A Payer's Guide: Reducing Tech Bloat with BOAT

How the Overlapping Automation Market Presents Opportunities for Consolidation?

It's no secret that the healthcare ecosystem today reflects years of fragmented modernization efforts, which has led to a patchwork of outdated legacy systems. In response to growing digital demands, many payers have adopted multiple point solutions to address specific pain points. However, this approach has left many payers with an increasingly complex and disjointed infrastructure.??

It is common for organizations to experience quick wins from initially implementing point solutions, but this is often followed by large efforts and investments to integrate these tools to support business processes.? IT teams are then faced with the burden of maintaining a bloated system that is inefficient, costly to manage, and challenging to keep in compliance with data security and privacy standards. Not to mention the challenges this scenario brings where IT is on the hook to deliver on net new strategic projects.?

This has contributed to "logo fatigue," which is especially prevalent in the healthcare industry due to the overwhelming number of technology vendors and solutions claiming to address similar challenges (think automation, data management, integration and so on). In fact, a recent study by Galen Growth and Finn Partners recently reported that there are over 14,000 digital health ventures worldwide with nearly 3,500 healthcare AI startups in the U.S. alone. The result is a confusing landscape that makes it difficult for healthcare payers to identify the right solutions for their strategies amidst a sea of seemingly identical products.?

One area that has grown in popularity with payers, as well as number of solutions, over recent years is hyperautomation.? Hyperautomation refers to the use of multiple tools that are integrated to automate as many business and IT processes and tasks as possible.? These tools span across departments, key functions and core business processes.? In fact, many payers use competing platforms (RPA, BPA, low-code, iPaaS) as different departments often work in silos, funding and prioritizing their own initiatives.?

The Hype Cycle & Hyperautomation?

Gartner's Hype Cycle for U.S. Healthcare Payers is a crucial resource for evaluating the maturity, adoption, and business impact of new technologies and practices. It helps payers make informed technology investment decisions, positioning them to leverage innovations that enhance operational efficiency and improve member outcomes.?

Within the Hype Cycle are 22 innovations that can support strategic initiatives and investments within payers looking to digitally modernize and transform their business.? One interesting insight is how one of those innovations, "Hyperautomation for Healthcare Payers", has accelerated past the "Peak of Inflated Expectations":?

While the healthcare industry has embraced hyperautomation tools, they often specialize in one aspect of automation while lacking in others.? They are integrated and managed like point solutions.? As these platforms enhance their automation capabilities, they start to all sound the same while payers realize these tools can't do it all.? This may explain why Hyperautomation is now headed for the "Trough of Disillusionment".?

With that being said, Gartner's Payer Priority Matrix maps Hyperautomation as an innovation with transformational benefits that is expected to mature within five years:?

As automation capabilities continue to blend, a new class of technology has emerged to address the demand for consolidation in the market.?

BOAT: The Convergence of Automation Capabilities?

At the recent Application Innovation & Business Solutions Summit in Las Vegas, Gartner announced a new concept called BOAT, or Business Orchestration and Automation Technologies.? This concept represents the next evolution of Hyperautomation where organizations seek a comprehensive solution that combines various automation technologies into a unified platform.?

The BOAT concept is a convergence of leading automation capabilities, tools and technologies (think robotic process automation (RPA), business process automation (BPA), integration platforms, and low-code application development platforms (LCAP)). BOAT emphasizes the following:?

• Process orchestration, seamless workflows and data consistency?
• Integration of automation with enterprise systems?
• Adapt to changing business needs?
• Enable the business?
• Enhance collaboration between business and IT?

Process Orchestration – The Key to BOAT?

At the heart of BOAT is business process orchestration, which seamlessly connects your workflows, technology, and people into fully automated, end-to-end processes. Achieving this requires a process automation platform that unifies BOAT's automation principles, providing full visibility and interaction with your entire workflow.?

A Few Examples:?

Member Enrollment - Process orchestration streamlines the member enrollment journey, efficiently managing tasks from application to disposition across various channels. It automates the verification of applicant details, assesses eligibility, and digests information from documents, thereby minimizing administrative efforts and enhancing the overall experience for members.?

Clinical Decisioning – Payers can utilize BOAT capabilities to create tailored applications and tools that allow clinical staff to set their own decision criteria and workflows as new treatments and medications emerge. By integrating clinical guidelines and employing data-driven, model-driven, and knowledge-driven decision-making, they can offer real-time recommendations for engagement and care. Additionally, data gathered from core business processes gives payers valuable insights into trends, risks, member behaviors, and preferences, which are essential for making informed decisions.?

Enhanced Member Experiences – Integrate with various systems and deploy AI virtual assistants to collect, classify and centralize member data.? Honor preferences, offer services, route inquiries and close care gaps that supports member-centric experiences. Then, leverage these insights for better decision-making and determining the 'next best action' for the use case at hand.?

Intelligent Prior Authorizations - Prior auths rely on a vast amounts of data, technology, integrations and cross-departmental collaboration.? From receiving the initial request, determining medical necessity based on business rules and decisioning criteria, possibly assigning it to one or many reviewers and determining an outcome, the process is complex. Process orchestration platforms offer a comprehensive view of this entire workflow, equipping the business with the tools to manage key components and rules, while minimizing manual tasks through the power of BOAT.?

Claims Processing - Business orchestration and automation capabilities can revolutionize claims processing by automating critical tasks, significantly reducing manual errors, and enhancing overall efficiency. For example, a payer organization can use BPM and RPA to automate the verification of patient eligibility and streamline the coding and billing process. AI can then analyze claims for potential fraud, prioritize complex cases, and ensure accurate adjudication. This combined approach not only speeds up processing times and reduces errors but also enhances fraud detection, leading to faster payments and better service for providers and members.?

Fraud, Waste, & Abuse -? configurable business rules, AI, and RPA can detect and manage potential fraud by flagging unusual patterns or discrepancies in claims data. RPA bots or AI can analyze large volumes of claims, comparing them against predefined rules and historical patterns, such as billing discrepancies or duplicate claims. Integrating these capabilities helps payer organizations streamline claims processing, improve compliance and reduce costs.?

By using a process orchestration and automation platform that encompass BOAT's full capabilities, IT teams can unify these systems, centralize control, and gain a holistic view of all processes. This enables the identification of inefficiencies and redundancies, allowing for the strategic consolidation of outdated systems, streamlining operations, and reducing the complexity and costs of maintaining fragmented tools.?

Embracing BOAT - Approach for Successful Modernization?

It is imperative for payers to invest in the right technologies that:?

• effectively support member care??
• drive down costs?
• are flexible to the evolving industry (member preferences, regulations)?
• future proof the business and provide a competitive advantage?

When transitioning from legacy technology to leveraging automation tools, especially those that unify BOAT's concepts, focusing on these five key areas will help ensure a successful transformation:?

While adhering to this methodology is crucial, its success ultimately depends on the people and teams who support it.? It is strongly recommended to stand up a COE at the beginning, which will serve as the backbone for a successful and sustainable modernization effort ensuring that initiatives are strategically aligned, governed and effectively executed.?

Summary?

Executing a one-time initiative to consolidate apps may work for a while, but without a long-term strategy, tech bloat eventually creeps back in. It must take precedence for all future technology related decisions and embraced throughout your leadership team.???

Finally, the goal is to simplify technology complexity across the organization while adhering to security standards and delivering measurable value - for your bottom line, end users and members. Embracing the BOAT approach to modernizing core areas of your business fosters cross-departmental collaboration and productivity, enables business users to handle minor changes and enhancements independently, and lessens the burden on IT.?