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Healthcare payers are turning to innovative digital solutions to maintain payment integrity. But ever-shifting guidelines can make it challenging to pay claims accurately the first time—costing time and money. It’s critical that your Prospective Payment Integrity solution operates using the most up-to-date regulatory information available so you can streamline workflows and improve accuracy. Our five-part blog series, titled HealthEdge Source™ Horizons, demonstrates how our Prospective Payment Integrity solution empowers health plans to remain compliant with ever-shifting regulations.

Read the entire series at the links below:

• Ensure Regulatory Compliance & Cost Transparency
• Improve Payment Accuracy and Efficiency with Advanced Automation
• New Market Expansion — coming soon
• Value-Based Care — coming soon
• Member Engagement — coming soon

As we move through 2024, the healthcare landscape is undergoing a significant transformation. Regulations such as the Transparency in Coverage (TiC) mandate and the No Surprises Act (NSA) are reshaping how payers interact with members and providers.

The Transparency Imperative

The Transparency in Coverage mandate represents a major shift in communication between payers and members. It demands unprecedented levels of clarity regarding cost and coverage, empowering consumers to make informed decisions–with the goal of fostering a more competitive and cost-effective healthcare market.

Protecting Patients from Surprise Bills

The No Surprises Act protects patients from unexpected bills for out-of-network services. Additionally, it establishes a new process for resolving billing disputes and eliminates “gag clauses” that prevent providers from discussing costs with patients.

While each regulation brings its own set of challenges, the underlying goal is clear: to promote transparency, efficiency, and patient empowerment within the healthcare system. For your health plan, navigating compliance with these regulations presents an opportunity to redefine your role and positively impact the healthcare continuum.

How HealthEdge Source™ Enables Payers to Remain Compliant

At HealthEdge Source, we understand the challenges and opportunities arising from the TiC mandate and NSA. We’re committed to empowering health plans and their members through data and pricing transparency.

Simplifying Transparency in Coverage

Maintaining compliance with the TiC mandate can be an ongoing challenge. This regulation necessitates that health plans make healthcare price information readily available to members before they receive services or incur any charges. The initial phase requires this data to be shared in a Machine-Readable File (MRF).

HealthEdge Source solution adheres to Centers for Medicare & Medicaid Services (CMS) mandates while accommodating your specific needs and system capabilities. With this platform, your health plan can:

• Generate MRFs containing specific rates based on your configurations within the HealthEdge Source system.
• Conveniently schedule and produce MRFs through a user-friendly interface (UI).
• Offer both monthly (as required) and on-demand scheduling choices.
• Calculate rates based on specific services and modifiers, going beyond configuration-based data.
• Incorporate data dictionary updates alongside MRFs to ensure clear data comprehension.

No More Surprises

Price transparency is at the core of our commitment to empowering both you and your members. Our Price Comparison Tool, seamlessly integrated with HealthRules® Payer, allows you to provide members with personalized cost estimates for various services and treatments. This promotes informed decision-making and compliance with both the NSA and TiC regulations.

Furthermore, we simplify compliance with the NSA through the Trial Claims functionality within HealthRules Payer. This feature enables you to deliver required pricing information to members through various channels, guaranteeing transparency and meeting all regulatory requirements.

Introducing the Retroactive Change Manager

As you navigate the evolving healthcare landscape shaped by regulations like the TiC mandate and NSA, ensuring accurate claims processing and compliance remains a top priority. At HealthEdge Source, we tackle these challenges head-on with our groundbreaking tool, the Retroactive Change Manager.

This revolutionary tool streamlines claims processing by automating critical tasks like monitoring, reconciliation, and repricing. This eliminates the risk of missed adjustments and guarantees accurate payments to providers. Additionally, the tool proactively identifies and corrects underpayments and overpayments, minimizing your audit risk.

With a user-friendly single API for managing all aspects of claim pricing, editing, configuration, and policy updates, the Retroactive Change Manager eliminates the need to toggle between multiple systems. This streamlines workflows and minimizes human errors.

By automating critical tasks and ensuring compliance with ever-changing regulations, the Retroactive Change Manager empowers you to focus on what truly matters – delivering exceptional healthcare experiences for both providers and members.

Embracing transparency, efficiency, and automation can make it easier for your health plan to navigate the changing healthcare landscape with confidence. HealthEdge Source is here to partner with you every step of the way. By leveraging our solutions, you can build trust with your members, foster informed decision-making, and achieve compliance with evolving regulations.

Healthcare payers are turning to innovative digital solutions to maintain payment integrity. But ever-shifting guidelines can make it challenging to pay claims accurately the first time—costing time and money. It’s critical that your Prospective Payment Integrity solution operates using the most up-to-date regulatory information available so you can streamline workflows and improve accuracy. Our five-part blog series, titled HealthEdge Source™ Horizons, demonstrates how our Prospective Payment Integrity solution enables health plans to work more efficiently and reduce manual efforts using advanced automation.

Read the entire series at the links below:

• Ensure Regulatory Compliance & Cost Transparency
• Improve Payment Accuracy and Efficiency with Advanced Automation
• New Market Expansion
• Value-Based Care
• Member Engagement

The healthcare industry loses billions of dollars annually due to payment errors, fraud, and overpayments. According to Gartner, 3-7% of all U.S. medical claims are paid incorrectly, with an estimated $100 billion lost to improper Medicare and Medicaid spending in 2023 alone.

With the increasing demands on healthcare resources and increasing costs, payment accuracy and efficiency are the next area of focus for payers. Health plan leaders are adopting modern digital solutions to address payment integrity and continue providing high-quality care to members.

Navigating Challenges in Healthcare Payments

Healthcare payers face numerous challenges that impede the efficiency and integrity of payment processes—negatively impacting their ability to deliver value to members, clinicians, and other stakeholders.

Integrated payment integrity solutions can help streamline claims processes and reduce losses by:

• Automating manual processes to expedite operations and reduce risk of errors
• Updating payment guidelines and regulations to prevent incorrect billing
• Using advanced fraud detection to prevent financial losses
• Breaking down internal siloes with an integrated data system

Achieving payment accountability requires a proactive and collaborative effort to standardize practices, share data, and make the most of digital solutions.

Leverage Integrated End-to-end Automation

Recognizing the inefficiencies in your claims and payment processes is a great start—but your health plan must also take action to stay competitive in an ever-changing healthcare industry. The HealthEdge Source™ solution is designed to streamline operational workflows and enable payers to accurately, quickly, and comprehensively pay claims the first time.

Source is an interoperable, cloud-based platform that delivers scalability and flexibility. The solution provides users with access to comprehensive content libraries for pricing and editing. It also leverages integrated end-to-end automation, transforming claims management for payers. This translates to a single, unified platform for managing edits, adjudicating claims, and running powerful analytics—all within the Source ecosystem.

Regular Intelligence Updates

Within the Source platform, editing and pricing tools are assessed simultaneously during claim adjudication, driving accurate and prompt decisions. Automatic bi-weekly product updates guarantee your edits and pricing data are always up to date and give your team access to the latest content. Regular updates also ensure decision-making processes are based on the most current data, increasing transparency and first-pass accuracy.

Seamless Integration and Data Interoperability

Source empowers health plans with a single source of truth. All data sources are fully integrated and interoperable within the platform, eliminating the need for juggling multiple systems. With all your data in one place, your plan able to:

• View daily metrics dashboards to analyze utilization and financial impacts on payment policies
• Assess the impacts of claims or contract edits before they go into effect
• Avoid unnecessary overpayments
• Improve provider relations
• Reduce need for manual management and review
• Proactively adapt to policy and rate changes to remain in compliance with shifting regulations

The Source platform is built to seamlessly integrate with your health plan’s existing technology infrastructure. By leveraging open Application Programming Interfaces (APIs), Source bridges the communication gap between electronic health record (EHR) systems, claims management platforms, and other healthcare IT systems.

In addition, the solution can effectively aggregate and reconcile information from disparate sources, including claims, clinical, and administrative. Data interoperability is essential for advanced analytics and predictive modeling—empowering your team to drive payment accuracy and efficiency.

Operational Efficiency and Adaptability

By increasing claims auto-adjudication, Source reduces the need for manual payments and reviews—eliminating bottlenecks and inaccurate payments. As the volume and complexity of claims transactions continue to increase, the solution can scale to meet new demands and help future-proof your operations.

To stay ahead in the constantly evolving healthcare sector, payers are adopting digital solutions that put automation and accuracy at the core of every workflow. It’s critical that your Core Administrative Processing System (CAPS) delivers the most up-to-date data available so you can improve automation rates and streamline processes. Our five-part blog series, titled HealthRules® Payer Horizons, demonstrates how our CAPS solution empowers payers to adapt to meet new market opportunities.

Read the entire series at the links below:

• Automating regulatory compliance and accuracy
• Enabling automation with integration
• Expanding new business opportunities
• Optimizing value-based care & reimbursement 
• Delivering superior customer service 

Leverage a single solution to improve the member experience

The healthcare industry is shifting toward a value-based care approach, pivoting away from traditional fee-for-service models to focus on improving healthcare outcomes and patient experiences. This transformation is powered by cutting-edge technology and innovative platforms—including HealthRules Payer. Our CAPS solution leverages the latest in AI enablement and cloud-based agility, simplifying the transition to VBC for health plans and elevating member engagement.

1. Provide superior customer service with first-call resolution

Nobody has time to be bogged down by playing phone tag or sitting on a call with slow customer service—especially members trying to navigate their healthcare options. HealthRules Payer recognizes this critical need for speed and efficiency. The platform boasts a Contact Center with a first-call resolution rate of more than 90%. This not only reduces member frustration but also boosts confidence in their health plan. By leveraging HealthRules Payer, health plan leaders can ensure their members are not just satisfied but genuinely pleased with the level of service they receive.

2. Make decisions at the point of care with real-time data

Healthcare decisions are too important to be delayed or based on outdated information. HealthRules Payer empowers health plans to make informed decisions at the point of care by providing real-time member data. This ensures that care providers can access the most up-to-date member information, enabling them to make the best possible decisions for patient care. Access to the most current member information streamlines the process and significantly improves clinical outcomes.

3. Enable self-sufficiency for members seeking cost transparency

One of the most significant barriers to satisfaction and improving member engagement in healthcare is the lack of cost transparency. Members often feel left in the dark about potential costs, leading to frustration and a decrease in trust. HealthRules® Payer addresses this issue head-on by enabling self-sufficiency for members looking for accurate cost information. Through the use of intuitive tools and features within the platform, members can easily compare prices and understand their cost-sharing responsibilities prior to receiving health services. This empowerment leads to a more engaged, informed, and satisfied member base.

4. Improve member satisfaction with faster and more accurate claims payments

The timely and accurate processing of claims is a backbone of member satisfaction. Delays or errors can lead to considerable dissatisfaction and can lead to dissatisfied members. By leveraging HealthRules Payer, health plans can drastically improve both the speed and accuracy of claims payments. The platform’s cutting-edge technology reduces manual processing demands, ensuring that claims are handled efficiently and correctly the first time around. This not only improves the operational efficiency of the health plan but also greatly enhances member satisfaction.

As the healthcare landscape continues to evolve toward a more member-focused, value-based care model, the need for innovative solutions like HealthRules Payer has never been more critical. By providing superior customer service, real-time data for point-of-care decisions, enabling member self-sufficiency, and ensuring faster, more accurate claims payments, HealthRules Payer is transforming the member experience. Health plan leaders looking to stay ahead in this dynamic environment will find HealthRules Payer an indispensable ally in their mission to improve member engagement and satisfaction.

At HealthEdge®, when we think about value-based care, we think about it in two main parts: provider pricing and contracting, and member care delivery. It’s critical that your Core Administrative Processing System (CAPS) is adaptable to your health plan’s changing needs and can integrate with your existing ecosystem to streamline value-based care delivery and payment processing. In our five-part blog series, HealthRules® Payer Horizons, we showcase how our CAPS solution can help your health plan make the most of value-based reimbursements.

Read the entire series at the links below:

• Automating regulatory compliance and accuracy
• Enabling automation with integration
• Expanding new business opportunities
• Optimizing value-based care & reimbursement
• Delivering superior customer service – coming soon

Streamline configurations and improve member satisfaction

The pivot to value-based care is not just a trend; it’s a significant shift necessitated by the urgent need to improve healthcare outcomes and patient experiences. The HealthRules® Payer solution suite can help simplify and streamline the transition.

1. Future-proof your plan with AI-enabled, cloud-based software

The move towards AI-enabled and cloud-based solutions represents a bold step away from traditional legacy systems that don’t always have the flexibility payers need to adjust to the healthcare market. This technological evolution enables health plans to adapt quickly to industry changes and regulatory requirements while also offering a scalable and reliable platform. HealthRules® Payer, with its intuitive design and cloud infrastructure, ensures health plans remain future-proof and ready to tackle challenges head-on.

2. Improve user understanding with the HealthRules Language

One of the most daunting aspects of integrating new technologies into your healthcare operations is the learning curve associated with adoption. The HealthRules Language, with its patented, English-like healthcare-specific vocabulary, addresses this challenge head-on. It democratizes the use of the application, making it accessible not just to IT professionals but also to business analysts, claims examiners, and customer service representatives. This universal understanding ensures seamless communication and operation across all departments, a critical component in delivering cohesive value-based care.

3. Quickly configure new benefit plans and contract arrangements

In the realm of value-based care, flexibility and speed are crucial. Health plans need to rapidly configure new benefit plans and adjust contract arrangements to stay competitive and responsive to market needs. The HealthRules Payer’s core administrative processing system and care management workflow solutions empower organizations to do just that. They enable the quick rollout of new products and benefits without the need for custom code or duplication of effort. This strength lies in the HealthRules Language’s ability to transparently define and manage complex configurations with ease.

4. Share actionable data with stakeholders

Value-based reimbursement models thrive on actionable data. The ability to share this data with stakeholders — from providers to members — ensures that everyone involved in the care continuum is informed and engaged. HealthRules Payer, through prospective payment integrity and enhanced member experience features, delivers precise and timely data. Consequently, health plans can make informed decisions, track performance against key performance metrics, and identify areas for improvement with unprecedented precision.

5. Realize value-based reimbursement & improved customer satisfaction

Ultimately, the goal of transitioning to value-based care reimbursement models is twofold: to enhance patient care and to achieve financial sustainability. With HealthRules Payer, health plans are witnessing real, measurable success in these areas. The platform boasts up to 96% billing accuracy even for claims incorporating complex value-based agreements. This accuracy not only mitigates financial risk but also improves customer satisfaction by delivering clear, understandable billing and benefits information.

The constant shifts in the healthcare industry demand innovative solutions, and HealthRules Payer is facilitating a smooth transition to value-based care reimbursement. Its unique blend of AI-enabled efficiency, the HealthRules Language, and configuration capabilities makes it an indispensable tool for health plan leaders aiming to excel in the healthcare market. By adopting HealthRules Payer, payers can ensure better outcomes for their members and set new standards in healthcare delivery.

Do you want to know more about how your health plan can drive quality performance and hit key benchmarks?

Read our brochure, “Health Plans With Home & Host Capabilities Are Market Leaders” to learn more about HealthRules Payer supports health plans with capabilities like support compliance, claims automation, and rapid implementation.

 

In the swiftly evolving landscape of healthcare, staying ahead demands not just understanding the market but redefining the competition. For health plan leaders, navigating these waters involves a delicate balance between scale and agility, particularly when facing off against smaller, more nimble competitors. It’s vital for your Core Administrative Processing System (CAPS) to deliver up-to-date intelligence so you can improve automation and efficiency. Our five-part blog series, titled HealthRules® Payer Horizons, demonstrates how our CAPS solution empowers payers to adapt and take advantage of new market opportunities.

Read the entire series at the links below:

• Automating regulatory compliance and accuracy
• Enabling automation with integration
• Expanding new business opportunities
• Optimizing value-based care & reimbursement – coming soon
• Delivering superior customer service – coming soon

Adapt to shifting healthcare industry demands with HealthRules® Payer

You know the healthcare market, but you need to compete differently than you have before. Smaller competitors are differentiating their offerings through rapid innovation and adaptability. What they may lack in funding, smaller plans make up for in their ability to test offerings on smaller populations and pivot accordingly. They’re also able to take on more manual work due to lower overall claims volumes.

While being responsible for more lives may mean longer implementation times for new initiatives, larger payers often have the resources to invest in comprehensive solutions and strategies that can help expand their business opportunities. HealthRules Payer, gives your health plan the tools to compete more effectively and grow your market share.

1. Establish new contracts faster

In an industry where timeliness is key, HealthRules Payer shines by reducing the set-up time for new contracts to as little as 10 minutes. This efficiency frees up valuable time, allowing health plans to focus more on fostering relationships with new partners rather than being bogged down by backend administration.

Using HealthRules® Promote, regional non-profit health plan expanded lines of business, and grew from operating in four to 12 states in six years. This achievement underscores the platform’s capacity to not just streamline processes but to amplify growth.

2. Configure (and reconfigure) benefit plans in less time

Create virtually any benefit plan or provider contract and start serving new members sooner. The adaptability to swiftly respond to changing market demands and regulatory landscapes is another critical advantage that HealthRules Payer brings to health plan customers. Or platform enables users to create and adjust benefit plans or provider contracts in mere hours or days, significantly reducing turnaround times.

In 2020, a metropolitan non-profit health plan was able to configure and re-configure benefit plans impacted by the COVID-19 pandemic in about two weeks by harnessing the HealthRules® Language. This feature allowed the payer to meet new regulatory requirements and remain focused on members’ well-being.

3. Personalized strategy support

HealthRules Payer is designed to reflect your plan’s unique needs and ecosystem, offering personalized strategy support that aligns with specific organizational objectives and market realities. The HealthRules® Answers feature empowers your team to better leverage real-time data to identify new opportunities as well as reduce costs, assess new offerings, and support modern digital workflows. Our in-house

This tailor-made approach ensures that solutions are not just effective but perfectly suited to each health plan’s individual context.

4. Easily scale to keep up with membership fluctuations

With HealthRules Payer, scalability becomes an operational advantage, enabling health plans to effectively manage membership fluctuations and achieve enrollment accuracy of up to 97%. This level of precision not only enhances operational efficiency but also supports sustained growth and market competitiveness. The combination of technology, strategic partnership, and experienced configuration teams help ensure health plans like yours can achieve their goals in the most timely and cost-effective way.

Do you want to learn more about how HealthRules Payer can empower your health plan to optimize system configurations and optimize business performance?

Read our Case Study “Configuration as a Service Expedites Time-to-Value for Health Plans” to see how our solution empowers customers to reduce delivery risk, increase quality, and maximize cost-efficiency.

 

 

In early May, HealthEdge hosted the 2024 Clinical Leadership Forum in Boston, Massachusetts. This event brought together more than 50 health plan executives, clinicians, and other healthcare leaders, and served as a platform to address key concerns and opportunities in the industry.

The forum focused on the role of integrated digital health management solutions in driving efficiency, clinical outcomes, and organizational goals by making the most of the resources payers already have. Speakers also discussed the need to embrace the constant change and modernization of the healthcare industry. Health plans across the U.S. are being asked to improve experiences and outcomes without raising costs—and the right digital health solutions can help. In this article, we delve deeper into the discoveries and experiences shared during our exclusive event.

“We need to think about how technology will change our processes to add more value to businesses and customer experiences, and then we have to organize ourselves to change those processes.”

-Steve Krupa, CEO, HealthEdge®

Key Takeaways: We’re being offered the opportunity to change everything we do

The pace of healthcare industry innovation continues to accelerate. Members expect a convenient and personalized experience, regulatory requirements keep shifting, and high-needs populations are growing. Three customer panels stood out for their emphasis on engaging members to improve health outcomes and the member experience.

Address Health Equity Using Digital Care Management

One of the forum’s highlights was a panel led by Dr. Sandhya Gardner, Chief Medical Officer at HealthEdge. Dr. Gardner facilitated a discussion between clinicians from three large regional health plans, who shared how they address health equity among their member populations using digital solutions.

This discussion underscored the benefits of offering digital health management tools to members and care managers. For care managers, integrated digital health tools help improve staff efficiency and make it easier for care managers to identify health equity challenges and social determinants of health. The insights care teams get from digital health solutions enables them to deliver more timely and relevant care that meets members where they are. Digital health tools can also improve the accessibility of healthcare services by giving members a single point of access where they can reach out to care teams, read relevant health and benefits information, and keep track of their health goals.

“What we’re really concerned about are the folks who are working but unavailable to us. They may be shift workers, they may be working overnight, or beyond the hours our regular care managers work. They may have a burner cell phone. All those things lead to disparities. So figuring out ways to reach people through other channels, whatever they may be, is critical to reducing disparities.”

-Vice President of Clinical Operations, Regional Health Plan

Combat Industry Pressure with Integrated Care Management

Healthcare payers are under a lot of pressure—trying to combat rising costs, satisfy regulatory requirements, and increase member satisfaction while trying to stay competitive. In a session with two statewide health plan executives, panelists discussed the role of integrated care management in empowering key member, care team, and health plan stakeholders to achieve their goals. The fusion of digital member engagement and hands-on care management empowers members to take control of their health and make more informed decisions.

Attendees were given an exclusive look into the ways connected care ecosystems enhance operational capacities and forge a more empathetic, responsive culture. A digitally enabled care management approach is particularly beneficial for high-risk populations, like maternity and Medicaid. Plus, demonstrations of the Care-Wellframe solution provided concrete examples of how this technology can be seamlessly integrated into existing workflows, offering a glimpse into a future where healthcare is both high-tech and high-touch.

“Instead of asking our staff to take on the additional cognitive burden of choosing which members to call, we can clearly identify exactly who the members are who have emerging risks. It also gives our members access to a repository of information that they can access 24/7, 365.”

-Chief Medical Officer, Regional Health Plan

Championing Change Management: Best Practices

In a rapidly evolving healthcare landscape, adaptability is key. In one session, leaders from three regional and national payers shared best practices based on their experience with change management throughout the digital implementation process. Earning buy-in from stakeholders and future users can be a challenge. One way to improve adoption and reduce pushback is to build trust with your internal team through transparent communication and early involvement.

Panelists also emphasized the importance of cultivating a company culture that not only adapts to digital innovations but thrives because of them. From workflow optimization to team engagement, the health plan leaders provided a comprehensive toolkit to support successful digital transitions. Most notably, this included the importance of transparency throughout the implementation process. When stakeholders and employees know the “why” behind a change, they’re more likely to feel involved in the solution.

“Once you have team members that understand the value of ‘why,’ and over-communicating the value of ‘why’ so it’s not just sitting with the clinical team, that’s how you gain some traction.” 

-Chief Medical Officer, National Health Plan 

Leveraging AI for Care Management

Discussions about the applications of AI are everywhere. But where can it have the greatest impact on health plan operations? Many AI solutions need more training before they can fully replace manual documentation. But digital health management platforms like GuidingCare® and Wellframe leverage AI algorithms to improve clinical decision-making and member outcomes.

An AI assistant helps improve staff productivity by suggesting message templates, flagging high-risk members, making engagement recommendations, and suggesting next best actions. HealthEdge views AI as a key component of helping our customers become digital payers through transformational consumer experiences and business agility enablement.

“What are you actually trying to use this technology to solve for? Are you trying to save people time, generate insights, proactively take something that took a lot of manual effort and uplevel their skills to work top-of-license? Those are all areas we think are core-value oriented.”

-SVP of Product Management, HealthEdge®

Looking Forward

The 2024 Clinical Leadership Forum was a testament to the power of collective insight and a shared commitment across the healthcare sector to drive positive change. The discussions and solution demonstrations highlighted not only the current capabilities of digital care management, but the possibilities for future innovations.

For health plan executives and healthcare leaders, the forum served as both a call to action and a way to build relationships with leaders at similar organizations. The Clinical Leadership Forum was a powerful reminder that the future we aspire to is not just a possibility but an inevitability if we continue to innovate, collaborate, and lead with empathy and vision.

Learn more about HealthEdge® digital health management and member engagement solutions, visit the GuidingCare® and Wellframe pages on our website.