HealthEdge® is driving digital transformation by streamlining automation and delivering real-time business and clinical insights that impact payers, providers, and patients. These innovations empower health plan leaders to stay on top of constantly shifting industry regulations and consumer expectations.

As a next-generation SaaS company, HealthEdge provides an integrated ecosystem of advanced solutions for core administration (HealthRules® Payer), payment integrity (Source), digital care management (GuidingCare®) and member experience (Wellframe). Our solutions enable health plans to leverage new business models, reduce costs, and improve clinical outcomes across member populations.

We firmly believe that maintaining product quality is a collective effort that extends beyond our quality engineers (QEs). HealthEdge’s Customer Satisfaction (CSAT) survey helps us measure the quality of the products we deliver to our customers—and how that affects their satisfaction. Used across industries as a key performance metric, CSAT score is based on a survey that asks customers how likely they are to recommend a product or service.

A culture of continuous improvement

Our approach to product development and innovation centers on delivering a high-quality digital solution that makes it easier for our customers to achieve their business goals. As an organization, HealthEdge is committed to continuous improvement, establishing quality standards and training to ensure consistent understanding and application of quality standards across the company.

The Quality Center of Excellence (QCoE) instills a culture of quality across scrum teams by adhering to industry standard testing practices and tooling. Some of the factors in this process include:

1.    Automation – first approach to product development and innovation

2.    Rigorous testing and quality checks

3.    Proactive issue identification

4.    Software development and feature planning

5.    Continuous integration and delivery

Automation-first approach to product development and innovation

HealthEdge utilizes an automation-first approach.

• Product developers ensure unit and integration testing is in place before code is merged (Test Driven Development).
• Quality engineers extend and create automated tests in close coordination with developers to ensure complete test coverage.

A robust automation suite ensures all functionality is automatically tested. This further allows additional manual testing efforts to focus on corner cases, sanity testing, and the user experience.

Rigorous testing and quality checks

HealthEdge products must pass several quality checks—including build, unit, integration, database verification, production transaction test (PTT), system integration test (SIT), static code analysis and performance testing—before reaching any customer environments.

Builds are triggered automatically for feature branches. Targeted integration tests including unit tests, integration, and static code analysis are run before any code is merged. Once these initial checks have passed, the code is merged. This triggers more complete and extensive sets of tests in downstream jobs. Multiple jobs, including Commit, DB verification and migration, Integration, PTT, SIT jobs, are run as part of continuous integration.

6. Once these jobs are successful, the distributions are made available to the Cloud Operations (Cloud Ops) team and for self-hosted customers as needed.

7. Cloud Ops and Customer Service Managers (CSMs) work with clients to schedule and deploy releases into SaaS (Software as a Service) lower environments where Post Deployment Verification (PDV) and Functional tests are run.

• Once all PDV and Functional tests are completed in one-to-many lower SaaS environments and in conjunction with testing from customers QA team, deployment is made to production and final sanity checks are performed

Proactive issue identification

The HealthEdge testing methodology is centered around proactively identifying issues, conducting thorough and detailed testing, bridging the gap between our team and customers, and consistently delivering the highest quality possible.

This structured approach aligns with industry standards, defining the precise automation of tests and their optimal execution environments. It serves to foster collaboration and understanding across the HealthEdge organization, emphasizing a commitment to comprehensive excellence and quality delivery.

The specific definitions are as follows:

• Unit Testing.
  • Validate individual components in isolation.
  • Ensure each unit functions correctly according to specifications.
• Integration Testing
  • Assess the interaction and collaboration between different components.
  • Identify and address issues related to the integration of modules.
• Functional Testing
  • Verify broader functionalities of the system.
  • Confirm that features work as intended from an end-user perspective.
• System Testing
• Examine the installation and verification of End-to-End system.
  • Upgrade time Quality Gate:
    • Identify database migration changes that cause long delays in the OLTP upgrade earlier and move the long-running scripts into either pre-migration or post-migration upgrade steps.
    • Detect and resolve any database migration errors discovered during upgrade testing.
  • Quality Criteria
    • Quality criteria ensure Functional Readiness, Interoperability & Compatibility, Serviceability, Performance & Scalability are validated for every release.
  • Production-like Testing
    • Creates a test environment that closely matches production for various customers.
    • Batch and UI Transactions are measured from version to version to detect any performance degradation.
    • PTT claims adjudication results are also compared against known results and detect any differences within a customer-like environment.
    • System Integration Testing on selected customer-like environments.
    • Specific feature testing on customer data.

Software development and feature planning

HealthEdge understands that quality is a driving force for software vendor selection. That’s why it is an integral consideration at every step of the software development lifecycle (SDLC). The following diagram highlights how we put this into practice—from feature planning through release.

Feature prioritization and planning

New features undergo a prioritization process, led by the product owner, before they are introduced for discussion within the scrum team. The product owner evaluates features based on their business value and the specific customer problems they address. Subsequently, the planning team engages in discussions to further refine the required functionality. As the requirements become better understood, the team then makes an estimation of how many story points this feature will take to complete .

Together, the team covers the following:

• Acceptance criteria
• Design Considerations
• Product Integrations
• Functional and non-functional testing (ex. performance & security)
• Story Point Estimation
• Documentation

Bug prioritization and planning

Bugs undergo a prioritization process, led by the product owner, before they are introduced for discussion within the scrum team. The bug fixing process allows issues to be scheduled and fixed on a predictable schedule.

Sprint planning

At HealthEdge we follow industry-standard, best agile practices, with sprint planning being an essential component. During sprint planning, features and bugs that are ready to be developed are added to the scrum board. The team then sets the assignments based on their historical completion rate (velocity).

• Feature Tickets: Features are discussed, broken down and tasks are created per assignee.
• Bug Fixes: Bugs are discussed, broken down and tasks are created per assignee.

8. QA only tickets: Where needed, performance and automation related stories are created and assigned to appropriate resources.

Feature test driven development

HealthEdge practices test driven development, where tests are written before the feature is coded. Subsequently, the code is written until the test passes. When the developer believes their feature is complete, a subset of tests is run to provide fast feedback and, if these tests pass, the code is merged automatically for downstream testing.

• Feature Grooming: Technical grooming sessions are conducted after business grooming is complete. This is a review of functional and technical aspects of the tickets in the backlog to verify they are complete and ready for development.
• Feature Development: Development team starts the design and architecture from the acceptance criteria listed by Product Owners in the ticket.
• Writing Unit & Integration Tests: Tests are written to validate key acceptance criteria for the feature.

9. Code Review: Once the above steps are complete, the code review will be done by subject matter experts (SMEs) to check that all standards and code coverage are followed.

Quality Assurance testing

Quality Engineers (QEs) write end-to-end tests and review them with the SMEs and Product Owners before execution. During execution, functional, regression, and impacted areas are covered as part of the testing. Additionally, QEs test specific tickets and features in customer-like environments when possible

• Research quality knowledge base: QEs investigate the internal quality knowledge base for existing functionality before preparing the test plan document.
• Test cases writing and review: QEs start writing the test cases based on acceptance criteria listed in the ticket. The test cases are reviewed with Product Owners and Development Leads. In some cases, test cases will also be reviewed with the client.
• Test environment setup: QEs set the test environment to the feature branch to test the above-mentioned test cases.
• Functional verification: During this phase, functional verification of test cases is completed, and any unexpected results will be raised.
• Writing integration tests: QEs contribute towards writing integrations test along with development team.
• Automation tests: QEs write automation scripts for all regression test scenarios.
• Customer data testing: QEs do a final round of testing in the customer–like environment to make sure the features work without any issues.
• Bug bash: Collaborative testing event on critical features that brings together QEs, Developers, Product Owners to “bash the product” to expose bugs.
• Customer demonstration: When the ticket is ready, a functional demo is given to internal stakeholders to make sure the acceptance criteria is covered.
• Functional demonstration: Demonstrations are also given to customers to further confirm expected requirements are met.

Continuous integration and delivery

Continuous Integration

At HealthEdge, we use a continuous integration workflow to ensure we create and test high-quality products quickly, securely, and efficiently. This workflow allows us to implement quality and security checks for every check-in. For quality checks, we run tests to provide rapid feedback. If there are test failures, developers are blocked from checking in additional changes until tests are passing again. For security checks, we leverage static code analysis and report any security vulnerabilities.

Types of Tests

• Unit Tests: Tests that focus on validating a very specific piece of code.
• Integration Tests: A comprehensive suite of product regression
• Database Verification Tests: Tests that verify new database schemas match upgraded database schemas.
• Production Transaction Tests: Production Transaction Tests use customer data and configuration to do A/B testing from one version to another and report any claim adjudication differences.
• System Integration Tests: System Integration Tests use customer data for specific test scenarios.
• Static Code Tests: Automated tools are used to identify code coverage, code violations, bug leakage, duplication on code, code smells, and vulnerabilities.
• End To End Tests (E2E): During System Testing, multiple products are installed together, and roundtrip tests are executed to confirm end to end processing.
• Database Migration Tests: Specific versions are selected based on expected paths a customer will take to ensure that the database migration scripts are successful.
• Performance Tests: A dedicated, production-grade system where key metrics are measured and compared from version to version to ensure that performance has either improved or not degraded.

Release Readiness

For every product release, HealthEdge Quality team follows a stringent Quality Criteria which comprises of below checks followed by a Go/No-Go meeting before giving a release sign off.

• Functional Readiness
• Interoperability & Compatibility
• Serviceability
• Performance & Scalability
• Stabilization Period Evaluation
• System Integration Testing (SIT)
• Data Migration Testing
• Real World Data Testing – Production Transaction Testing (PTT)
• Testing Improvements

Continuous Delivery

HealthEdge follows Continuous Delivery practices to deliver fully tested releases ready for customer environments through a general availability (GA) or a release candidate (RC) program. GA releases are available to all customers. The [VS31] Release Candidate (RC) program allows participating customers to test features and provide feedback within a defined 4-week window prior to GA.

Deployments in SaaS environments are scheduled into customers’ lower environments first and then, upon successful acceptance testing, releases are deployed into production. Post Deployment Verification (PDV) checks, User Acceptance Tests (UATs) and Functional Tests provide the necessary quality checks for each environment before code is promoted to the next environment. HealthEdge Customer Service Managers (CSM) and Cloud Operations (Cloud Ops) members work closely with clients and follow specific protocols for each deployment to ensure there is no negative impact to the customer experience.

Production monitoring

At HealthEdge, the Incident Management team uses AppDynamics to monitor hosted customers, and proactively views and escalates issues affecting performance. This allows us to maintain system availability, enhance the user experience, and resolve issues as soon as possible. Monitors are set up to continuously check metrics and alert the Incident Management team when critical shifts occur, allowing them to act quickly to resolve the issues.

In Summary

We truly believe that simplification and standardization have biggest impact on Quality. The above-mentioned practices lay a sturdy groundwork for our quality program. QCoE team ensures stringent quality criteria are met for releases and monitors Objectives and Key Results (OKRs) to gauge whether quality is trending in the right direction.

Authors: David Price, David Tauer, Karthikeyan Thirugnanam, Nischal Kondareddy, Rahul Jain, Sanchit Chavan

Recently, we met with health plan business and technology leaders to discuss trends in the healthcare industry, and the strategies they’re using to stay on top of consumer expectations and regulatory demands. Two key themes emerged: the pace of disruptive forces is rapidly increasing, which is, in turn, increasing the urgency for health plans to move to modern technology.

Some of the market forces shaping health plans’ priorities include:

1. Retail experiences shape consumer buying behaviors. Consumers expect a digital experience like online shopping and prefer healthcare services that provide virtual scheduling, services, and information access. They’re also looking for access to comprehensive information about healthcare quality and prices.
2. New entrants in healthcare bring innovation and enhanced services that elevate consumer expectations. New entrants in healthcare, including consumer-focused retailers, startups, and innovative care models, use digital technologies to improve the patient experience and fill gaps in the current medical infrastructure. They encourage innovation in care delivery and refine the consumer experience while bringing increased competition.
3. Growing participation in Medicare Advantage and individual marketplaces. Medicare Advantage enrollment increased steadily over the past two years, with over half of the eligible Medicare population opting for coverage. In 2022, the average MA beneficiary had access to 39 plans. The individual marketplaces have also seen insurers expanding their service areas, with the Accountable Care Act marketplace reporting over $16M members and an average of five insurers per state.
4. Regulation requirements evolve quickly, now with penalties. Healthcare regulations in the U.S. are constantly changing due to legislative mandates, administrative updates, and market trends. These changes make it challenging for health plans to keep up and result in increasing fines for non-compliance. While regulations aim to improve health coverage, consumer demands increase competition and require adaptation costs for health plans.
5. Availability of data and maturing interoperability standards. The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) set specific API requirements that help improve access to health records for patients, providers, and payers. This enhances data sharing, improves care quality, and increases competition among health plans. However, achieving interoperability is complex due to differences in data standard implementation in legacy platforms, which slows down progress toward compliance.

HealthEdge Accelerates the Journey to Becoming a Digital Payer and Achieving Transformational Outcomes

Our conversations with healthcare leaders focused on solutions and opportunities amid mounting industry disruption. Many payers are already unlocking transformational outcomes through HealthEdge solutions, anchored by its modern Core Administrative Processing System (CAPS), HealthRules® Payer.

Recently, CAPS modernization has surged to the forefront of funding priorities. In 2023, 59% of payers prioritize allocating resources to CAPS, a significant leap from the 17% reported in 20221. This shift underscores the urgency and strategic importance of enhancing consumer experiences and streamlining operations. Here are a few examples of how health plan leaders benefit from HealthEdge solutions to support their digital payer journeys:

1. Remaining agile, adaptable, and accurate in an ever-evolving regulatory landscape. HealthRules Payer addresses the rapidly evolving regulatory landscape by enabling health plans to adjust claims processing rules or modify payment protocols quickly and easily to ensure timely compliance. When regulations are updated retroactively, HealthRules Payer facilitates revisiting claims, ensuring compliance, and making necessary adjustments.

“HealthRules Payer helped our Medicaid group transition from a legacy platform where auto adjudication was significantly lower. Using the English-based configuration rules allows us to make significant changes relatively quickly and, as a result, improve auto adjudication and ultimately improve payment accuracy by eliminating the human factor in determining what needs to happen with a claim.”

Senior Vice President of Medicaid Operations at National Health Plan

 

2. Enabling automation and accuracy at the core of every process and workflow. The evolution of health insurance technology moved from initial integrated systems—which aimed for functionality consolidation but struggled with adaptability—to a best-of-breed approach that adopted specialized software, offering greater expertise and flexibility. However, this approach led to challenges integrating care management software and claims processing due to siloed functions, complex integration, and vendor fragmentation.

Today, health plans look to modern solutions that offer the efficiency of specialized applications and the seamless integration of a single vendor’s ecosystem, providing key advantages such as controlled integration. As the HealthEdge solution portfolio races toward integrated end-to-end solutions, barriers are coming down. This is allowing health plans to take full advantage of a best-of-breed approach while benefiting from a cohesive ecosystem. In addition to productized integrations between HealthEdge solutions—HealthRules Payer, HealthEdge Source™ payment integrity platform, GuidingCare® care management platform, and the Wellframe member experience platform—HealthEdge products themselves support an integrated end-to-end approach with numerous modules that are purpose-built.

“We outperformed our commercial platform within several months. Our Medicare business has been on a steady climb. When we launched it, we were expecting an auto adjudication rate of about 50%. But at the start, we actually hit 65% and very quickly got up to 82% or 83%, where we are right now. Our end users have grown, and we currently have over three million members on the platform.”

Executive Director, Product Management and Development, National Health Plan

3. Improving payer-provider collaboration on healthcare administrative spending and waste.  In 2020, health spending in the United States reached approximately 20% of the country’s gross domestic product. However, at least half of administrative spending is deemed wasteful. Collaborative efforts between payers and providers are essential to healthcare payment integrity and optimizing revenue cycles.

HealthEdge’s technology fosters collaboration and efficiency while addressing fraud and waste in healthcare. HealthRules Payer empowers health plans by streamlining administrative processes, enhancing efficiency, and ensuring accuracy. At the same time, Source revolutionizes claim payment through proactive business intelligence that prevents improper payments, saves time, and minimizes recovery efforts. With AI-enabled fraud detection, HealthEdge’s capabilities combat fraudulent claims, safeguard payer resources, and improve care outcomes.

“The health plan value proposition is losing, and the provider value proposition is being threatened by new entrants. Companies are either acquiring or incubating digitally focused healthcare start-ups or monetizing existing health plan platforms (analytics, claims processing, care management, sales, and marketing) by selling them as a service to other payers or into the emerging risk-bearing provider market. The demand for integrated end-to-end advanced automation across traditional payer and provider functions enables automation and accuracy at the core of every process and workflow.”

Leading Industry Analyst of Payer IT Strategies

4. Market expansion to beat the competition. The health insurance landscape in 2024 has significantly transformed, with new market expansion driving competition and growth. Providers have adapted to changing consumer preferences and the evolving competitive landscape. In this new consumer-focused era, health plans must appeal to diverse populations with unique needs, requiring flexibility and quick decision-making. With 62% of health plan leaders investing in digital transformation, modern systems such as HealthRules Payer are critical for supporting growth plans. To meet the demands of this new market paradigm, payers leverage modern technology in key areas like rapid benefit package creation, digital care management, and ASO arrangements.

“We use technology to solve the problems that you’ve had to solve for the past 30 years differently so you can go to market faster. So you can get to trends faster. So you can win new business faster.”

Alan Stein, Chief Product & Strategy Officer, HealthEdge

5. Managing and supporting Value-Based Care (VBC): The healthcare industry has shifted from a fee-for-service model to VBC, which aligns the interests of patients, providers, and payers by introducing financial incentives for healthcare providers to ensure patients stay healthy. As of 2023, 90% of CMS payments are linked to value, with 40% flowing through alternative payment models. However, fee-for-service arrangements persist. Many legacy systems cannot support this transformation, so the move to software solutions such as HealthRules Payer, which can support value-based care, is essential.

“Being a digital health plan for Highmark’s Medicaid segment means we are no longer in the era of calling our members between the hours of 9 and 5. They want to interact with us on their terms when they are available, whether through apps, portals, or web content. We have to meet the members where they want to be met. Highmark’s Medicaid members are looking for the Amazon experience. They want it simple.”

Senior Vice President of Medicaid Operations, National Health Plan

6. Exceeding member engagement expectations by providing a digital healthcare experience. Today’s healthcare consumers expect convenient and engaging experiences from their health plans. Therefore, payer leaders must adapt by offering self-service mobile tools and greater pricing transparency. Regulatory developments like the Transparency in Coverage Act and CMS’ Star Ratings changes emphasize the need for a strong focus on member experience.

In fact, two recent studies (the 2023 Consumer Satisfaction Survey of nearly 3,000 healthcare consumers and the 2024 HealthEdge Annual Market Report of 350+ health plan leaders) speak to this urgent need to focus on the member experience. Consumers expect health plans to leverage social determinants of health (SDOH) data to deliver more personalized services relative to their experiences. Customer service and self-service tools have emerged as top satisfaction enablers, along with a plan’s ability to adhere to members’ communication preferences.

“As a consumer, I focus on things that are important to me. When I am trying to order prescriptions or looking at lab results, what I would expect as a consumer is to have the right price, the right information about my quality of care, my claims, and my out-of-pocket expenses. Consumers feel the same way. It’s important that we give our members the same type of transformation to have access to a lot of good information, timely information, and quality information at their fingertips. We use HealthRules Payer, agile applications, and our network providers to make sure that the product is not only timely but also accurate.”

Vice President of Operations, Regional Health Plan

The Road to Becoming a Digital Payer

Digital transformation is a marathon, not a sprint. The critical steps in the change management and implementation process include:

• Defining Success: Clearly outline your goals and objectives.
• Plan and Prepare: Strategize and lay the groundwork.
• Design for the Future State: Create solutions that align with your vision.
• Build According to the Plan: Execute your strategy.
• Monitor KPIs: Track how you’re measuring against key performance indicators.
• Optimize and Customize: Continuously improve and adapt.

By automating business workflows and seamlessly exchanging data in real-time across the ecosystem, health plans deliver improved member experiences, increased quality, greater business transparency, ever-reducing transaction costs, and increased service levels. Through collaboration such as HealthEdge’s Leadership Forum, the company and health plan leaders are teaming up to ensure a path to success.

To learn more about how HealthEdge solutions can support an integrated end-to-end approach to your enterprise, visit www.healthedge.com.

 

Health plans are facing unprecedented challenges in accurately pricing claims due to a growing number of value-based payments and government regulatory requirements. As providers’ expectations for more efficient and accurate payments continue to rise, health plan leaders are turning to modern technology for help.  In the past, health plans used a traditional approach to solving these challenges. They relied on multiple business units and stacked third-party claims editing solutions—which resulted in a fractured approach that focused solely on measuring a percentage of recovered savings downstream. 

The future of payment integrity is shifting towards Payment Accountability®, an enterprise-wide approach that brings together different business units to increase focus on measuring cost avoidance instead of just recovery. Payment accountability emphasizes creating transparency to address root cause inaccuracies so that payers can pay claims accurately, quickly, and comprehensively the first time.  

Industry experts claim that this enterprise-wide approach can reduce medical expenses by 10% or more, with the potential for significant reductions in administrative expenses. An enterprise approach to claims adjudication can shift processes upstream, solve root-cause issues, increase accuracy, and reduce provider abrasion.  

The Source Approach to Payment Accountability 

HealthEdge Source™ (Source) was specifically designed and intentionally built to enable payers to allow health plans to insource more functionality, derive valuable analytics, and increase transparency and interoperability.  

The Source platform, to meet evolving market demands, is focused on the following core areas: 

• Real-time integration expansion: Seamless integrations with third party solutions that expand payment integrity and reimbursement offerings and reduce the administrative burden on clients using multiple vendors. 
• Continued content expansion: To deliver added automation, savings, and accuracy, including additional Medicaid, Medicare, Cost Containment, and other specialty edits and pricers. 
• Improved accuracy: By including additional validating datasets such as prescriptions, medical records, and others. 
• Adoption of AI/ML technologies: To automate and/or assist manual and tedious workflows. 
• Efficient workflow and best-in-class user experience: Through self-service tools like policy creation, implementation, and management. 
• Creating insights for data-driven decisions. 

But the team doesn’t stop there. Our product investment strategy includes a multi-year roadmap focused on enhancing the content, features, and technology to drive continuous improvement in the solutions we deliver. We’re currently piloting an AI-enabled chat bot that allows users to type questions in natural language regarding the Source edits, pricers, functionality, and other capabilities. This results in quick and accurate responses, freeing auditors or provider relations team members from scouring through multiple user guides, worksheets, and other materials. The chatbot can provide the necessary information in seconds.  

Additionally, Source is streamlining the process of managing configuration by utilizing APIs to create, manage, and publish edit changes to production. This process reduces the need for manual user intervention, allowing the payment integrity and configuration team members to focus on other critical business tasks. 

A Guiding Hand from the Payment Integrity Experts 

Source experts are available to participate in a Payment Integrity Health Check as part of the implementation process. This helps our team gain a better understanding of your current processes, data, and internal expertise so that we can work together efficiently and provide a solution that enhances your health plan’s strengths and aligns with the long-term payment integrity goals. Source experts will also work with our customers continually after go-live, to review data and identify areas that can add value to your payment integrity program. 

Post-implementation, Source maintains close partnerships with our clients. We gather feedback and input on our product roadmap in many ways, such as conducting 1:1 user research and design sessions with the product and engineering teams, monthly user groups, semi-annual customer advisory boards, regulatory steering committees, bi-annual virtual customer events, and annual client conferences.  

From Payment Integrity to Payment Accountability 

At Source, our solution aims to redefine payment integrity by shifting the industry from a black box to an open-book approach. Unlike traditional payment integrity solutions that often operate retrospectively and give limited intelligence to health plans, Source is designed to deliver transparency in editing solutions. Our goal is to empower payers with technology that enables them to gain control of their IT ecosystems, address root-cause issues, and reduce waste in the healthcare system.  

Source accomplishes this differentiation by providing the following unique features:  

• The ability to configure contract reimbursement terms, edit and price claims, and run analytics in a single call to Source. 
• Extensive editing and pricing content libraries that are out of the box and always up-to-date and accurate through our two-week update cycle. 
• Configurable and customizable edits to make pre-payment claim decisions based on a health plan’s intellectual property. 
• Real-time analytics to monitor utilization and financial impacts of edits prior to enabling their impact in the live adjudication workflow. 
• Claims pricing based on negotiated fee schedules, including CMS and Medicaid methodologies, to ensure edits and reimbursement are accurate prior to adjudicating the claim. 
• Continuous member claims history analysis by the Source team to recommend new edits that solve recurring post-payment issues.  
• Integrated third-party content within the solution to improve accuracy, promote higher and faster automation, simplify workflows and vendor contracting, and keep all data in a single location. 

To learn more about how Source can help your organization successfully make the shift to payment accountability, visit the Source webpage.  

Regulatory compliance and transparency are more than healthcare industry buzzwords: they’re key areas of focus for regulatory agencies and consumers. Staying compliant with shifting state and federal regulations can be a challenge, requiring efficient access to the most up-to-date information available. And pricing transparency has become an essential way for health plan members to make informed care decisions.

At HealthEdge®, we are committed to supporting our customers in achieving and maintaining compliance. Our mission is to empower your organization to become a digital payer, achieving key business goals—like improving the member experience and reducing costs—by leveraging innovative digital technology.

Introducing HealthRules® Machine Readable Files Suite

The HealthRules® Machine Readable Files Suite 3.x stands as a testament to our commitment to innovation, compliance, and transparency in the healthcare industry. Designed to address the requirements of the Transparency in Coverage final rule, our pioneering software solution offers a robust framework for generating machine readable files (MRFs) that detail negotiated rates for in-network providers and allowed amounts for out-of-network providers.

This initiative is not merely about complying with regulations; it’s about ushering in a new era of clarity and trust between health plans and their members.

3 Key benefits of using Machine Readable Files

Real-Time Reporting

Leveraging the power of cloud technology, our solution suite allows health plans to their own reports in real-time, ensuring your team has consistent access to the most up-to-date information.

Intuitive User Interface

The platform’s user interface was designed to make compliance as straightforward as possible and significantly reduce the complexity of generating machine readable files through the HealthRules solution.

Native Integration

As the only machine-readable file generation tool built natively into a Core Administration Platform Solution (CAPS), our MRF suite seamlessly integrates into your existing systems—minimizing disruptions and enhancing operational efficiency.

Key goals of offering an integrated MRF suite within the HealthRules solution are to clarify compliance needs, enhance transparency, and improve the member experience for our health plan customers. This innovative feature is just one representation of our dedication to not just meeting the needs of payers today but shaping the future of healthcare. Partnering with HealthRules can help your team work more efficiently to transform industry challenges and demands into opportunities.

Are you looking for more information on our advanced Core Administrative Processing System (CAPS) and how it can integrate with your health plan’s existing platforms? Visit the HealthRules® Solution Suite.