Value-Based Contracting Success Demands Modern CAPS

For all the talk about value-based care models, few payers have actually discovered the secret to successfully deploying these types of arrangements with a significant portion of their provider network partners.

However, several payers, including Independent Health, a New York-based not-for-profit health plan with 387,000 members that leverages HealthRules® Payer as its core administrative processing system (CAPS), appear to have discovered the secrets to success. In fact, Independent Health now has 98% of its primary care practice members in full capitation contracts, with solid alignment of goals with its provider network.

So, what’s the secret?

According to Dave Mika, Vice President, Enterprise Core System Operations at Independent Health, it comes down to the flexibility and power of technology.

“When we give providers data that shows how they are performing relative to required or recommended services for members within various demographics and disease states, we’re doing so with the ability to drill down to the individual patient level.

When we understand where a single patient stands relative to utilization of inpatient and outpatient services, we can offer clarity into everything from who needs to be more active in managing their own care to how cost calculators and digital health tools can be better utilized – by providers and their patients.”

The Role of HealthRules Payer

With HealthRules Payer, health plans can quickly address market opportunities and stay in front of competition. All this while achieving high levels of customer satisfaction and transparency by providing accurate, real-time information to everyone involved in the care continuum. HealthRules Payer has also significantly lowered administrative costs for our customers by simultaneously automating critical manual business processes, resulting in an enhanced bottom line.

“HealthEdge allows us to achieve speed to market with our products in the rapidly changing healthcare environment, with the capability to configure and implement products quickly and on the fly,” says Mika. “The solution also gives us the capability to drive alternative reimbursement models for our customers, now and in the future, as evolving needs – and regulations – dictate.”

With results like this, it’s no wonder that HealthRules Payer has been named “Best in KLAS” by KLAS Research for Claims & Administration Platforms for the past two years.

Finding the Value in Value-Based Care Contracts

As the healthcare industry continues to undergo transformation away from fee-for-service models to value-based payment models, digital health plans have a unique opportunity make this transition highly successfully for all stakeholders: payers, providers, and patients. They can do so by leveraging the advanced automation capabilities and real-time data insights that are readily available in modern CAPS like HealthRules Payer. With the right CAPS in place, the value of value-based contracts becomes crystal clear:

  • Cost Control: Value-based care models can help health plans control costs over the long term by focusing on preventive care and early intervention
  • Improved Member Health: By promoting healthier lifestyles and proactive healthcare management, value-based care can lead to improved health outcomes among members. This not only enhances members satisfaction but also reduces the financial burden on payers.
  • Competitive Advantage: Payers that embrace value-based care early gain a competitive edge. They can attract providers and members who appreciate the benefits of this approach.

By harnessing the power of automation and aligning incentives with value-based care, health insurance companies can play a pivotal role in transforming the way healthcare is delivered and financed, ultimately benefiting both patients and the industry as a whole.

To learn more about how HealthRules Payer helped Independent Health, read the full case study today, and reach out to see how HealthEdge can help your organization embrace value-based care contracting by visiting

Behind the Scenes: HealthEdge® Customer Operations Team

With hundreds of health plans depending on HealthEdge’s HealthRules® Payer core administrative processing system (CAPS) every day, members of the Customer Operations team have their work cut out for them.

How HealthEdge Customer Operations Team Supports Health Plans

This team is comprised of four different groups that work cohesively together to ensure customers have the best possible experience:

  1. The infrastructure operations team ensures the company’s private cloud, networks, and operational spaces are secure and available.
  2. The technical support services team manages the response to all inbound customer product inquiries and support tickets by coordinating with customers and product team members to facilitate fast responses and resolutions to any issues that may arise.
  3. The customer success management team is ultimately responsible for understanding the current and future needs of HealthRules Payer customers and prioritizing the work for the rest of the organization. They are the customer “captains” who understand each customer end-to-end from an operations perspective.
  4. The business intelligence team works with the data to enable the rest of the team and customers to gain actionable insights so they can proactively address opportunities for improvement.

Although much of this work sounds technical, the “north star” for this group of hard-working, seasoned professionals is all about helping HealthEdge customers give their members access to the healthcare benefits and services they need when they need them.

The internal tagline of being “Customer Obsessed” is ever-present among all team members who constantly strive to learn more about their customers’ business to provide a more personalized experience.

Equally important is the team leaders’ focus on humanizing the healthcare technology experience for employees. The work is more than just solving a technical problem. It’s about making sure that the eligibility file goes through correctly so that the mother gets access to the medications her sick child needs or the grandmother can get the medical procedure she needs to experience the joys of playing with her grandchild.

These scenarios remind the HealthRules Payer customer operations team members of their purpose: to always do what is best and suitable for their customers so their customers, in turn, can do what is best and ideal for their members.

The Future is Bright

As the HealthEdge customer community continues to expand, the customer operations leadership team is also looking to improve the lives and experiences of their employees. By establishing more standardized processes and proactively addressing the demand for unplanned work items, they are giving employees more time to focus on discovering innovative ways to support the growing customer base – all for the betterment of HealthEdge customers.

In addition, the team is working toward more standardized processes and a more integrated experience for customers of multiple HealthEdge solutions, including GuidingCare® for care management, Source for payment integrity, and Wellframe® for digital member engagement. As more integration points across these solutions become available, customers will have a more seamless experience working with HealthEdge.

Finally, as the organization encourages and enables health plans to become digital payers, HealthEdge is adopting more digital-centric capabilities that automate repetitive, manual tasks and improve productivity. Modern technologies that proactively monitor and adjust server capacity are also being implemented to benefit team members and customers alike.

The HealthEdge Customer Operations team is more than just a group of engineers and technical resources who support clients. They are members of a dedicated group focused on making a difference in people’s lives by enabling high-quality healthcare at the right time and the right place.

To learn more about the HealthEdge customer experience, visit

Future-proof Your Claims Editing Solution

As the U.S. healthcare system is undergoing rapid transformation, many health plans are looking to modernize their core administrative processing systems (CAPS). In fact, according to the 2023 Gartner® How U.S. Healthcare Payer CIOs Can Future-Proof Claims Editing report1, “Increasing member expectations and operational demands are pushing payer CIOs to modernize their core administration systems.” A recent Gartner survey shows that:

  • 60% of respondents are moving their core administration system from on-premises to the cloud.
  • 34% are consolidating to a common platform.
  • 26% are replacing proprietary solutions with commercial off-the-shelf (COTS) solutions.
  • 17% are re-platforming to a modern architecture.”

However, the report also warns that the business goals associated with transitioning to more real-time claims processing are in jeopardy if CIOs do not simultaneously consider the capabilities of their claims editing solutions.

“With the modernization of claims administrative processing systems (CAPS), new business requirements and a heightened focus on real-time operations and interoperability, you need to reevaluate your claims editor’s performance.”1

This report provides detailed questions CIOs should use to evaluate claims editing solutions and ensure they can be prepared for the future. The Source team offers these answers in response to the Gartner proposed evaluation criteria.

Modern Claims Editing Solution

Core Capabilities of Source Editing Solution

  • Supports all lines of business in a single platform,
  • Seamlessly integrates with virtually every major CAP system and offers complete interoperability with its sister product, HealthRules Payer (Payer-Source).
  • Cloud-based solution means all maintenance and support costs are included in the monthly subscription fee, and all pricing and policy updates are proactively applied every two weeks, reducing IT and administrative burdens.
  • Clients average a 30+% increase in first-pass adjudications.
  • Clients find cost savings through many different edits, including validation, reimbursement, payment and billing guidelines, and medical necessity.
  • Supports 39 months of claims history to help identify improper payments.
  • Clients can easily customize any existing edit in Source libraries or build a custom edit in minutes.
  • And much more!

Advanced Capabilities of Source Editing Solution to Support Future-Proof Initiatives

  • By design, Source includes a real-time Analytics module that models claims after the editing, pricing, and audit processes occur for our client’s core claims adjudication. Source real-time analytics are run continuously and automatically.
  • Source features a centralized advanced audit trail with rich data and reporting to provide complete transparency for audit and provider relations teams.
  • Source allows users to set an edit to Monitor Mode to review its impact before it is put into production.
  • All new edits/policies are delivered to the non-production environment where they can be tested, promoted to production in the “off” mode, and then instantaneously turned on through the system and published by the end user as needed for their required timelines.
  • And much more!

Claims editing solutions’ critical role in enabling a real-time claims processing environment cannot be overstated. But even if organizations are not undergoing massive system transformations, the Source Editing solution can deliver powerful savings without changing anything in the existing editing stack.

For example, in recent data studies conducted by the Source team, millions of dollars in savings were identified when Source was placed in front of third-party editing solutions.

  • 7M Medicare Advantage claims spend $648M, resulting in a $11.1M savings opportunity for a mid-size regional health plan
  • 1M Medicaid claims spend $571M, resulting in a $9.1M savings opportunity for a large regional health plan
  • 1M Medicaid and Dual Eligible claims spend $790M, resulting in a $8.7M savings opportunity for a national health plan

To read more about the Gartner recommendations on future-proofing your claims editing, click here for complimentary access to this report.

1 Source: Gartner, How U.S. Healthcare Payer CIOs Can Future-Proof Claims Editing. Austynn Eubank, 20 April 2023. GARTNER is a registered trademark and service mark of Gartner, Inc. or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved. Gartner does not endorse any vendor, product, or service depicted in its research publications and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner’s research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

Next-Generation Core Administrative Processing Solutions: A Top Priority for Many Payers

The healthcare landscape is in a constant state of evolution, with technology innovations serving as a guiding force for payers striving for efficiency, accuracy, and enhanced operations. In this journey, the Gartner Hype Cycle for U.S. Healthcare Payers 20231 report delivers insight into the maturity levels and adoption rates of 28 different innovations. In this report, one of the innovation mentioned is next-generation core administrative processing solutions (CAPS).

For the 13th consecutive year, HealthEdge, has been recognized as a Sample Vendor in the report, under the category next-generation core administrative processing solutions (CAPS).

We believe this recognition underscores HealthEdge’s commitment to innovation, excellence, and its unwavering pursuit of transformative solutions.

The Power of HealthRules Payer

HealthRules Payer is more than just a solution; it’s a catalyst for transformation in the healthcare payer domain. Its unparalleled flexibility empowers health plans to embrace new business models, adapt to changing regulations, and expand into new markets seamlessly.

Elevating Business Impact

Next-generation CAPS like HealthRules Payer can have substantial influence across multiple facets of the healthcare insurance industry, including:

  • Efficiency Enhancement: HealthRules Payer reduces transaction costs, improves access to real-time data, and streamlines operations, ushering in a new era of operational efficiency.
  • Modern Architecture: HealthRules Payer supports real-time data and transaction processing through its modern architecture, bolstering the agility and responsiveness of health plans.
  • Adapting to Change: With HealthRules Payer, health plans can now embrace new business models, such as value-based payment arrangements, and capitalize on cloud technology’s economies of scale and security.
  • Simplified Integration: HealthRules Payer supports multiple interfaces that are configurable and user-friendly to ease the integration process with both payer and third-party applications.
  • Reducing IT Dependence: HealthRules Payer’s cloud-based infrastructure and advanced automation minimizes the reliance on IT resources, resulting in increased autonomy and operational efficiency.


In the report, Gartner analysts provide user recommendations to payers about considerations they should make when selecting a next-generation CAPS. These recommendations include:

  • Prioritize strategic versus commodity CAPS capabilities to evaluate investment decisions. The former include FHIR enablement, real-time processing or effective-now configuration to accommodate scenarios such as the Dobbs decision’s regulatory fragmentation.
  • Analyze whether licensed applications, SaaS or business process outsourcing (BPO and BPaaS) solutions for each CAPS capability are best.
  • Evaluate new versions of CAPS as greenfield. Old CAPS versions are not representative. However, weigh prior experience with vendor delivery heavily.
  • Search for modular CAPS components that allow a partial or phased implementation and prioritize solutions that offer configurable interfaces.
  • Validate the vendor’s primary market. Some CAPS have their most significant footprint in a segment like provider-led health plans, third-party administrators or dental. Consider whether influencing a vendor’s product roadmap outweighs the early adopter risk.
  • Address the diminishing resource pool available to support legacy systems. Updated technologies will entice job candidates.

A Brighter Future

To us, HealthEdge’s recognition in the Gartner Hype Cycle for U.S. Healthcare Payers, 2023 under the category next-generation CAPS reflects its dedication to shaping the future of healthcare payer operations. As the industry marches towards next-generation CAPS adoption, HealthRules Payer will undoubtedly continue to serve as a benchmark for excellence, innovation, and transformative solutions in the health insurance industry.

To learn more about how HealthRules Payer can help your organization adopt a next-generation CAPS, visit

1 Source: Gartner, Hype Cycle for U.S. Healthcare Payers, 2023. Mandi Bishop, Connie Salgy, Austynn Eubank, 10 July 2023. GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally, HYPE CYCLE is a registered trademark of Gartner, Inc. and/or its affiliates and are used herein with permission. All rights reserved.. Gartner does not endorse any vendor, product, or service depicted in its research publications and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner’s research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

Claims Analytics for Health Plans: A Guide for CFO’s

health plan analytics | healthedge

Health plans face financial decisions every day that impact their bottom line. What terms will make a new provider contract more beneficial? How should a new payment policy be implemented for Medicare Advantage or Commercial business? To answer these questions well, health plans need solutions that enable them to overcome the limitations of their existing technology and leverage claims analytics insights for business decisions and negotiations.

But some health plans run on multiple core claims systems that use several disparate pricing, editing, and payment integrity point solutions to try to pay claims accurately. Claims administrators spend hours looking at data from disparate sources and compiling information.

Historically, claims analytics can be disjointed. A payer may need to export claims from multiple sources, then process them in multiple batches using a separate solution to get the analytical data they need. This back-and-forth process produces old information that cannot be relied on for accurate analysis. It causes delays for everyone involved, and if decision-makers do not have quality information in a timely manner, there is less confidence for those in medical management and contracting when they make crucial decisions for a health plan’s financial success.

How Claims Analytics Can Help CFOs

It is time for health plans to invest in integrated systems that allow data, and therefore analytics, to land in one centralized place. There is an opportunity to simplify the entire payment ecosystem and seamlessly connect to multiple claims systems and third-party solutions. Rather than connecting individually with different systems for Medicare and Medicaid pricing or specialty systems like genetic testing, the data should be available in a single location.

To gain a competitive edge in the evolving health care market, health plan CFOs need access to real-time claims analytics data and the ability to view and analyze all claims as they are processed. Imagine that you could look at scenarios quickly with accurate data and evaluate “what if” modeling to discover better ways to do business. This information can transform a business, delivering immense value — like predicting the potential savings from structuring a contract differently.

Financial decisionmakers need a modeling tool that can take claims from one provider and run those claims through another provider’s contract to see how they would have priced differently. Imagine heading to the negotiation table armed with this data. A simple payment term could hold up an agreement – on the surface, one might assume this would deliver a big financial hit, but what if the data said otherwise? What if the data showed that there would not be a significant impact? Then the payer and provider could quickly agree to a contract that satisfies all parties without a contentious debate.

With the right technology and business intelligence tools, payers can model and forecast different pricing scenarios. They can make customizations and edits to see how different pricing rules calculate down to the cent. Reliable, real-time, integrated analytics unlock new possibilities and enable complete business transformation.

How Core Configuration Can Reduce a Health Plans PMPM

PMPM Healthcare | Healthedge

How many resources does it take to run the core configuration of your enterprise?  What type of custom external tools are required to build and maintain the configuration?  What are the financial impacts associated between the complexity of the configuration in a system and the cost per member per month (PMPM) in healthcare or total cost of ownership (TCO) figures?

As we evolve into the next generation of core systems, these types of questions top the list for the potential vendors looking to modernize a core platform for a prospective health plan.  One thing is clear, as we continue forward in the market, the time of the core systems that require high administration costs in terms of the number of resources and custom solutions it takes to configure and maintain is coming to an end.

Currently, the savviest health plans in the market are shifting from the predominant solutions for configuring the system with offshore-based services and/or custom-developed utilities and toolsets to ones focused on out-of-the-box automation enabled by best-in-class configuration.

Can a system be both flexible and provide streamlined next-generation configuration capabilities?  Putting myself in the shoes of any given health plan in the market today for a core modernization and the surrounding ecosystem, one key focus would be on the core configuration and the level of automation that the system brings.

Is the system’s configuration overly complex, disparate, and requires custom external tools to build and maintain?  Can my current staff pick up the complexity of all the aspects of a system that need to be considered when implementing and maintaining my business?  Consequently, what does that ramp-up time look like?  The steeper the learning curve, the greater the chance staff will likely resist adopting the new technology, and the project suffers or fails outright.

In my career, I have seen far too many health plans that implemented their solutions 20 years ago and are faced with complete re-implementation of the existing platform.  Their current systems do not possess the flexibility nor the automation to provide the ability to implement enhancements to optimize existing configuration over time. The level of effort and analysis is simply too high when maintaining production states are the operational primary focus.

By addressing these considerations and embracing modernization, health plans can navigate the evolving landscape while optimizing PMPM healthcare costs and achieving efficient configuration management.