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The healthcare landscape is fiercely competitive, with both established payers and innovative disruptors vying to capture market share. Yet, in this rush, a crucial factor often gets overlooked: member engagement.

In our five-part blog series, HealthEdge Source™ Horizons, we demonstrate how our payment integrity solution empowers health plans to achieve compliance, expand market reach, and manage value-based care. In this blog, we will dive into how health plans can enhance payment accuracy and transparency, the cornerstones of member trust and engagement.

Read the entire series at the links below:

• Ensure Regulatory Compliance and Cost Transparency
• Improve Payment Accuracy and Efficiency with Advanced Automation
• How Payment Integrity Innovation Helps Expand New Business Opportunities
• Simplifying Value-Based Care Contracts & Reimbursements
• Increase Member Engagement & Build Trust with Cost Transparency

Why member engagement matters

Member engagement goes beyond profit; it directly impacts health outcomes. Engaged members take a more active role in their healthcare, leading to better health outcomes and lower long-term costs for your plan.  However, factors such as inaccurate payments, lack of transparency, and delays can erode trust and disengage members.

Our recent webinar, “Empowering Modern Health Care Consumers,” highlights the importance of member satisfaction. We emphasize the critical role of payment accuracy and transparency in building member engagement. By offering clear explanations of benefits, coverage details, and out-of-pocket expenses, you enable members to make well-informed healthcare decisions. This not only reduces anxiety about surprise bills but also fosters collaboration, leading to a stronger partnership and better health outcomes.

Increase health plan efficiency to improve member relationships and engagement

Reduce clinician burnout from administrative overload

Clinicians are drowning in administrative tasks, leading to burnout and less time spent with patients. Every minute spent on paperwork steals valuable time from direct patient care, hindering the ability to deliver personalized and attentive care.

HealthEdge Source alleviates this burden for clinicians, creating a ripple effect of positive outcomes. Our solution automates essential claims and payment processes, freeing up time for clinical decision-making. By streamlining routine tasks and simplifying complex processes, we eliminate the need for time-consuming manual reviews. This allows clinicians to refocus their energy on what matters most—delivering high-quality patient care.

With more time dedicated to patients, improved communication and a more positive patient experience naturally follow. And reduced clinician burnout leads to lower turnover rates, saving on costly recruitment and training expenses.

Offer pricing transparency and easy access to information for members

Transparency in healthcare costs and coverage is a top priority for both your members and regulatory agencies including the Centers for Medicare and Medicaid Services. Empowering your members with clear, accurate information is key to building trust and driving engagement.

Here’s how we help health plans achieve transparency:

• Eliminate Surprise Billing: Our cloud-based system ensures accurate estimates upfront, preventing surprise bills and fostering trust from the beginning.
• Real-Time Information Access: With 24/7 data access, your plan or any providers can proactively communicate coverage details and potential cost-saving options directly to members.

Cloud-based data delivery ensures that your plan has the most up-to-date and accurate content and regulatory updates, eliminating confusion and errors. Furthermore, cloud-based processing reduces wait times by streamlining claims and inquiries. Most importantly, the cloud provides a secure and scalable environment to protect member data and ensure smooth system performance even during peak demand.

Happy providers = Happy members

Building strong provider relationships is crucial for a health plan’s success. Happy providers lead to happy members, yielding better health outcomes and reducing long-term costs. Designed for true Payment Accountability, HealthEdge Source not only streamlines internal operations but also allows you to nurture these crucial relationships.

Traditional claim processing frustrates providers with errors and inconsistencies. Our Platform Access technology solves this issue by streamlining internal operations, ensuring accuracy, transparency, and comprehensive claims payments upstream in the adjudication process. Now you can transform your business, organize your data in a single place, address root cause issues, and pay claims right the first time.

With key features including:

• Editing Library with History: Access historical data, parameters, and exceptions for edits, allowing for informed decision-making.
• Custom Edit Builder: Tailor specific edits to meet your unique payment arrangements and cost-saving goals.
• Real-Time Analytics: Gain valuable insights into performance metrics and the impact of edits on your claims process.
• Monitor Mode: Test the impact of edits on your system before implementation, minimizing disruptions.
• Comprehensive Audit Trail: Track and view claim-level edit details for complete transparency.

Our platform seamlessly integrates with your existing systems, eliminating the need for disruptive rip-and-replace solutions. Regular updates ensure your system stays current, while the scalable design allows you to adapt to future needs.

By providing a single, streamlined platform for accurate and efficient claims processing, we can help you to build stronger relationships with your providers. This translates to a win-win for everyone: happier providers delivering better care, a more satisfied member base, and a healthier bottom line for your health plan.

Ready to learn more?

Explore our blog series, “HealthEdge Source™ Horizons,” to discover how our solution can help you achieve compliance, expand market reach, and manage value-based care.

Want to learn more about how your health plan can access valuable analytics while increasing payment accuracy and transparency? Read our blog, “The Shift to Payment Accountability®: An Enterprise Approach to Healthcare Payment Integrity.”

Has your health plan ever processed claims for the month, only to be hit with a new regulation or a provider contract update? This frustrating cycle of retroactive changes is a consistent pain point for healthcare payers, causing delays, errors, and wasted time. Don’t make your team backtrack, re-evaluate claims, and scramble to adjust payments. HealthEdge Source™ offers a retroactive change management tool that ensures all adjustments are accurately tracked and implemented.

Leveraging Retroactive Change Management to Improve Payment Accuracy

Retroactive change management refers to the process of adjusting previously completed healthcare claims transactions to correct errors or reflect new information. For healthcare payers, this is essential for maintaining accuracy and compliance. HealthEdge Source solution incorporates retroactive change capabilities, helping healthcare payers to manage discrepancies and avoid financial losses.

The Costs of Making Retroactive Payment Changes

Throughout 2024 alone, experts anticipate over 600 changes to fee schedules, edits, and pricing logic. Updates to guidelines and regulations come from various sources, including:

• Regulatory bodies (e.g., Center for Medicare and Medicaid Services (CMS) updates, Medicaid rate changes)
• Network contracts (e.g., modifications to provider agreements or payment policies)
• Internal configurations (e.g., changes in fee schedules or other system configurations)

Retroactive changes can impact a health plan’s bottom line in a few ways. Delays in enacting these changes may result in overpayments to providers, leading to financial losses. Conversely, underpayments can strain relationships with providers and pose administrative burdens for your team. Both overpayments and underpayments can damage your health plan’s reputation and expose you to potential regulatory penalties.

Implementing a solution with retroactive change management capabilities can help payers improve:

1. Accuracy: Ensures all payment adjustments are accurate and compliant.
2. Efficiency: Streamlines the process of managing retroactive changes.
3. Compliance: Keeps up with regulatory requirements by applying necessary changes retroactively.

Shift from a Reactive to Proactive Strategy

Manually managing retroactive changes is a time-consuming and error-prone process that diverts valuable resources away from other important tasks. The volume and complexity of retroactive changes can be overwhelming for staff. But health plans can mitigate manual roadblocks with a proactive approach to reimbursement management.

Here at HealthEdge, we understand the financial burden retroactive changes create. Our solution aims to reduce overpayments and underpayments and ensure claims are paid correctly—the first time. With our Retroactive Change Manager (RCM) tool, your team can spend less time finding, chasing, and collecting what’s already gone out the door.

HealthEdge Source™ Retroactive Change Manager

Last year, HealthEdge Source launched the first phase of the Retroactive Change Manager. The tool helps healthcare payers automate core tasks, such as flagging claims that will be automatically eligible for reconciliation upon delivery. Scheduled reviews save valuable time that would have been spent on manual searching.

Additionally, RCM users receive regular variance reports that detail all the claims impacted by retroactive changes, along with the exact adjustments needed. This comprehensive approach gives health plans a clear picture of financial exposure and eliminates guesswork. This initial rollout laid the foundation for a more proactive approach to managing reimbursements, saving time and money, and avoiding potential payment issues.

Latest Enhancements to the Retroactive Change Manager

The latest enhancements to the Retroactive Change Manager go beyond regulatory updates. They empower health plans with a range of features designed to streamline workflows and maximize financial security.

With new targeted analyses and streamlined operations, healthcare payers can:

• View configuration updates within specific timeframes to focus analysis on impacted claims related to provider types or edits.
• Receive timely email notifications and enhanced claim summary reports for a clear understanding of adjustments needed.
• Enhance the user experience with increased performance and stability for smoother operations.

Leveraging the RCM directly translates to a healthier financial bottom line for health plans in three primary ways. First, it automatically recovers overpayments that might have been missed before. Second, faster and more accurate payments to providers lead to stronger relationships and fewer disputes—which can save time and administrative costs. Finally, the RCM keeps claims data organized and readily available, ensuring health plans are always audit-ready. This peace of mind allows payers to focus on strategic initiatives that drive organizational growth.

By shifting from a reactive to a proactive claims management approach, health plans can leverage a single system to identify and address retroactive changes. Imagine complete data sets analyzed automatically, underpayments identified and addressed proactively, and overpayments recovered internally. This not only saves time and money, but also fosters stronger provider relationships and ensures compliance. With fully incorporated industry changes and provider configurations healthcare payers can finally move from reactive adjustments to proactive control.

For more information about how your health plan can leverage retroactive change management, watch our on-demand webinar, “Optimizing Retroactive Configuration Changes”.

Healthcare payer claims operations teams often face additional work and processing when working with multiple claims or data systems. Scattered processes and data lead to waste, inaccuracies, and friction within a health plan’s IT ecosystem that translates to the payer-provider relationship. 

Gain a Competitive Edge by Consolidating Your In-Network and Out-of-Network Pricing Management

Specifically designed to extend to third-party best-of-breed content solutions, HealthEdge Source™ uniquely addresses these challenges. With this integration, payers can seamlessly incorporate FAIR Health data into their workflow to streamline in-network and out-of-network pricing for Medicare parts A and B, or any line of business that utilizes FAIR Health. 

FAIR Health is a renowned third-party vendor that collects data for pricing management. It uses pricing benchmarks based on the region and zip code, as well as national averages, providing just the kind of data needed to streamline your operations and cut out wasteful processes.  

The Value of Integrating FAIR Health’s Data with HealthEdge Source

Utilizing FAIR Health’s robust data offerings and bringing them to Source is a significant step in providing our clients with more value. It enables Source members to deliver unique insights and analytics that could transform your claims operations – making them more efficient and cost-effective. 

The FAIR Health integration will not only resolve common issues you face but also potentially introduce UI changes based on client requests. This can include data reference views and new pricers connected to the FAIR Health fee schedule. The latter is similar to wrapper pricers and other third-party pricers presently in Source.  

Moreover, users can expect potential enhancements in configurations, unlocking even greater capacity for your operations. Our development teams are working behind the scenes on utilizing a data pipeline for file transformation to ensure this integration provides maximum advantages for your health plan operations. 

The End Goal: Smoother Workflow and Seamless Integration

Ultimately, the end goal is to facilitate a smoother workflow and a more seamless integration between multiple claims or data systems. The integration of FAIR Health content into HealthEdge Source opens up a myriad of opportunities for healthcare payer claims operations teams to streamline their processes and work more efficiently. 

Implementing value-based care has become crucial for many payers looking to enhance patient outcomes while managing costs. HealthEdge Source™ makes it easier for health plans to understand the value-based care landscape, streamline payments, and reduce inaccuracies.

Our five-part blog series, HealthEdge Source™ Horizons, highlights how our payment integrity solution helps healthcare payers adapt and scale to meet their organizational goals.

Read the entire series at the links below:

• Ensure Regulatory Compliance and Cost Transparency
• Improve Payment Accuracy and Efficiency with Advanced Automation
• How Payment Integrity Innovation Helps Expand New Business Opportunities
• Simplifying Value-Based Care Contracts & Reimbursements
• Member Engagement

The shift to value-based care (VBC) raises the bar for care standards, establishing a healthcare system where quality and value take precedence. This approach aims to improve patient experiences, health outcomes, and cost efficiency while promoting preventive care.

However, navigating the complexities of a value-based care delivery system presents challenges for health plans.

Simplifying Value-Based Care with Payment Integrity Solutions

Modern payment integrity solutions offer the tools health plans need to thrive in the VBC environment. These solutions go beyond error prevention to ensure accurate reimbursements, optimize resource allocation, and strengthen relationships with providers.

These solutions enable health plans to extend their existing resources and analyze key historical data and coding patterns to identify wasteful practices, such as avoidable readmissions. Early detection enables payers to implement proactive interventions and collaborate with providers to reduce costs and improve patient outcomes through high-quality care delivery.

HealthEdge Source: An Innovative Approach to Simplifying Value-Based Care

The intricacies of value-based care contracts can be challenging for healthcare payers to understand and abide by. HealthEdge Source offers key features that reduce payment complexity for your plan:

• Always Accurate Pricing: Bi-weekly updates provide up-to-date data for complex contracts, eliminating costly overpayments and underpayments.
• Streamlined Workflow: A single platform for claims pricing, editing, and configuration simplifies customization and saves time.
• Seamless Integration: Third-party content synchronizes to the platform, reducing administrative burdens and automating your operations.

In addition, the Source solution offers the flexibility to operate alongside traditional fee-for-service contracts. With customizable terms, a single configuration layer, and shared business rules, Source makes it easier for health plans to manage multiple scenarios.

Supporting All Payment Models: Prospective and Retrospective

No matter how your health plan approaches value-based care, Source has you covered. The solution handles both prospective and retrospective payment models, ensuring accuracy and efficiency in aligning payments with outcomes.

For prospective payment bundles, Source encourages efficiency by ensuring accurate payments for bundled care episodes, incentivizing quality improvement. When it comes to retrospective payment bundles, health plans can reconcile payments based on actual outcomes achieved, motivating providers to deliver high-quality care while controlling costs. This flexibility fosters collaboration and accountability, leading to better patient outcomes. 

Empowering Informed Decision-Making

Health plans must have access to updated intelligence and performance insights to remain flexible and compliant with regulations. HealthEdge Source empowers payers to make more informed strategic decisions with advanced tools like embedded analytics and predictive modeling.

With embedded analytics, centralized data lets you benchmark performance and model different VBC strategies. The modeling tool makes it easy to create multi-dimensional reports and “what-if” scenarios to compare provider claims against various contract terms. Payers gain real-time insights into the potential impact of edits, allowing for proactive decision-making. This data-driven approach ensures you’re making the best choices for your VBC initiatives.

Building Trust and Reducing Provider Abrasion

At the heart of HealthEdge Source lies a commitment to reducing provider abrasion, a common challenge in value-based care adoption. We demonstrate this commitment through:

• Single Point of Management: Manage contracts, configurations, and payments in one place—eliminating the need to juggle multiple systems and simplifying communication with providers.
• Transparency Breeds Trust: Real-time data access and clear reporting foster trust between you and your providers. This transparency promotes accountability, drives improvements in care delivery, and ultimately, leads to better patient outcomes.

With HealthEdge Source, you can build strong provider relationships that are key to thriving in the value-based ecosystem.

Holistically Addressing Value-Based Care Requirements

HealthEdge Source delivers a holistic solution that empowers payers to address obstacles throughout the value-based care journey. When using the Source payment integrity platform, health plans can expect access to:

• Fair & Fast Payments: Eliminate errors and ensure providers receive accurate compensation on time, reducing frustration and fostering collaboration.
• Smoother Operations: Consolidate multiple sources of payment integrity editing into one platform, minimizing internal resources and simplifying workflows for cost savings.
• Enhanced Decision-Making: Gain full insights across all payment functions, empowering you to make informed business decisions.
• Simplified Adjudication: Leverage a single platform for pricing and editing, leading to faster claim processing.
• Beyond Basic Integrity: Access to a suite of additional solutions like modeling and analytics can root out the causes of key inefficiencies.

Don’t just survive the transition – thrive with a solution that simplifies complexity, ensures accurate reimbursements, and fosters collaboration for a future of quality, patient-centered care.

Healthcare payers are adopting flexible, scalable digital solutions to meet market demands and grow membership. HealthEdge Source™ is designed to help health plans win new business opportunities through payment integrity innovation.

Our five-part blog series, HealthEdge Source™ Horizons, highlights how our payment integrity solution helps healthcare payers achieve their organizational goals.

Read the entire series at the links below: 

• Ensure Regulatory Compliance and Cost Transparency
• Improve Payment Accuracy and Efficiency with Advanced Automation
• How Payment Integrity Innovation Helps Expand New Business Opportunities
• Value-Based Care
• Member Engagement

Stay Ahead of Industry Changes with a Flexible Payment Solution

The healthcare landscape is in constant flux, with new regulations, shifting reimbursement models, and technological breakthroughs. To stay competitive, health plans need to be adaptable. A flexible payment solution can help you adapt to new regulations, seamlessly integrate systems, and scale into new markets —all while providing valuable data for continuous improvement.

HealthEdge Source offers a platform that gives your organization control of claims payment workflows to reduce dependency on third-party vendors. The solution also delivers unified data that allows for real-time business decisions, enhancing efficiency and improving transparency. This integrated digital solution helps prevent inaccurate payments and resource wastage by ensuring claims are paid correctly the first time.

Support All Claims Systems and Provider Types with a Single API

Payer IT ecosystems can be a patchwork of different systems and providers. This kind of internal fragmentation can make it challenging for payers to properly scale their solutions and expand into new markets. HealthEdge Source simplifies this process with a single application programming interface (API) that can connect with any claims systems and support all provider types:

• Unified Access: One gateway for pricing, editing, and analytics. No more interface juggling – it’s all here.
• Cloud-Based Efficiency: Our solution was built to support cloud-based delivery—unlike many of our competitors—keeping you up-to-date on compliance and improving accuracy.
• Seamless Integration: Connect to your claims systems through a single instance, streamlining your workflow and eliminating integration headaches.
• Automated Third-Party Connections: Gain access to the latest industry edits through automated connections.

Easily Create and Customize Contract Configurations with Rules Management Synchronization

Complex contract configurations are often bottlenecks to health plan growth. Different lines of business (LOBs) often have unique contract needs, resulting in numerous configurations that demand time and resources. HealthEdge Source cuts through the clutter with a user-friendly solution that simplifies and streamlines configuration management to facilitate your market expansion journey.

Effortless Configuration, Exceptional Results:

• Easy Setup: Remove redundancy with one configuration layer for edits and pricing, freeing you to focus on growth.
• Consistent Results: Shared business rules ensure consistency and compliance, with customization options for specific needs.
• User-Friendly Customization: Create and adjust contract settings easily with an accessible interface.
• Pre-Production Powerhouse: Model new contracts in a test environment before launch, guaranteeing a smooth transition.

HealthEdge Source goes beyond basic configuration. It’s a comprehensive solution that optimizes your claims processes through an emphasis on payment integrity innovation.

Scale Your Organization’s Growth, Agility, and Transformation

HealthEdge Source isn’t just built for today’s needs—it anticipates tomorrow’s challenges. Whether your organization is focusing on the commercial sector, government programs, or niche markets, the payment integrity solution can adapt to support your growth.

• Simplified Workflow: One solution handles pricing, editing, and contract configuration to help your health plan quickly resolve payment integrity issues.
• Reduced Maintenance, Increased Efficiency: Bi-weekly updates ensure minimal maintenance when contract terms evolve.
• Enhanced Analytics: Get valuable insights from a unified source. Model and analyze data to conduct “what-if” scenarios on contract changes to negotiate better contracts and confidently enter new markets.
• Compliance Confidence: Transparency and a single workflow lead to improved compliance through enhanced detection and resolution of issues. Focus on delivering exceptional care, knowing your payment integrity is in good hands.

Your organization doesn’t have to turn to disruptive “rip-and-replace” solutions. HealthEdge Source offers a platform access approach that seamlessly integrates with your existing workflow, empowering you with a smooth onboarding process and the ability to scale up as your needs evolve. Our approach ensures your solution grows with you, meeting your needs today and well into the future. With HealthEdge Source, you can embrace a future-proof solution that empowers your confident growth in any market.

Access Comprehensive Support for Medicaid Reimbursement 

Medicaid is a significant segment of the healthcare landscape, and HealthEdge Source can support your reimbursement needs across 19 states (and counting). We go beyond typical inpatient and outpatient Medicaid pricing and payment policies to deliver content that is automatically updated on time to ensure adherence and accuracy.

Investing in HealthEdge Source for Medicaid unlocks several benefits for your health plan:

• Boost Efficiency: No more manual tasks like research and vendor management. HealthEdge Source streamlines your processes so you can focus on what matters.
• Ensure Accuracy: Our thorough Medicaid edits and contract configurations mean fewer mistakes.
• Speedy Payments: 12% of claims are stuck in accounts receivable for longer than 120 days. With Source real-time editing and pricing, claims get processed faster, keeping your members and providers happy.
• Audit Confidence: Stay audit-ready with frequent updates and a robust audit trail. With HealthEdge Source, you’re prepared for anything.

Your Launchpad for Growth in Healthcare

HealthEdge Source empowers you to conquer new markets, seamlessly configure for diverse needs, and navigate change with agility. Our dedication to payment integrity innovation empowers health plans like yours to streamline workflows, optimize efficiency, and reduce administrative burdens – all while delivering exceptional care.

HealthEdge Source isn’t just a payment integrity solution; we’re your trusted partner in driving digital transformation, streamlining automation, and delivering real-time insights. Let’s unlock the potential of your organization – together.

Want to learn more about how your health plan can access valuable analytics and increase transparency? Read our blog, “The Shift to Payment Accountability®: An Enterprise Approach to Healthcare Payment Integrity.”