Meet Health Cloud for Payers
Learning Objectives
After completing this unit, you’ll be able to:
- Explain how Health Cloud addresses payer business challenges.
- List the main benefits of using Health Cloud for payers.
- Identify the major components of Health Cloud for payers.
Before You Start
Before you start this module, consider completing the following recommended content.
Healthcare Payers Challenges
Cumulus Health Plans is a national health insurance company that offers a wide range of insurance products to employer groups, government agencies, individuals, and families.
One of the key performance indicators (KPIs) for Cumulus is its medical loss ratio (MLR). MLR measures the percentage of premium dollars Cumulus spends on medical claims and quality improvements compared to administrative costs.
The senior leadership team is concerned about the sluggish adoption of new technologies. As Cumulus grew over the years, it delayed consolidating many services and systems.
Further, all payers face ongoing regulatory demands, which are increasingly difficult to navigate. Cumulus currently expends far too many resources in ensuring compliance.
In the highly competitive health insurance industry, there’s always a risk of becoming obsolete. Many payers are now facilitating and enabling better healthcare through shifts in payment models, analytics, and other mechanisms.
Ultimately, Cumulus lags behind the general market in making transformational changes. To develop Cumulus’s business strategy and drive growth, the senior leadership team identifies the following core priorities.
Priority |
Description |
|---|---|
Improve member experience |
Because consumers compare the health insurance experience with other industries, it’s critical to create an OmniChannel user experience driven by personalization and efficiency. |
Decrease medical costs |
Cumulus wants to reduce its inflated medical costs without compromising the quality of care its members receive. |
Ensure security of member information |
With constantly changing technology, Cumulus must assure airtight security and privacy of member information. |
Improve existing systems and processes |
Cumulus wants to enable data-driven decision-making and sharing by integrating its disparate data sources in a secure cloud environment. |
Comply with regulatory requirements |
To maintain regulatory compliance, Cumulus has implemented new software, but it still struggles to work with electronic health record (EHR) providers to make the data interoperable. |
What can empower Cumulus to meet all these challenges? It’s Health Cloud, of course! Here’s how.
Enter Health Cloud
Built on the Salesforce Platform, Health Cloud is an integrated solution for delivering equitable, whole-person care from anywhere.
Here’s how Health Cloud benefits health plans like Cumulus and solves their core priorities.
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Manage affordable, high-quality coverage: Value-based care is an increasingly important delivery model in which providers are paid based on patient health outcomes. To support this model, Health Cloud provides tools for payers to manage affordable, data-driven, high-quality coverage for all members.
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Digitize user experiences: Health Cloud, in concert with Experience Cloud, offers OmniChannel member, provider, and partner experiences that enable health plans to deliver individualized, high-touch care at scale.
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Provide whole-person care from anywhere: Health Cloud equips payers with the tools to help improve health outcomes for all, particularly its most vulnerable member population. Health plans can target social determinants of health to improve equitable health outcomes. Further, virtual care capabilities enable health plans to connect members and providers virtually.
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Accelerate data and automation: Health Cloud unlocks the power of hyper-automation, guiding health plans to automate countless business processes. This results in unlocking productivity, accelerating time-to-market, and transforming user experiences.
Health Cloud Capabilities for Payers
Health Cloud has many features that—in tandem with other Salesforce products—power solutions for common healthcare industry scenarios. For ease of reference, the features are categorized into feature groups, which are non-exclusive groupings of Health Cloud features into a set of industry-recognized categories.
Here’s a look at the feature groups relevant to payers.
- Patient and Member Services
- Care Orchestration
- Provider Network and Relationship Management
- Utilization Management
Patient and Member Services
These features focus on healthcare payer engagement with members. Increasingly, payers must understand member data, answer questions, and resolve concerns with speed, accuracy, and empathy. Using these features, payers can track and verify member health and information, deliver personalized service to members, and support their access to care.
Payers can use Contact Center for Health Cloud to digitize key customer service processes required to operate health insurance plans across all lines of business. This solution personalizes contact center experiences, such as caller validation, member relationship mapping, interaction tracking, and call wrap-up. These tools can help payers achieve greater member satisfaction and agent productivity and lower service costs and case resolution time.
Learn how the features in this group map to tasks that different Health Cloud users do.
Members
Health Plan Professionals
To learn more about these features, see Engage with Your Patients and Members.
Care Orchestration
Care Orchestration consists of care management and care coordination, and it focuses on the actual delivery of care to members. The feature also orchestrates when, where, and how the members receive the care. With Care Orchestration, payers can track and manage eligibility, enrollments, care plans, and social determinants while keeping members engaged in their health.
Learn how the features in this group map to tasks that care managers do.
Provider Network and Relationship Management
These features help you build and manage a provider network from recruitment, credentialing, contracting, appointment, onboarding, and beyond. The features reduce provider onboarding times and improve provider satisfaction. They also minimize operational costs across multiple departments and improve the accuracy of provider data.
Learn how the features in this group map to tasks that recruiting, credentialing, contracting, and onboarding specialists do.
Provider relationship features give users a full view of their provider network, including facilities, licenses, education, work history, references, and professional liability coverage.
To learn about provider network management and relationship features in detail, see Provider Network Management and Provider Search and Cards.
Utilization Management
This group of features ensures patients receive the right care, at the right time, and in the right setting. Employ Utilization Management for utilization reviews, such as prior authorization and service requests, to better manage the cost of care. Assess the feasibility of treatment with evidence-based guidelines before a service is provided. With these Health Cloud features, respond constructively and transparently to any denial of care.
Learn how the features in this group map to tasks that intake specialists, UM nurses, and medical directors do.
To learn more about these features, see Utilization Management in Health Cloud.
Additional Capabilities
Health Cloud offers these additional capabilities for payers.
Distribution Management
Track producer data for licenses, education, training, and more. Distribution Management provides guided workflows to manage the entire producer lifecycle. Health plans can efficiently qualify and appoint new selling partners and then use analytics tools to closely manage and monitor broker performance. Using Experience Cloud, payers can provide self-service tools that integrate seamlessly with Health Cloud data.
Commercial Sales
Use Commercial Sales to build and sell benefits to customers across all markets. Health plans can launch a modern rate, quote, and apply shopping experience across all lines of business, including individual, group, Medicare, and ancillary.
To support these processes, the solution comes with a full product catalog and rating engine. Prebuilt business processes enable prospective members to shop, compare, and select plans with ease.
You now have a better idea of the challenges facing payers and how Health Cloud fits in. In the next unit, take a closer look at how Health Cloud meets these challenges.
Resources