Understanding the Risks of Healthcare System Disruptions

In the world of healthcare, so many things are interconnected – between technology systems, platforms and other business operational functions. If errors, shutdowns or broad sweeping external factors disrupt operations, the impacts can be far reaching and significant to members and providers.

What are some of the ways that systems, technology and platform disruption can have on the healthcare ecosystem?

Health Insurers:

• Operational Disruptions: Delays in claims processing and increased manual workloads can lead to operational inefficiencies and higher administrative costs.
• Financial Impact: Increased claims processing times and potential for fraud during disruption could lead to financial losses.
• Regulatory Compliance Risks: Difficulty in meeting regulatory reporting requirements and compliance deadlines could result in penalties and reputational damage.
• Member Satisfaction: Delays in claims processing and potential confusion about coverage could lead to decreased member satisfaction and trust.

Health Plan Beneficiaries:

• Access to Care: Delays in prior authorization and claims processing may temporarily limit access to necessary medical services or medications.
• Financial Burden: Beneficiaries might face higher out-of-pocket costs or delays in reimbursement for healthcare services.
• Confusion and Anxiety: Lack of clear information and potential disruptions in service could lead to confusion and anxiety among patients regarding their care continuity and coverage.

Providers:

• Revenue Cycle Management: Delays in claims submissions and reimbursements can strain financial liquidity and impact the overall financial health of healthcare providers.
• Administrative Burden: Increased administrative work to manage manual claims processing and communications with health insurers can divert resources from patient care.
• Patient Care Impact: Potential delays in receiving payments may affect the ability of providers to offer timely and comprehensive care, especially for smaller practices with limited financial reserves.

Pharmacies:

• Prescription Processing Delays: Disruptions in electronic prescription services and insurance verification processes can lead to delays in dispensing medications to patients.
• Financial Impact: Cash flow issues may arise from delays in reimbursement from insurers, affecting the operational stability of pharmacies.
• Customer Service Challenges: Pharmacies may face increased pressure from customers experiencing delays or issues with medication access, impacting customer satisfaction and loyalty.

Downstream Entities (e.g., labs, medical device companies):

• Operational Disruptions: Entities reliant on timely data exchange and payment processes may experience operational delays and inefficiencies.
• Supply Chain Impact: Disruptions in payment and ordering processes could affect the supply chain, leading to delays in delivering medical supplies and devices.
• Financial Strain: Delays in payments for services or products could impact on the financial stability of these entities, particularly those with tight operating margins.

If your plan is ever impacted by these types of disruptions, ProspHire is equipped to support you. Our deep expertise in strategy, operations and technology within the healthcare sector positions us perfectly to assist health plans in navigating the complexities. Here are several ways we could provide valuable assistance:

Strategic Response and Recovery Planning

Rapid Impact Analysis:

• Our team of payor experts and delivery consultants can quickly produce an impact analysis with plans for developing or executing your existing downtime procedures. We’ll aim to establish governance and track business needs until normal operations proceed.
  • Identify services of most impact (Prior Authorizations, Claims, etc.)
  • Rapidly develop, review and execute business continuity procedures.
  • Establish governance processes and tracking to minimize operational impacts.
  • Establish transition procedures to return to normal operations.

Incident Response Strategy:

• Help develop or refine an incident response plan tailored to cyberattack scenarios, ensuring quick and effective action to minimize damage. Enhanced with agile capabilities and processes to continually prioritize pain points.

Business Continuity Planning:

Assist in creating or updating business continuity plans that specifically address cyber threats, ensuring that critical operations can continue with minimal disruption.

• Compliance and Risk Management: Guide health plans through the complex landscape of healthcare regulations (such as HIPAA) related to cybersecurity, helping them to meet compliance requirements and manage risks effectively.
• Technology Implementation Support: Advise on the selection and implementation of advanced cybersecurity technologies and practices, including encryption, multi-factor authentication and network segmentation.
• Process Optimization: Review and optimize operational processes to enhance efficiency and resilience, ensuring that manual processes are in place to maintain operations during digital system outage and robust planning to ensure a swift return to operational effectiveness.
• Communication Planning: Help develop communication plans that clearly outline how to communicate with internal and external stakeholders during and after a cyberattack.

If you or your health plan leadership needs support to navigate technological or system disruption, connect with us today.