI can automate tasks like documentation, charting, and scheduling, allowing providers to focus more on patient care. Additionally, AI-driven automation in revenue cycle management tasks, such as billing and coding, can reduce the administrative workload associated with value-based care. Price Transparency Technology Price transparency empowers patients to seek cost-effective care, a core principle of value-based models. When providers comply with transparency regulations, patients can better understand their costs and make informed decisions. For providers, leveraging price transparency tools ensures compliance and facilitates partnerships with payers by enabling more effective negotiation, which supports the overall goals of value-based care. As healthcare continues shifting to value-based models, investing in these technologies is critical for providers aiming for long-term success. While these tools rdo equire substantial investment, they are essential for improving patient outcomes, optimizing care quality, and ensuring sustainability in value-based care. When evaluating and choosing healthcare technology tools, contact Tectonic for help. Like1 Related Posts Salesforce OEM AppExchange Expanding its reach beyond CRM, Salesforce.com has launched a new service called AppExchange OEM Edition, aimed at non-CRM service providers. Read more The Salesforce Story In Marc Benioff’s own words How did salesforce.com grow from a start up in a rented apartment into the world’s Read more Salesforce Jigsaw Salesforce.com, a prominent figure in cloud computing, has finalized a deal to acquire Jigsaw, a wiki-style business contact database, for Read more Health Cloud Brings Healthcare Transformation Following swiftly after last week’s successful launch of Financial Services Cloud, Salesforce has announced the second installment in its series Read more

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November 22, 2024in AI Tools, Artificial Intelligence, Data, Life Sciences Cloud, Salesforce, Salesforce Development Services, Salesforce Foundations, Salesforce Health and Life Sciences Solutions, Salesforce Health Cloud, Salesforce Implementation Services, Salesforce Optimization, Technology0 Comments
Enhance Payer Patient Education
30Jul

Enhance Payer Patient Education

Data and Technology Strategies Enhance Payer Patient Education Analytics platforms, omnichannel engagement tools, telehealth, and other technological advancements have become essential in driving successful, enhanced payer patient education. Cathy Moffitt, MD, a pediatrician with 15 years of experience in the pediatric emergency department and now the senior vice president and Aetna chief medical officer at CVS Health, understands the critical role of patient education. “Education is empowerment. It is engagement. It is very critical to making patients more equipped to handle their healthcare journey,” Moffitt said in an episode of Healthcare Strategies. “Even overseeing a large payer like Aetna, I still believe tremendously in health education.” Enhance Payer Patient Education For large payers, effective patient education begins with data analytics and a deep understanding of their member population. Through data, payers can identify key insights, including when members are most receptive to educational materials. “People are more open to hear you and to be educated and empowered when they need help right then,” Moffitt explained. Timing is crucial—offering educational resources when they’re most relevant to a member’s immediate needs increases the likelihood that the information will be absorbed and acted upon. Aetna’s Next Best Action initiative, launched in 2018, exemplifies this approach. Through this program, Aetna employees reach out to members with specific conditions, offering guidance on the next best steps for managing their health. By providing education at a time when members are most open to it, the initiative ensures that patient education is both timely and impactful. In addition to timing, payer data can shape patient education by providing insights into a member’s demographics, including race, sexual orientation, gender identity, ethnicity, and location. Tailoring educational efforts to these factors ensures that communication is accessible and resonates with members. To better connect with a diverse member base, Aetna has integrated translator services into its customer support and trained representatives on sensitivity to sexual orientation and gender identity. Additionally, updating the provider directory to reflect demographic data is crucial. When members see providers who share their language, culture, and experiences, they are more likely to engage with and retain the educational materials provided. “Understanding, in a multicultural and multifactorial way, who our members are and trying to help understand what they need…as well as understanding both acute and chronic illness from an actionability standpoint, where we can best engage to good effect as we reach out to people—that’s the cornerstone of our intent and our philosophy around how we scrub data,” Moffitt shared. With over 20 years in the healthcare industry, both as a provider and now in a payer role, Moffitt has observed key trends and identified strengths and weaknesses in patient education efforts. She noted that the most successful patient education initiatives have been in mental health and preventive care, with technology playing a crucial role in both areas. Patient education has significantly reduced the stigma around mental healthcare and highlighted the importance of mental wellness. Telemedicine has vastly improved access to care, particularly in mental health, Moffitt noted. In preventive care, more people are now aware of the benefits of cancer screenings, vaccines, wellness visits, and other preventive measures. Moffitt suggested that the increased use of home health visits and retail clinics has contributed to these improvements, particularly among Aetna’s members. Looking ahead, Moffitt predicted that customized engagement is the next frontier for patient education. Members increasingly want educational materials delivered in a personalized and streamlined manner that suits their preferences. Omnichannel engagement solutions will be vital in meeting this demand. While significant progress has been made in enabling members to receive educational materials through various channels such as email, text, and phone calls, Moffitt anticipates even more advancements in the future. “I can’t tell you exactly where we’re going to be in 10 years because I wouldn’t have been able to tell you 10 years ago where we are now, but we will continue to respond and meet the demands with the technological commitments that we’re making,” Moffitt said. Like Related Posts Salesforce OEM AppExchange Expanding its reach beyond CRM, Salesforce.com has launched a new service called AppExchange OEM Edition, aimed at non-CRM service providers. Read more Salesforce Jigsaw Salesforce.com, a prominent figure in cloud computing, has finalized a deal to acquire Jigsaw, a wiki-style business contact database, for Read more Health Cloud Brings Healthcare Transformation Following swiftly after last week’s successful launch of Financial Services Cloud, Salesforce has announced the second installment in its series Read more Top Ten Reasons Why Tectonic Loves the Cloud The Cloud is Good for Everyone – Why Tectonic loves the cloud You don’t need to worry about tracking licenses. Read more

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July 30, 2024in Life Sciences Cloud, Public Sector Solutions, Salesforce Health and Life Sciences Solutions, Salesforce Implementation Services
Boosting Payer Patient Education with Technology
22Jul

Boosting Payer Patient Education with Technology

Data and Technology Strategies Elevate Payer-Driven Patient Education Analytics platforms, omnichannel engagement, telehealth, and other technology and data innovations are transforming patient education initiatives within the payer space. Dr. Cathy Moffitt, a pediatrician with over 15 years of emergency department experience and now Chief Medical Officer at Aetna within CVS Health, emphasizes the crucial role of patient education in empowering individuals to navigate their healthcare journeys. “Education is empowerment; it’s engagement. In my role with Aetna, I continue to see health education as fundamental,” Moffitt explained on an episode of Healthcare Strategies. Leveraging Data for Targeted Education At large payers like Aetna, patient education starts with deep data insights. By analyzing member data, payers can identify key opportunities to deliver educational content precisely when members are most receptive. “People are more open to hearing and being educated when they need help right then,” Moffitt said. Aetna’s Next Best Action initiative, launched in 2018, is one such program that reaches out to members at optimal times, focusing on guiding individuals with specific conditions on the next best steps for their health. By sharing patient education materials in these key moments, Aetna aims to maximize the impact and relevance of its outreach. Tailoring Education with Demographic Data Data on member demographics—such as race, ethnicity, gender identity, and zip code—further customizes Aetna’s educational efforts. By incorporating translation services and sensitivity training for customer representatives, Aetna ensures that all communication is accessible and relevant for members from diverse backgrounds. Additionally, having an updated provider directory allows members to connect with healthcare professionals who understand their cultural and linguistic needs, increasing trust and the likelihood of engaging with educational resources. Technology’s Role in Mental Health and Preventive Care Education With over 20 years in healthcare, Moffitt observes that patient education has made significant strides in mental health and preventive care, areas where technology has had a transformative impact. In mental health, for example, education has helped reduce stigma, and telemedicine has expanded access. Preventive care education has raised awareness of screenings, vaccines, and wellness visits, with options like home health visits and retail clinics contributing to increased engagement among Aetna’s members. The Future of Customized, Omnichannel Engagement Looking ahead, Moffitt envisions even more personalized and seamless engagement through omnichannel solutions, allowing members to receive educational materials via their preferred methods—whether email, text, or phone. “I can’t predict exactly where we’ll be in 10 years, but with the technological commitments we’re making, we’ll continue to meet evolving member demands,” Moffitt added. Like Related Posts Salesforce OEM AppExchange Expanding its reach beyond CRM, Salesforce.com has launched a new service called AppExchange OEM Edition, aimed at non-CRM service providers. Read more The Salesforce Story In Marc Benioff’s own words How did salesforce.com grow from a start up in a rented apartment into the world’s Read more Salesforce Jigsaw Salesforce.com, a prominent figure in cloud computing, has finalized a deal to acquire Jigsaw, a wiki-style business contact database, for Read more Health Cloud Brings Healthcare Transformation Following swiftly after last week’s successful launch of Financial Services Cloud, Salesforce has announced the second installment in its series Read more

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July 22, 2024in Data, Salesforce, Salesforce Health and Life Sciences Solutions, Technology
Boost Payer Patient Education
19Jul

Boost Payer Patient Education

As a pediatrician with 15 years of experience in the pediatric emergency department, Cathy Moffitt, MD, understands the critical role of patient education. Now, as Senior Vice President and Aetna Chief Medical Officer at CVS Health, she applies that knowledge to the payer space. “Education is empowerment. It’s engagement. It’s crucial for equipping patients to navigate their healthcare journey. Now, overseeing a large payer like Aetna, I still firmly believe in the power of health education,” Moffitt shared on an episode of Healthcare Strategies. At a payer organization like Aetna, patient education begins with data analytics to better understand the member population. According to Moffitt, key insights from data can help payers determine the optimal time to share educational materials with members. “People are most receptive to education when they need help in the moment,” she explained. If educational opportunities are presented when members aren’t focused on their health needs, the information is less likely to resonate. Aetna’s Next Best Action initiative, launched in 2018, embodies this timing-driven approach. In this program, Aetna employees proactively reach out to members with specific conditions to provide personalized guidance on managing their health. This often includes educational resources delivered at the right moment when members are most open to learning. Data also enables payers to tailor educational efforts to a member’s demographics, including race, sexual orientation, gender identity, ethnicity, and location. By factoring in these elements, payers can ensure their communications are relevant and easy to understand. To enhance this personalized approach, Aetna offers translation services and provides customer service training focused on sensitivity to sexual orientation and gender identity. In addition, updating the provider directory to reflect a diverse network helps members feel more comfortable with their care providers, making them more likely to engage with educational resources. “Understanding our members’ backgrounds and needs, whether it’s acute or chronic illness, allows us to engage them more effectively,” Moffitt said. “This is the foundation of our approach to leveraging data for meaningful patient education.” With over two decades in both provider and payer roles, Moffitt has observed key trends in patient education, particularly its success in mental health and preventive care. She highlighted the role of technology in these areas. Efforts to educate patients about mental health have reduced stigma and increased awareness of mental wellness. Telemedicine has significantly improved access to mental healthcare, according to Moffitt. In preventive care, more people are aware of the importance of cancer screenings, vaccines, wellness visits, and other preventive measures. Moffitt pointed to the rising use of home health visits and retail clinics as contributing factors for Aetna members. Looking ahead, Moffitt sees personalized engagement as the future of patient education. Members increasingly want information tailored to their preferences, delivered through their preferred channels—whether by email, text, phone, or other methods. Omnichannel solutions will be essential to meeting this demand, and while healthcare has already made progress, Moffitt expects even more innovation in the years to come. “I can’t predict exactly where we’ll be in 10 years, just as I couldn’t have predicted where we are now a decade ago,” Moffitt said. “But we will continue to evolve and meet the needs of our members with the technological advancements we’re committed to.” Contact UsTo discover how Salesforce can advance your patient payer education, contact Tectonic today. Like Related Posts Salesforce OEM AppExchange Expanding its reach beyond CRM, Salesforce.com has launched a new service called AppExchange OEM Edition, aimed at non-CRM service providers. Read more The Salesforce Story In Marc Benioff’s own words How did salesforce.com grow from a start up in a rented apartment into the world’s Read more Salesforce Jigsaw Salesforce.com, a prominent figure in cloud computing, has finalized a deal to acquire Jigsaw, a wiki-style business contact database, for Read more Health Cloud Brings Healthcare Transformation Following swiftly after last week’s successful launch of Financial Services Cloud, Salesforce has announced the second installment in its series Read more

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July 19, 2024in Salesforce Health and Life Sciences Solutions, Salesforce Implementation Services, Salesforce Managed Services
Improve Patient Care and Trust
09Jun

Improve Patient Care and Trust

A recent survey conducted by Kyruus Health and shared with HealthPayerIntelligence reveals that consumers are demanding more accurate online provider data from payers to enhance access to care. Healthcare solutions from Tectonic and Salesforce improve patient care and trust by improving data accuracy. The survey, fielded by Wakefield Research in April 2024, involved 1,000 healthcare consumers. Nearly three-quarters of respondents (72%) had private health insurance, with Medicare being the second most common form of coverage (18%). The participants represented an even distribution across U.S. regions and age groups, with 57% identifying as women. Payers have historically struggled to maintain up-to-date provider directories, and this survey highlights the significant impact of these challenges. About 30% of consumers reported skipping care due to inaccurate provider information, with 70% of them seeking this data online. Consumers primarily rely on health plan websites or apps for provider information, with 32% naming these platforms as their first resource. Medicaid enrollees were particularly dependent on their plan’s digital resources, with 64% turning to these tools first. Besides health plan websites and apps, consumers also used general internet searches, provider or clinic websites, and healthcare information sites like WebMD. Social media platforms were also popular for care searches, with 77% of users turning to Facebook and 61% to YouTube. The survey also revealed that payers often fail to provide accurate cost predictions. Only 32% of respondents said their health plans offered accurate cost information. Price transparency tools are particularly important to younger generations, with 76% of Millennials and 80% of Gen Z respondents using these tools. However, 40% of Baby Boomers were unsure if their plans even offered such tools. Among those who did use them, 34% found that the tools presented incorrect provider data, with 45% of Gen Z reporting this issue. Inaccurate provider information can lead to significant negative consequences for consumers, including delays in accessing care, difficulties contacting preferred providers, and higher costs. Some consumers even reported accidentally receiving out-of-network care or forgoing care altogether due to these inaccuracies. These experiences not only hinder access to care but also damage consumer trust in their healthcare providers and payers. Overall, 80% of respondents said that inaccurate provider data affected their trust, with 27% losing trust in their health plans and 22% losing trust in their providers. The survey results underscore a clear call to action. Over 60% of consumers, and nearly 75% of Gen Z specifically, want their health plans to provide more accurate data. Tectonic has decades of experience applying Salesforce solutions to health care providers and payers. To address these concerns, the report recommends that health plans take three key steps: First, engage with members through appropriate channels, including social media. Second, unify and validate their provider data to ensure accuracy. Third, introduce self-service capabilities within their digital platforms to empower consumers. Reach out to Tectonic today if your organization needs help applying these three steps. Like Related Posts Salesforce OEM AppExchange Expanding its reach beyond CRM, Salesforce.com has launched a new service called AppExchange OEM Edition, aimed at non-CRM service providers. Read more The Salesforce Story In Marc Benioff’s own words How did salesforce.com grow from a start up in a rented apartment into the world’s Read more Salesforce Jigsaw Salesforce.com, a prominent figure in cloud computing, has finalized a deal to acquire Jigsaw, a wiki-style business contact database, for Read more Health Cloud Brings Healthcare Transformation Following swiftly after last week’s successful launch of Financial Services Cloud, Salesforce has announced the second installment in its series Read more

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June 9, 2024in Mulesoft, Salesforce Health and Life Sciences Solutions, Salesforce Health Cloud, Salesforce Implementation Services, Salesforce Managed Services, Salesforce Optimization
TEFCA could drive payer-provider interoperability
20May

TEFCA could drive payer-provider interoperability

Bridging the Interoperability Gap: TEFCA’s Role in Payer-Provider Data Exchange The electronic health information exchange (HIE) between healthcare providers has seen significant growth in recent years. However, interoperability between healthcare providers and payers has lagged behind. The Trusted Exchange Framework and Common Agreement (TEFCA) aims to address this gap and enhance data interoperability across the healthcare ecosystem. TEFCA could drive payer-provider interoperability with a little help from the world of technology. TEFCA’s Foundation and Evolution TEFCA was established under the 21st Century Cures Act to improve health data interoperability through a “network of networks” approach. The Office of the National Coordinator for Health Information Technology (ONC) officially launched TEFCA in December 2023, designating five initial Qualified Health Information Networks (QHINs). By February 2024, two additional QHINs had been designated. The Sequoia Project, TEFCA’s recognized coordinating entity, recently released several key documents for stakeholder feedback, including draft standard operating procedures (SOPs) for healthcare operations and payment under TEFCA. During the 2024 WEDI Spring Conference, leaders from three QHINs—eHealth Exchange, Epic Nexus, and Kno2—discussed the future of TEFCA in enhancing provider and payer interoperability. ONC released Version 2.0 of the Common Agreement on April 22, 2024. Common Agreement Version 2.0 updates Common Agreement Version 1.1, published in November 2023, and includes enhancements and updates to require support for Health Level Seven (HL7®) Fast Healthcare Interoperability Resources (FHIR®) based transactions. The Common Agreement includes an exhibit, the Participant and Subparticipant Terms of Participation (ToP), that sets forth the requirements each Participant and Subparticipant must agree to and comply with to participate in TEFCA. The Common Agreement and ToPs incorporate all applicable standard operating procedures (SOPs) and the Qualified Health Information Network Technical Framework (QTF). View the release notes for Common Agreement Version 2.0 The Trusted Exchange Framework and Common AgreementTM (TEFCATM) has 3 goals: (1) to establish a universal governance, policy, and technical floor for nationwide interoperability; (2) to simplify connectivity for organizations to securely exchange information to improve patient care, enhance the welfare of populations, and generate health care value; and (3) to enable individuals to gather their health care information. Challenges in Payer Data Exchange Although the QHINs on the panel have made progress in facilitating payer HIE, they emphasized that TEFCA is not yet fully operational for large-scale payer data exchange. Ryan Bohochik, Vice President of Value-Based Care at Epic, highlighted the complexities of payer-provider data exchange. “We’ve focused on use cases that allow for real-time information sharing between care providers and insurance carriers,” Bohochik said. “However, TEFCA isn’t yet capable of supporting this at the scale required.” Bohochik also pointed out that payer data exchange is complicated by the involvement of third-party contractors. For example, health plans often partner with vendors for tasks like care management or quality measure calculation. This adds layers of complexity to the data exchange process. Catherine Bingman, Vice President of Interoperability Adoption for eHealth Exchange, echoed these concerns, noting that member attribution and patient privacy are critical issues in payer data exchange. “Payers don’t have the right to access everything a patient has paid for themselves,” Bingman said. “This makes providers cautious about sharing data, impacting patient care.” For instance, manual prior authorization processes frequently delay patient access to care. A 2023 AMA survey found that 42% of doctors reported care delays due to prior authorization, with 37% stating that these delays were common. Building Trust Through Use Cases Matt Becker, Vice President of Interoperability at Kno2, stressed the importance of developing specific use cases to establish trust in payer data exchange via TEFCA. “Payment and operations is a broad category that includes HEDIS measures, quality assurance, and provider monitoring,” Becker said. “Each of these requires a high level of trust.” Bohochik agreed, emphasizing that narrowing the scope and focusing on specific, high-value use cases will be essential for TEFCA’s adoption. “We can’t solve everything at once,” Bohochik said. “We need to focus on achieving successful outcomes in targeted areas, which will build momentum and community support.” He also noted that while technical data standards are crucial, building trust in the data exchange process is equally important. “A network is only as good as the trust it inspires,” Bohochik said. “If healthcare systems know that data requests for payment and operations are legitimate and secure, it will drive the scalability of TEFCA.” By focusing on targeted use cases, ensuring rigorous data standards, and building trust, TEFCA has the potential to significantly enhance interoperability between healthcare providers and payers, ultimately improving patient care and operational efficiency. Like Related Posts Salesforce OEM AppExchange Expanding its reach beyond CRM, Salesforce.com has launched a new service called AppExchange OEM Edition, aimed at non-CRM service providers. Read more Salesforce Jigsaw Salesforce.com, a prominent figure in cloud computing, has finalized a deal to acquire Jigsaw, a wiki-style business contact database, for Read more Health Cloud Brings Healthcare Transformation Following swiftly after last week’s successful launch of Financial Services Cloud, Salesforce has announced the second installment in its series Read more Top Ten Reasons Why Tectonic Loves the Cloud The Cloud is Good for Everyone – Why Tectonic loves the cloud You don’t need to worry about tracking licenses. Read more

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May 20, 2024in Salesforce Health and Life Sciences Solutions
Salesforce Success Story
21Mar

Case Study: Healthcare Health Cloud Marketing Cloud Large Childrens Hospital

Large children’s hospital needs a usable data model and enhanced security to deliver excellent patient outcomes. Healthcare Health Cloud Marketing Cloud Large Childrens Hospital. Industry: Healthcare Client is a large children’s hospital with pediatric healthcare offering acute care. Problem: Implemented : Our solution? Results: In order to improve operations, provide physician-facing services, and move data—including PHI and PII—to the cloud, we have assisted healthcare providers in overcoming these obstacles. Salesforce offers all-inclusive solutions specifically designed to meet the demands of payers (insurance companies) and providers (healthcare organizations). Better health outcomes, more operational effectiveness, and increased patient engagement are the goals of these solutions. Salesforce solutions for the health and life sciences are tailored to the particular requirements of the medical industry. Salesforce offers digital transformation technology for health and life sciences industries. If you are considering a Salesforce healthcare implementation, contact Tectonic today. Like2 Related Posts Salesforce OEM AppExchange Expanding its reach beyond CRM, Salesforce.com has launched a new service called AppExchange OEM Edition, aimed at non-CRM service providers. Read more The Salesforce Story In Marc Benioff’s own words How did salesforce.com grow from a start up in a rented apartment into the world’s Read more Salesforce Jigsaw Salesforce.com, a prominent figure in cloud computing, has finalized a deal to acquire Jigsaw, a wiki-style business contact database, for Read more Health Cloud Brings Healthcare Transformation Following swiftly after last week’s successful launch of Financial Services Cloud, Salesforce has announced the second installment in its series Read more

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March 21, 2024in Salesforce, Salesforce Health and Life Sciences Solutions, Salesforce Health Cloud, Salesforce Marketing Cloud, Salesforce Sales Cloud, Salesforce Shield, Salesforce Success Stories
The Promise of AI in Health Outcomes
16Dec

The Promise of AI in Health Outcomes

As President Biden has highlighted, artificial intelligence (AI) holds tremendous promise and potential peril. This is especially true in healthcare. On October 30, the President underscored his commitment by signing a landmark Executive Order aimed at governing AI development and use to improve health outcomes for Americans while safeguarding their security and privacy. The Biden-Harris Administration is leveraging every tool at its disposal to advance responsible AI in healthcare. However, U.S. government action alone cannot achieve the bold vision laid out by the President. By integrating AI into their platform, Salesforce aims to empower public health organizations with actionable insights and predictive analytics. From disease surveillance to population health management, AI-driven solutions have the potential to revolutionize how we approach public health initiatives. Therefore, policy priorities include managing and measuring the environmental impacts of AI by requiring emissions disclosures, adding environmental impact as a risk factor, and establishing efficiency standards for high-risk AI systems. In response to the Administration’s leadership, leading healthcare providers and payers have announced voluntary commitments to the safe, secure, and trustworthy use of AI in healthcare. These commitments build on ongoing efforts by the Department of Health and Human Services (HHS), the AI Executive Order, and earlier commitments from 15 leading AI companies to develop models responsibly. Today, 28 providers and payers have joined these commitments, including Allina Health, Bassett Healthcare Network, Boston Children’s Hospital, Curai Health, CVS Health, Devoted Health, Duke Health, Emory Healthcare, Endeavor Health, Fairview Health Systems, Geisinger, Hackensack Meridian, HealthFirst (Florida), Houston Methodist, John Muir Health, Keck Medicine, Main Line Health, Mass General Brigham, Medical University of South Carolina Health, Oscar, OSF HealthCare, Premera Blue Cross, Rush University System for Health, Sanford Health, Tufts Medicine, UC San Diego Health, UC Davis Health, and WellSpan Health. The commitments align with the “FAVES” principles—Fair, Appropriate, Valid, Effective, and Safe. Under these principles, companies commit to informing users when they receive content that is largely AI-generated and not reviewed by humans. They will adhere to a risk management framework to monitor and address potential harms of AI applications. Additionally, they pledge to develop AI solutions responsibly, advancing health equity, expanding access to care, making care affordable, improving care coordination, reducing clinician burnout, and enhancing patient experiences. Healthcare is an essential service, and quality care can be a matter of life and death. AI-enabled tools used for clinical decisions must undergo appropriate testing, risk mitigations, and human oversight to avoid costly or dangerous errors. AI diagnoses can be biased if not trained on diverse data, and AI’s data-collection capabilities could create privacy risks. Addressing these risks is crucial. Despite these risks, AI holds enormous potential to benefit patients, doctors, and hospital staff. AI can help doctors deliver higher-quality, more empathetic care and cut healthcare costs by hundreds of billions of dollars annually. It can also help patients make more informed health choices by better understanding their conditions and needs. Consider some examples: Each year, hospitals produce 3.6 billion medical images worldwide. AI helps doctors analyze images more quickly and effectively, detecting signs of breast cancer, lung nodules, and other conditions earlier than ever before. AI is also streamlining drug development, matching drug targets with new molecules faster and cheaper, translating to better care for patients. Additionally, new generative AI applications can alleviate clinician burnout by automating data extraction, form population, note recording, and patient communications. The Promise of AI in Health Outcomes To understand AI applications and the necessary risk-mitigation measures, the Biden-Harris Administration has engaged with healthcare providers, payers, academia, civil society, and other stakeholders. These engagements have informed the Administration’s approach, including the President’s October AI Executive Order, which tasks HHS with a wide range of actions to advance safe, secure, and trustworthy AI. These actions include developing frameworks, policies, and potential regulations for responsible AI deployment, documenting AI-related safety incidents, prioritizing grants for innovation in underserved communities, and ensuring compliance with nondiscrimination laws in AI deployment in healthcare. The private-sector commitments announced today are a critical step in our whole-of-society effort to advance AI for the health and well-being of Americans. These 28 providers and payers have stepped up, and we hope more will join these commitments in the coming weeks. The Promise of AI in Health Outcomes has been addressed by governments everywhere. In March 2024, Salesforce strengthened its AI commitment to healthcare. Salesforce’s Einstein 1 Platform powers Einstein Copilot with your healthcare organization’s unique data and metadata from Data Cloud to capture and summarize patient details, quickly update patient and member information, and automate manual processes Assessment Generation digitizes paper assessments and surveys to capture and track patient data Customers like Baptist Health South Florida and HarmonyCares are using Salesforce to personalize patient interactions and create a single, unified view of each patient Today, Salesforce announced AI and data innovations for CRM to help make healthcare operations more efficient and personalized. Einstein Copilot: Health Actions, a conversational AI assistant that will deliver trusted AI responses grounded with your healthcare organization’s own trusted and private data, Assessment Generation, and Data Cloud for Health help automate and streamline clinical summaries, deliver more personalized communication, and help compile tailored patient assessments faster for care teams, all from a single platform. These new innovations are powered by Salesforce’s Einstein 1 Platform, which helps organizations safely unlock their data to create better patient experiences and augment employee productivity. Why it matters: Nearly a quarter of U.S. healthcare spending is wasted on administrative costs, presenting a potential cost savings of up to $320 billion for healthcare organizations, according to McKinsey and Co. AI could be the solution, with recent Forrester data revealing that 82% of healthcare data leaders say AI is a top focus area that will drive operational efficiency.  Content updated April 2024. Like Related Posts Salesforce OEM AppExchange Expanding its reach beyond CRM, Salesforce.com has launched a new service called AppExchange OEM Edition, aimed at non-CRM service providers. Read more Salesforce Jigsaw Salesforce.com, a prominent figure in cloud computing, has finalized a deal to acquire Jigsaw, a wiki-style business

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December 16, 2023in Generative AI, Salesforce Einstein
AI Potential to Improve Prior Authorizations
17May

AI Potential to Improve Prior Authorizations

AI’s Potential to Reduce Provider Burdens in the Prior Authorization Process Artificial intelligence (AI) has the potential to significantly ease the documentation and substantiation burdens providers face during the prior authorization process. Prior authorization, a critical step where health plans approve or deny coverage for services or prescriptions before they’re administered, is a key cost-control mechanism in the U.S. healthcare system. While it helps payers avoid unnecessary spending, the process poses significant challenges, especially for healthcare providers tasked with gathering and submitting documentation. AI Potential to Improve Prior Authorizations examined. Historically, prior authorization has been a major regulatory challenge for providers, surpassing other issues such as electronic health record (EHR) interoperability and compliance with the No Surprises Act. Despite its cumbersome nature, prior authorization isn’t likely to be eliminated, as it plays a crucial role in balancing healthcare affordability and access to quality care. AI Potential to Improve Prior Authorizations The transactional nature of many prior authorization tasks makes them ripe for automation. Increasingly, stakeholders are turning to AI and other technology-driven solutions to streamline the process, making it less burdensome for providers. How AI Can Streamline Prior Authorization AI has already been applied to various aspects of healthcare, from automating hospital discharges to alleviating the administrative burdens of nurses. When applied to prior authorization, AI can speed up the approval process for both providers and payers, reducing delays in patient care and lowering administrative costs. Health insurance companies are already beginning to leverage AI to expedite prior authorization and claims decisions. However, concerns are growing over whether the use of AI in these areas complies with state and federal regulations. For example, a 2023 AMA Annual Meeting resolution cited an investigation revealing that Cigna doctors denied over 300,000 claims in two months, spending an average of just 1.2 seconds per case using AI. UnitedHealthcare has also employed AI to make “fast, efficient, and streamlined coverage decisions,” raising questions about whether these decisions adhere to regulatory standards for fairness and accuracy. AMA’s Call for Oversight on AI in Prior Authorization Recognizing the risks, the American Medical Association (AMA) has called for increased regulatory oversight of AI in prior authorization. Specifically, the AMA advocates for: AI could potentially reduce the time-consuming, manual tasks associated with prior authorization. However, as AMA Trustee Dr. Marilyn Heine cautioned, “AI is not a silver bullet.” The increasing reliance on AI for prior authorization must not add to the already overwhelming volume of requirements that burden physicians and hinder patient care. Nor can it increase the threat of cyberattacks. Fixing Prior Authorization: AMA’s Role Addressing the challenges of prior authorization is a key part of the AMA’s Recovery Plan for America’s Physicians. The organization is committed to reducing the overuse of prior authorization and improving the fairness of existing processes, ensuring that the use of AI in healthcare supports—not hinders—patient care. To that end, the AMA continues to research the costs and impacts of prior authorization on healthcare providers and patients. To learn more about the proper use of AI in medicine and the AMA’s efforts to reform prior authorization, visit the AMA’s resources on healthcare AI. Content updated September 2024. Like Related Posts Salesforce OEM AppExchange Expanding its reach beyond CRM, Salesforce.com has launched a new service called AppExchange OEM Edition, aimed at non-CRM service providers. Read more Salesforce Jigsaw Salesforce.com, a prominent figure in cloud computing, has finalized a deal to acquire Jigsaw, a wiki-style business contact database, for Read more Health Cloud Brings Healthcare Transformation Following swiftly after last week’s successful launch of Financial Services Cloud, Salesforce has announced the second installment in its series Read more Top Ten Reasons Why Tectonic Loves the Cloud The Cloud is Good for Everyone – Why Tectonic loves the cloud You don’t need to worry about tracking licenses. Read more

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May 17, 2023in Artificial Intelligence, Salesforce Health and Life Sciences Solutions, Salesforce Implementation Services, Technology
Salesforce Health Cloud
13May

Salesforce Health Cloud for Payers

Utilization Management (UM) has been a familiar term since the 1970s, but its significance has grown considerably as a tool for managing medical costs. The pressure to contain costs amid overutilization and resource waste has intensified, prompting health insurers (payers) and employers to seek ways to control premiums and claims trends. Salesforce Health Cloud for Payers explained. What started as a rudimentary pre-hospitalization check has evolved into a multifaceted utilization review process involving prospective, concurrent, and retrospective evaluations. Modernizing a decades-old process, addressing fragmented UM systems, and establishing a unified source of truth for care management pose significant challenges. Enter Salesforce Health Cloud. Salesforce Health Cloud streamlines care requests, enabling payers to manage precertification and prior authorization efficiently. The Care Request feature in Health Cloud supports various payer UM processes, including prescription drug preauthorizations, service preauthorizations, and admissions review, facilitating informed decision-making and ensuring patients receive necessary care. How Tectonic can help: Tectonic specializes in providing solutions to payers facing UM challenges. Leveraging Salesforce products, we assist health and life sciences clients in maximizing authorizations, creating member service solutions, and deriving actionable insights from captured data. With our industry expertise and tailored consultation, we offer a blueprint for success across all functional areas within payer organizations. Discover how Tectonic can empower your organization to overcome UM challenges and achieve operational excellence. Contact us today. Like1 Related Posts Health Cloud Brings Healthcare Transformation Following swiftly after last week’s successful launch of Financial Services Cloud, Salesforce has announced the second installment in its series Read more Salesforce Government Cloud: Ensuring Compliance and Security Salesforce Government Cloud public sector solutions offer dedicated instances known as Government Cloud Plus and Government Cloud Plus – Defense. Read more PII Explained Personal Identifiable Information (PII) is defined as: Any representation of information that permits the identity of an individual to whom Read more Case Study: Health Payer/Provider Onboarding/Network Growth After doing their initial Sales Cloud implementation and SAP integration over 12 years ago, this company was only leveraging Salesforce Read more

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May 13, 2021in Salesforce Health and Life Sciences Solutions, Salesforce Health Cloud
Tectonic-Ensuring Salesforce Customer Satisfaction
29May

Tectonic’s Successful Salesforce Track Record

Salesforce Technology Services Integrator – Tectonic has successfully delivered Salesforce in a variety of industries including Public Sector, Hospitality, Manufacturing, and Health Life Sciences.  Read on about Tectonic’s successful Salesforce track record. Our primary focus is assisting clients with their Salesforce needs to solve business challenges. We work at the intersection of CRM, Marketing, Big Data, and Analytics. Public Sector Experience/Focus Proven Delivery – Tectonic delivers Salesforce Implementation, Integration and Managed Services, utilizing a modified Waterfall / Agile Delivery Method, leveraging US and International Delivery Center (IDC) resources, and delivering with strong, experienced Project Management Health and Life Sciences Focus We’ve helped healthcare providers navigate the challenges of moving data, including PHI and PII, into the cloud, providing physician facing services and improving operations. Salesforce provides comprehensive solutions tailored for the healthcare industry, addressing the specific needs of both payers (insurance providers) and providers (healthcare organizations). These solutions are designed to enhance patient engagement, improve operational efficiency, and drive better health outcomes. Financial Services Focus Transforming financial service delivery, optimizing operations, and cultivating community well-being and trust are at the core of Salesforce Financial Services Solutions. By automating every banking customer experience and uniting teams through Salesforce’s intelligence and a shared view of real-time customer data, a comprehensive banking solution is created, fostering customer satisfaction and loyalty. Travel and Hospitality Focus Salesforce provides tailored solutions for the hospitality and travel industry, helping businesses in this sector deliver exceptional customer experiences, streamline operations, and drive growth. These solutions leverage the power of the Salesforce Customer 360 platform to centralize data, enhance communication, and provide a personalized experience for guests. Manufacturing, Distribution, and Energy Focus We’ve helped small and large manufacturers optimize their sales operations and drive efficiencies in their contact center. Salesforce offers a suite of solutions tailored for manufacturing and distribution industries to enhance processes, improve collaboration, and drive overall efficiency. These solutions are designed to streamline operations. Designed improve customer relationships and provide valuable insights. Nonprofit Focus We’ve helped nonprofits and NGO’s optimize their operations and drive efficiencies in their fundraising and mission efforts. Salesforce offers a suite of solutions to nurture relationships and scale impact. Solutions with AI-driven, personalized services. Salesforce allows you to take control of your data on a single integrated platform. Nonprofit Cloud brings a nonprofit CRM, fundraising, programs, marketing engagement, and outcomes together in a single product. Strategic Relationship with Salesforce – Salesforce Ventures invested in Tectonic in Q3 2015.  We maintain strong working relationships with Salesforce License Sales, Professional Services and Alliances. Tectonic’s successful Salesforce track record stems from our great relationship with Salesforce and grows through each customer interaction. Like1 Related Posts Salesforce OEM AppExchange Expanding its reach beyond CRM, Salesforce.com has launched a new service called AppExchange OEM Edition, aimed at non-CRM service providers. Read more The Salesforce Story In Marc Benioff’s own words How did salesforce.com grow from a start up in a rented apartment into the world’s Read more Salesforce Jigsaw Salesforce.com, a prominent figure in cloud computing, has finalized a deal to acquire Jigsaw, a wiki-style business contact database, for Read more Health Cloud Brings Healthcare Transformation Following swiftly after last week’s successful launch of Financial Services Cloud, Salesforce has announced the second installment in its series Read more

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May 29, 2019in Data, Salesforce, Salesforce Development Services, Salesforce Financial Services Solutions, Salesforce for Nonprofits, Salesforce Health and Life Sciences Solutions, Salesforce Hospitality Travel and Transportation, Salesforce Manufacturing Automotive Energy, Salesforce Public Sector Solutions, Technology

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