A Member Journey After the No Surprises Act: How Plans Meet Regulatory Mandates and Satisfy Members with HealthRules® Payer

Meet Janelle, a health plan member

Janelle has been struggling with knee pain ever since she sustained a basketball injury in college. Her finances are pretty tight, so when she finally decides to schedule a needed knee surgery, she is careful to make sure it is with a surgeon who is a participating provider in her health plan, YourHealth.

When it’s time for the surgery, Janelle checks in at Midtown Surgery Clinic, a participating facility and pays an expected co-pay. The surgery goes well and once the anesthesia wears off, she heads home to recover. Janelle does not anticipate any additional bills as she and her surgeon fulfilled all prerequisites of her coverage.

Prior to the No Surprises Act

Two months later, Janelle receives a $600 bill from Midtown Anesthesiology. After waiting on-hold with the clinic, then her health plan, Janelle finally speaks to customer service and learns that while her surgeon was in-network, the anesthesiologist was not. Now, she is responsible for a cost-sharing bill she can’t afford.

Behind the scenes, Janelle’s surgery results in multiple, separate claims to YourHealth. Midtown Surgery bills YourHealth for the surgery and Midtown Anesthesiology bills $600 for an anesthesiology service. During claim adjudication, YourHealth identifies the anesthesiologist as an out-of-network provider and processes the anesthesiology claim with out-of-network deductible and co-insurance responsibilities for Janelle, which results in her receiving the $600 bill.

This process takes over 60 days, leaving Janelle with a significant, unexpected bill that arrives months after a service she expected to be fully covered. The process leaves Janelle surprised, confused and angry with her health plan, the doctor, and the healthcare system in general.

She becomes disinclined to engage in the recommended follow-up services and may try to avoid everything but emergency services in the future.

After the No Surprises Act

Prior to the scheduled surgery, Janelle uses the price comparison tool through her member portal and easily confirms the cost of the surgery and what her cost sharing responsibilities will be.

Following the visit, the Midtown facility and physicians bill YourHealth for the surgery and a $600 anesthesiology service, minus the collected co-pay. The out-of-network anesthesiologist claim is processed applying in-network cost sharing, holding Janelle harmless from the higher out-of-network cost sharing amounts.

The facility and physicians who provided Janelle’s care send their service claims to her health plan. YourHealth, has prepared for No Surprises Act (NSA) compliance, leveraging the flexibility of HealthRules Payer to:

  • Configure out-of-network claims using NSA criteria
  • Auto-adjudicate the out-of-network claim appropriately using the Qualified Payment Amount for the service
  • Populate price comparison tools with provider and member-specific details using HealthRules Payer’s Trial Claim Feature, so Janelle was able to get personalized cost information well before surgery.

Later that year, YourHealth negotiates a slightly higher contracted fee schedule with Midtown Anesthesiology–expanding their network and improving provider and member satisfaction. They continue to monitor evolving NSA rulings, knowing that with the flexibility of HealthRules Payer they can prepare for future rulings like those anticipated for advanced explanations of benefits (AEOBs)–using the Trial Claim Feature and existing explanation of benefits processes to generate individualized claims detail for anticipated services.

Janelle receives no additional bill and engages in important physical therapy follow-up. By continuing to engage in preventive healthcare and treatment, Janelle optimizes her health outcomes and reduces lifetime health costs to herself and her health plan.

No Surprises Act, Regulatory Compliance, & HealthRules Payer

HealthRules Payer from HealthEdge, is a modern core administrative processing system with existing features that support plans in maintaining regulatory compliance. Designed for easy configuration, HealthRules Payer gives health plans the tools and support they need to succeed, even as transparency regulations evolve.

Learn more about how HealthRules Payer gives plans the tools to succeed as the No Surprises Act and industry regulation evolves.


Leveraging Source for Efficient Claims Audit and Inquiry

Health plans face complex and multifactored pricing and payment demands. With a robust and flexible platform like HealthEdge’s Source, plans can increase automation while working to optimize resource-intensive and manual processes like claims audits. This case study highlights one plan’s experience integrating Source with existing legacy technology and improving first-pass adjudication rates and efficiently managing claims audit and inquiry processes.


HealthEdge® representatives recently talked to two members of the provider reimbursement team from a large non-profit health plan in the northeast. At the time of interview, the Plan was primarily using Source for pricing and reimbursement, leveraging the extensive library of pricing edits and bi-weekly updates that come standard with the Source platform. The conversation focused on two common and critical health plan challenges related to provider reimbursement. First, was the need for the Plan to replace an older tech platform while assuring the new platform would integrate with other legacy components of their tech stack. Second, was the need for the provider reimbursement team and other health plan system users to be able to audit claims and address ongoing retroactive claims inquiries from internal and external stakeholders.

Solution = HealthEdge Source

In 2021, the Plan began a phased implementation process, sunsetting an older payment and pricing platform and upgrading to Source. While Source is a modern payment integrity platform, the Plan was still working with a legacy core administration processing system (CAPS) and had concerns about platform integration especially given the significant complexity inherent in their hierarchical provider payment arrangements. Fortunately, Source has built-in integration with 10+ claims systems, ensuring that implementation wasn’t waylaid by key technology integration challenges. Source also offers hierarchical edit capabilities, enabling for example, the six different enterprise-level configurations overlaying mapping rules for 75 different rate configurations used just for one (Centers for Medicare and Medicaid; CMS) fee schedule at this particular health plan.

Not only was Source able to integrate with the Plan’s legacy CAPS system and accommodate complex hierarchical pricing configurations, but the integration and upgrade also led to a significant improvement in their first-pass claims adjudication rate. As noted by the Plan’s Reimbursement Initiatives Manager, prior to integrating their CAPS system with Source, their first-pass rate averaged about 80% and is now near 98% according to their CAPS measurement criteria. She noted that improvements are tied to both the Source product and the improved integration with their CAPS system, which has streamlined a variety of reimbursement processes.

“The overall end-to-end process was improved from the way it worked before, when we had to use robots, compared to how we’re using Source now… There are a lot of things we can do in Source now that we couldn’t do before.” – Health Plan Reimbursement Initiatives Manager

Retroactive claims inquiries and adjustments are another ongoing challenge for the Plan, particularly for providers who bill using a percentage of CMS fee schedules. CMS fee schedules are subject to ongoing policy updates and payment changes, but because only a small percentage of the Plan’s contracted providers use the CMS fee schedules, the Plan does not automatically make claims adjustments based on retroactive CMS change policies. Instead, issues usually come to their attention following a claims complaint or audit.

While the reimbursement team noted how helpful Source’s automated and bi-weekly updates are, they also noted that CMS release data gives limited information about when retroactive changes should impact reimbursement for specific types of providers. An example was when they received a complaint about 50 different claims payments across different hospital facilities that they contract with using the CMS fee schedules. In this situation, with multiple and dispersed claims issues, it was difficult to trace a payment change back to a specific CMS release.

The Reimbursement Initiatives Manager noted how critical Source’s audit feature is to address these types of provider complaints. It enables her to download relevant claims from the production to the pre-production environment and reprocess them, compare the two side-by-side, and identify changes like a capital payment amount or wage index change, that could drive such dispersed claims complaints.

“One of the best features of Source that I love is the ability to download a claim from one environment to another environment. That’s very handy.” – Health Plan Reimbursement Initiatives Manager

It is easy to see how this regional plan serves to benefit from this type of automation, and this addition may be a next step on their payment integrity journey. But Source is designed to support plans at all stages, and the audit feature (one of the Plan’s most widely used Source features) enables the Plan to meet their retroactive claims inquiries and audit needs manually. Source’s audit feature is critical for the Plan’s customer service team members who access claims detail to answer questions from providers and members, and for the audit team who hold claims audit responsibility. Further, the provider reimbursement team regularly uses the audit feature to respond to inquiries from Plan leaders.

For example, the Reimbursement Initiatives Manager was recently asked to explain to the Plan’s leadership team how ambulance services (a particularly expensive line-item for plans), are priced by CMS. It was easy for her to use Source’s audit feature to search for hospital outpatient provider type, filter by an ambulance code to narrow down the results, then find examples of claims that contained the ambulance code. With this information, she was able to provide a detailed response to Plan leadership about how CMS reimburses those ambulance services


  • Pre-existing integration capabilities minimize challenges inherent in integrating new platforms with legacy tech stack components
  • Optimizing automation will drive accuracy while minimizing resource-intensive and manual work and re-work for prospective and retroactive pricing changes
  • Retroactive pricing updates aren’t going away; the right tool will enable plans to leverage robust audit features for inquiries and manual adjustments while considering more automated solutions
  • Choosing an industry-specific tech partner like HealthEdge gives plans the support they need to optimize automation and accuracy despite the complexity of diverse pricing and provider arrangements

I have found the HealthEdge Source system to be very robust and flexible with regards to all of the different types of CMS and non-CMS based pricing methodologies that it offers.” – Health Plan Reimbursement Initiatives Manager

Navigating the Payer-Provider Landscape: Wins, Losses, and Future Trends

The complex relationship between payers and providers plays an important role in shaping the accessibility and quality of healthcare services. In 2023, this relationship underwent significant shifts, leading to both wins and losses. Looking ahead to 2024, several trends seem poised to further reshape how individuals access and experience healthcare.

Wins and Losses in 2023:



1. Enhanced Digital Experience:

The integration of digital platforms and telehealth into benefit plans improved access to healthcare services. Insurers made strides in offering user-friendly apps, enabling policyholders to view their coverage, schedule appointments, and access medical records effortlessly. Some of these advancements were the direct results of regulations taking effect.

2. Value-Based Partnerships:

Payers embraced value-based care models even more, forging deeper partnerships with providers. The continued shift incentivizes better outcomes and promotes cost-effective, quality care.

3. Preventive Care:

Payers continued their focus on preventive care, offering incentives and reduced premiums for policyholders who proactively engaged in wellness programs and screenings. This approach aims to mitigate future healthcare costs by preventing diseases, benefiting the entire system.

4. Streamlined Claims Processing:

Technological advancements, like those of HealthEdge’s core administrative solution, HealthRules® Payer, led to faster and more accurate claims processing, reducing administrative burdens for both providers and payers. This improved efficiency in healthcare delivery and reduced claim disputes.


1. Rising Premiums:

Despite efforts to improve efficiency, health insurance premiums continued to rise in 2023. This posed a challenge for individuals and businesses trying to balance the cost of insurance with adequate coverage.

2. Narrower Provider Networks

Some plans opted for narrower provider networks to control costs. While this helped in cost containment, it limited the choices available to members, leading to dissatisfaction and potential delays in care.

3. Data Privacy Concerns

The increasing use of digital platforms raised concerns about the security and privacy of healthcare data. Instances of data breaches and unauthorized access underscored the importance of robust data protection measures. Data breaches were felt by both payers and providers at varying levels of severity.

Looking Ahead to 2024


Anticipated Trends:

1. Personalized Healthcare

Consumers are still hungry for a retail experience from their healthcare partners that is personalized to their specific needs. Artificial Intelligence (AI) is set to revolutionize healthcare by enabling personalized treatment plans based on an individual’s unique health data. But in an industry known to trail others, we may still be years away from being able to utilize AI to tailor coverage and support.

2. Virtual Reality in Telemedicine

Virtual Reality is poised to enhance telemedicine experiences, providing immersive consultations and medical training. Payers may integrate Virtual Reality into their offerings to improve patient engagement and understanding. However, like AI, this may be decades in the making.

3. Global Telehealth Access

Improved infrastructure and cross-border agreements may lead to global telehealth access, allowing individuals to consult with healthcare providers from different parts of the world, expanding their healthcare choices. Global telehealth access is more important now than ever as unrest rumbles in parts of the world.

Next-generation, digital core administrative processing systems, like HealthRules Payer, can help health plans better prepare for the future and respond to regulations and market trends. Across the industry, HealthRules Payer is known for its simplified but comprehensive configuration, allowing payers to move quickly and take advantage of new growth opportunities.

The relationship between payers and providers continues to evolve, presenting both challenges and opportunities. The shifts in 2023 indicate a growing focus on enhancing the digital experience, promoting preventive care, and streamlining processes. Looking forward to 2024, exciting advancements are on the horizon, promising a more personalized and accessible healthcare landscape. Learn more about our core administrative processing solution.

7 Strategies for Navigating the Medicaid Disenrollment Challenge

New data shows that states are struggling with the administrative components of redetermination. How did we get here, and how do we solve this problem?

Following the end of the COVID-19 public health emergency this spring, states began the process of redetermining which residents are eligible for Medicaid coverage. As of early this August, KFF reports that nearly 4 million Medicaid enrollees have been disenrolled based on data reported from 41 states and the District of Columbia. Further, the U.S. Department of Health and Human Services (HHS) projects that 15 million people will lose Medicaid coverage once redeterminations are complete.

As health plans adjust to this new reality, proactive measures must be taken to offset the reduction in Medicaid enrollment. The below list describes effective medicaid redetermination strategies that health plans can adopt to ensure continued coverage for vulnerable populations while maintaining their commitment to providing accessible healthcare services.

1. Enhanced Communication and Outreach

Engage in targeted communication campaigns to educate existing and potential enrollees about the importance of maintaining Medicaid coverage. Leveraging modern technology, such as HealthEdge®’s Wellframe® digital engagement platform, to take an omni-channel approach to beneficiary communications, can improve connectivity and effectiveness. In these communications, payers should highlight the array of benefits Medicaid offers and emphasize how it positively impacts their health and financial well-being.

2. Streamlined Enrollment Processes

Simplify the enrollment and renewal processes to minimize administrative burdens on beneficiaries. Provide user-friendly online platforms that guide enrollees through the application process. Utilize technology, such as HealthEdge’s HealthRules® Payer core administrative processing system, to streamline enrollment and even pre-populate application forms and ease the documentation requirements, ensuring that the process remains as hassle-free as possible.

3. Collaboration with Community Organizations

Forge partnerships with community organizations, local clinics, and non-profits to increase awareness about Medicaid and support beneficiaries in navigating enrollment challenges. Community-based assistance can play a pivotal role in helping eligible individuals complete applications and renewals accurately. Payers who depend on HealthEdge’s GuidingCare modern care management platform are able to easily create and manage these partnerships with its extensive API services and more than 75+ pre-built integrations, including some with services for social determinants of health (SDOH).

4. Personalized Assistance

Offer personalized assistance through customer service representatives or enrollment specialists. Provide dedicated helplines to address enrollees’ questions and concerns, helping them navigate the complexities of the enrollment process.

5. Outreach to Lapsed Enrollees

Implement outreach strategies aimed at lapsed enrollees. Send reminder notifications about re-enrollment deadlines, emphasizing the potential risks of going without coverage and the ease of reinstating benefits. Once again, an omni-channel approach to beneficiary communications has the potential to drive higher levels of engagement.

6. Education on Benefits

Conduct education campaigns to inform beneficiaries about the range of benefits available through Medicaid. Highlight services such as preventive care, prescription medications, mental health support, and pediatric care. Demonstrating the value of these benefits can incentivize individuals to maintain their enrollment.

7. Data Analytics for Targeted Outreach

Utilize data analytics to identify trends and patterns in disenrollment. This data can guide the creation of targeted outreach efforts, focusing on areas or demographic groups that are experiencing higher disenrollment rates. For example, care management systems like GuidingCare – which have dynamic business intelligence capabilities – grant greater access to real-time data and analytics to make this process easy for care teams and business leaders.

The Medicaid disenrollment trend following the expiration of the Emergency Act presents a challenge that health plans must address with urgency and compassion. By implementing a combination of enhanced communication, simplified processes, community partnerships, personalized assistance, and targeted outreach efforts, health plans can offset the reduction in Medicaid enrollment. These strategies not only help maintain coverage for vulnerable populations but also underscore health plans’ commitment to ensuring access to quality healthcare services for all.

To learn more about how HealthEdge is helping health plans architect and execute their Medicaid redetermination strategies, visit www.healthedge.com.

Tools: From the Garage to Health Plan Administration

HealthRules Payer® gives plans the tools to succeed as the No Surprises Act and industry regulation evolves.

When it comes to home repair, there isn’t a lot of tool flexibility. A 1/8” Allen wrench cannot be substituted for a 3/16” Allen wrench and a Phillips head screwdriver won’t help with a flathead screw.  Every home renovation project seems to add another tool to your toolbox.

Digital tools, however, are a different story. Consider even a common tool like Microsoft Excel. While many of us use this software to perform basic calculations, we are barely scratching the surface of its capabilities. Excel is a powerhouse, and users who have taken the time to unlock more of the tool’s abilities are running advanced analytics and macros to feed critical business decisions.

From the health plan perspective, the constant evolution of health care practices, policies and communication standards can be much like the never-ending stream of repairs and renovations faced by homeowners. Health plans that invest wisely in their technology, however, can avoid an overflowing ‘toolbox’ and leverage the power and flexibility inherent in existing solutions – even as their operational and process renovation projects evolve.

The Challenge of Regulatory Evolution: The No Surprises Act

A particularly timely example is the No Surprises Act (NSA). This recent legislation requires significant revisions to the current administrative processes of most health plans, requiring plans to:

  • limit member cost-sharing responsibilities
  • manage out-of-network provider bills with federally regulated qualifying payment amounts
  • establish web-based provider directories and price comparison tools for healthcare services
  • prepare for anticipated guidelines around providing members with advanced explanations of benefits (AEOBs) detailing both pricing and individualized accumulator information

For some plans, this may feel like an overwhelming list of processes to develop and/or overhaul. But the tools for the job may already be at hand. For example, HealthRules Payer is a Core Administrative Processing Solution (CAPS) with existing technology to:

  • manage conditional payment structures
  • combine provider-level pricing information with individual level plan and accumulator data
  • generate accurate claims data after, or in advance of a scheduled service, without triggering a claims payment

These are the foundational functions underlying many of the NSA requirements, and many plans may not be aware of the functionality that already exists in their HealthRules Payer solution. For example, HealthRules Payer has Trial Claim feature, used to prospectively review various claims payment arrangements in a test environment. This same function can be used to populate price comparison data and accurately generate claims information in advance of scheduled services. In addition, HealthEdge is continuously adding new platform features.

HealthEdge is an industry-specific technology partner and is staffed by leaders passionate about technology and healthcare – including policy. The HealthEdge team is continually innovating, serving clients with new features and platform upgrades that occur automatically with no disruption to day-to-day operations. With the NSA top of mind across the industry, soon-to-be-released HealthRules Payer features will make it even easier for plans to succeed in the existing and evolving regulatory environment.

Building on Success

With a robust and flexible CAPS, payers can meet new regulatory requirements using existing and flexible features. And, much like complex home repair projects, it will pay off to have the right partner on board. HealthEdge clients have the benefit of our deep industry expertise and technical know-how at their fingertips, making it easy to nail regulatory compliance now and into the future.

What can HealthEdge do for you? See how in our No Surprises Act Data Sheet.

About HealthEdge

HealthEdge® is the health insurance industry’s first digital nervous system to provide automation and seamless connectivity between all parts of a payer’s administrative and clinical systems. HealthEdge provides modern, disruptive healthcare IT solutions that health insurers use to leverage new business models, improve outcomes, drastically reduce administrative costs, and connect everyone in the healthcare delivery cycle. Its next-generation enterprise solution suite is built on modern, patented technology and is delivered to customers via the HealthEdge Cloud or onsite deployment. In 2020, funds managed by Blackstone became the majority owner. HealthEdge and its portfolio of mission-critical technology assets for payers, including HealthRules Payer®, Source, GuidingCare® and Wellframe are collectively driving a digital transformation in healthcare. Follow HealthEdge on Twitter or LinkedIn.