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At HealthEdge®, we are continually seeking ways to improve our users experience and help maximize the value customers get from our solutions. That’s why we designed the HealthEdge Help Center, a one-stop online platform that helps users leverage our solutions more effectively by enabling them to quickly locate the information they need. The Help Center provides convenient access to resources like documentation and troubleshooting, as well as on-demand training assets.

Below, we’ve highlighted a few ways the Help Center benefits HealthEdge customers.

Empowering Users With An Exceptional Experience

We built the Help Center with efficiency in mind. It offers a centralized location where users can easily search and access relevant information, so teams can spend less time looking and more time doing. The Help Center even allows for printing or PDF downloads to offer flexibility and inclusivity in information access.

Comprehensive Trainings Accessible Any Time

The Help Center provides on-demand training videos, FAQs, quick tips, and other insights. It is accessible at any time, so users can find the data and documentation they need at their convenience. The Help Center includes documentation for the HealthRules® Payer, Connector, Installer, and Provider Data Management solutions, with more to come.

Through the Help Center, users can also find comprehensive documentation for all HealthEdge product releases, making it easier to stay informed about system updates and improvements.

Built For Ongoing Evolution

HealthEdge built the Help Center to be highly scalable, allowing ongoing improvement to both the content and features it provides. Platform analytics help us measure which resources and features drive the greatest value for our customers.

The Help Center is just the beginning. We are continuously working on improvements to further assist our users, such as AI-powered personalized content recommendations, and enhanced mobile support.

Accessing the HealthEdge Help Center 

The Help Center is available to all customers upgrading to HealthRules Payer 24.1. To learn more and see how you can gain access to the Help Center, contact your Upgrade/Implementation team or Customer Service Executive.

Not a current HealthEdge customer but interested in learning more? Contact us here.

Join us in this transformative journey towards a digital healthcare system. The HealthEdge Help Center is here to help you make the most of your HealthEdge experience.

Member satisfaction is vital for health plans to grow communities and improve outcomes. At the AHIP Consumer Experience & Digital Forum (CDF) 2024, Susan Beaton, Vice President of Health Plan Strategy at HealthEdge, addressed this topic with her presentation on “Driving Member Satisfaction Through an Integrated Care Management Strategy.”

The presentation highlighted how integrating digital tools with traditional workflows can transform care management delivery to drive member satisfaction. This is especially important considering care managers’ increasing responsibilities, the direct connection between member experience and satisfaction, and the rising demand for innovative digital solutions from members.

Key takeaways from the presentation include:

1. Care Managers Face Increasing Responsibilities And More Significant Challenges Than Ever Before

Care managers face rising challenges as their responsibilities expand to address a wide range of complex business and member needs. Workforce shortages make their role even more complicated, while manual administrative tasks take up valuable time that could be spent on direct member care. Members’ expectations are rising for more personalized interactions and immediate information. Navigating complex regulatory requirements only adds to care managers’ workload while they perform an essential role in a member’s care journey.

2. The Care Manager’s Experience Directly Impacts Member Satisfaction

Improving care managers’ experience through digital tools enhances efficiency, improves member outcomes, and increases satisfaction. Streamlining their workflows and providing user-friendly tools that reduce manual administrative work allows them to apply their expertise effectively, so they spend more time addressing member needs and providing personalized and proactive care. Care managers who are empowered to consistently anticipate and meet member needs foster trust with members, drive better health outcomes, and create a more positive overall member experience.

3.Members Expect Innovation And Are Comfortable With Digital Tools

As technology transforms members’ daily lives, they are increasingly comfortable using digital tools to manage their health. The 2024 HealthEdge® Consumer Survey found that 64% of members are comfortable using mobile apps to access health information, while 65% are open to utilizing AI-powered tools provided by their health insurers. These findings highlight the rising expectations for innovation and digital engagement in healthcare, as members now anticipate seamless, technology-driven interactions like those in retail, travel, and other areas of their lives.

4. It’s Time For Health Plans To Rethink Care Management Delivery

The increasing challenges for care managers, alongside rising expectations from members, present an opportunity for health plans to apply modern technology to enhance traditional workflows. Integrated Digital Care Management merges traditional care management practices with digital tools and technologies to improve efficiency, effectiveness, and reach. This approach combines clinical data, real-time member insights, and traditional care workflows to create a more efficient, member-centered approach, ultimately improving the care experience and delivering better health outcomes at lower costs.

A HealthEdge study using Wellframe data highlights how digital tools dramatically scale care management resources and boost member engagement with the same staff levels, leading to results such as:

• 2x increase in active caseload size, allowing care managers to handle more members without additional staff.
• 6x increase in member interactions, driven by enhanced digital engagement and self-service tools.
• 91% increase in successful outreach that improves care delivery and ensures members receive timely support.

This data shows how integrating digital tools can significantly enhance the effectiveness and reach of care management programs.

5. The Benefits Of Digital Tools Are Accelerating

Integrating digital tools in care management is proving transformative, significantly enhancing operational efficiencies and the scope of services to members. The benefits are only accelerating as tools become more mature and advance integrations with other platforms to streamline care team workflows. Additionally, sophisticated digital tools incorporate artificial intelligence (AI) technology into their platforms to drive further efficiencies and member personalization. These accelerated benefits support various business initiatives, from launching concierge services that provide targeted clinical support to identifying and driving new initiatives to improve the member experience and member satisfaction.

6. Successful Adoption Of Digital Tools Requires Change Management Best Practices

Organizations must prioritize robust change management strategies for digital tools to be effectively adopted by care managers and integrated into their daily workflows. This includes pillars such as focusing on the care manager’s experience with new tools and ensuring leadership commitment to transformation. Key strategies for success include digital transformation, aligning incentives, and collaborating with the right vendors to support long-term goals. In addition, health plans can benefit from intentional rollouts of new tools that focus on optimal use cases to establish high impact, early success, and internal buy-in.

7. The Time Is Now for Integrated Digital Care Management

As the healthcare industry evolves, the need for Integrated Digital Care Management is more urgent than ever to drive member satisfaction. Strategic concerns for health plans include the following:

• Market Dynamics and Consumer Expectations. With more health plan options available, members expect healthcare experiences that mirror the convenience and immediacy of digital retail services, which is crucial to drive member satisfaction.
• Regulatory Pressures. New regulations focusing on health equity and social determinants of health (SDOH) data require modern digital tools for compliance, which can impact member satisfaction scores and financial incentives like Star Ratings.
• Operational Efficiency and Cost Reduction. Digital tools, automation, and AI streamline administrative tasks, helping health plans do more with fewer resources, while alleviating the workload of care managers.
• Competitive Advantage. By adopting Integrated Digital Care Management, health plans can position themselves as innovators, gaining a competitive edge in attracting and retaining members, while preparing for future technological advancements.

Beaton’s presentation from AHIP CDF 2024 provides a roadmap for health plans to leverage digital tools to elevate care management practices, and enhance member and care manager experiences.

Using the Wellframe solution, a Blue Cross Blue Shield plan drove member engagement and increased care management capacity to better serve their 21 million members. To learn more about how the health plan improved phone call success rates, active caseload size, and member interactions, read the case study.

The ever-changing healthcare landscape requires health plans to have access to the insights and agility necessary to control costs, embrace change, and move quickly to take advantage of new opportunities. For many payers, upgrading to modernized health plan core administrative processing systems (CAPS) is a key strategy to remain flexible and competitive in the market.

To stay ahead of industry changes, many health plans are transitioning to cloud-based solutions. Doing so makes it easier for payers to consolidate their applications, reducing reliance on third-party point solutions and outdated proprietary systems. This forward-thinking approach streamlines operational efficiencies and meets the growing demand for agility in the ever-shifting healthcare regulatory environment.

Payers increasingly recognize that investing in modern health plan core administrative processing systems is essential to improving both member and provider experiences— needs that remain largely unmet by legacy systems. Leveraging cloud-based CAPS solutions make it easier for health plans to embrace the industry shift toward data accessibility and real-time claim adjudication while empowering them to react swiftly to stakeholder demands.

6 Key Trends Driving Investment in Health Plan Core Administrative Processing Systems

Healthcare payers must navigate a complex landscape of demands and opportunities to succeed. Several trends have emerged that are shaping payers’ decisions to reinvest in their existing CAPS solutions. An industry-wide shift toward a value-based care model is compelling executives to reevaluate their organizational workflows and internal processes. As a result, payers are more closely evaluating which CAPS partners will be ideal for long-term partnership in the dynamic healthcare environment.

1. Claims Processing for Non-Medical Services

One significant trend is the integration of claims processing for non-medical services. To support members holistically, payers are addressing social determinants of health (SDOH) by facilitating claims for services beyond traditional medical care. Examples of covered SDOH services include community-based programs—such as housing stabilization and emergency food access—as well as transportation to and from appointments. These offerings help support broader member needs, leading to better clinical outcomes, lower long-term care costs, and greater member satisfaction.

2. Low-Friction Support for Price Transparency and Interoperability

A regulatory focus on pricing transparency is driving payers to adopt integrated CAPS solutions that support low-friction access to updated pricing information. Delivering accurate pricing information not only satisfies compliance mandates but also empowers members to make more informed healthcare choices, fostering trust and improving satisfaction. Interoperability is the cornerstone of compliance for payers working across technology systems and disparate data sources, helping ensure seamless information sharing between stakeholders and across platforms.

3. Adoption of API & FHIR Capabilities

Data integration is vital for delivering accurate pricing information, enhancing the provider and member experience. The adoption of Application Programming Interface (API) and Fast Healthcare Interoperability Resources (FHIR) capabilities is a critical aspect of this strategy. These standards enable the efficient exchange of healthcare data between systems, empowering payers with the most accurate and up-to-date information available.

4. Transition to Commercial Cloud Hosting 

An industry-wide shift toward commercial cloud hosting demonstrates a significant increase in health plans’ agility and scalability in the market. By leveraging cloud services, payers can reduce IT overhead costs by reducing or eliminating the need for on-site hardware and servers. Cloud-based solutions also make it easier to increase data security and deploy updates more quickly—which are vital to earning and maintaining trust in the rapidly evolving healthcare industry.

5. Self-Serve Member & Provider Portals

When it comes to member engagement and support, healthcare consumers have high expectations. They’re looking for personalized, digital experiences that they can access when it’s convenient for them.

Investing in easy-to-navigate self-service portals can be valuable tools for improving member engagement and delivering more personalized support. Member care management apps or resource portals serve as hubs for provider communication, personalized resources, coverage information, and other valuable services. Solutions like these can empower members with the information they need at the right time, helping them make more informed health decisions while fostering trust in their health plan.

6. Value-Based Care Administration

Value-based care models have gained prominence in the healthcare industry and are redefining health plan operations. To take full advantage of the outcomes-based care model, health plans must shift their focus to prioritize care quality over service volume. If payers invest in CAPS solutions with robust analytics and performance tracking, they will be well-positioned in the evolving market.

Trends across the healthcare industry are pushing payers to invest (or reinvest) in CAPS solutions that facilitate data integration, transparency, and high care quality. Effectively leveraging capabilities like these can enhance operational efficiency and position health plans as trusted partners within the healthcare ecosystem. For leaders willing to adapt and embrace modern CAPS solution, there is no shortage of potential.

HealthRules® Payer is more than a health plan core administrative processing system—it is a revolutionary tool tailored to meet the demands of the modern healthcare industry. By leveraging cutting-edge technologies, including artificial intelligence (AI), HealthRules Payer provides payers with the efficiency, agility, and competitive advantage necessary to stay ahead of the market.

Not sure what to expect when it comes to a CAPS implementation? Check out our eBook, “5 Steps to a Successful CAPS Implementation”.

 

Latest Release: 2024 Gartner® Hype Cycle™ for U.S. Healthcare Payers

Gartner has published its highly anticipated Hype Cycle for U.S. Healthcare Payers. HealthEdge® was recognized as a Sample Vendor in two categories. Prospective Payment Integrity Solutions was named in the report since 2019, and we have been recognized for this category 3 consecutive times starting 2022. And AI-Enabled Fraud Detection has been named in the report since 2023, and we have been named as a Sample Vendor for both years – 2023 and 2024.

“This Hype Cycle provides critical input for strategic planning by tracking the maturity level and adoption rate of payer technologies and deployment approaches. U.S. healthcare payer CIOs should use this to plan new and manage existing investments for business optimization and transformation.” (1)

AI-Enabled Fraud Detection

Artificial Intelligence (AI) is one of the most prevalent terms in healthcare publications today, with use cases spanning from clinical to administrative functions. One of the more popular applications of AI in healthcare is fraud detection.

Fraud in the healthcare industry is believed to cost the U.S. healthcare system tens of billions of dollars annually. According to the National Health Care Anti-Fraud Association (NHCAA), financial losses due to health care fraud can range from a conservative estimate of 3% to as high as 10% of total healthcare expenditures. The General Account Office estimates that fraud, waste and abuse may account for as much as 10% of all healthcare spending. With healthcare expenditures now exceeding one trillion dollars every year, over $100 billion may be lost annually due to fraud, waste and abuse.

Health insurance companies are on the front line of detecting this fraud and often bear the brunt of these costs.

A Fresh Approach

The traditional approach to fraud detection and prevention has focused on rule-based systems within the claims processing workflows. This approach, while well-intentioned, is unable to keep up with the growing complexity of claims and sophisticated fraud schemes.

To enhance fraud detection and prevention, HealthEdge solutions seamlessly integrate with AI and machine learning (ML) engines. Additionally, HealthEdge is developing partner integrations to provide customers with built-in fraud detection technology.

Analytics tools by HealthEdge Source™ (Source) offer health plans valuable insights that directly impact their bottom line. Monitor Mode allows payers to view the financial impact of edits or new policies in real-time, while the Retroactive Change Manager automates the management of retroactive policy and pricing changes. Together, these tools streamline workflows, reduce costs, and improve the integrity of the claims process. By analyzing specific providers, regions, configurations, and contracts, business leaders can make well-informed business decisions.

Prospective Payment Integrity

Since their inception, health plans have often struggled to detect and prevent improper and inaccurate claim payments. In fact, Gartner states that “between 3% and 7% of all healthcare claims are paid inaccurately — and only a fraction of those claims payments are later corrected.” (1)

Traditionally, payers have layered multiple editing solutions to address payment integrity concerns. However, this approach has its own drawbacks:

• Each editing solution operates on its own update schedule and data sets, leading to fragmented processes and siloed information.
• The inherent incentive for primary and secondary editing vendors to protect their own intellectual property has hindered collaboration and sharing among stakeholders. This not only hampers the overall accuracy of the payment process, but also perpetuates a cycle of continuous charging for the same issues without any resolution.

What is Prospective Payment Integrity?

“Prospective payment integrity (PPI) solutions enable payers to proactively avoid paying claims improperly, versus paying and then chasing claims dollars. These technologies facilitate accurate claims processing with minimal payment leakage, addressing contracts and services, eligibility, and payment accountability, along with fraud, waste and abuse (FWA). They incorporate claims editing, data mining and complex clinical review, as well as advanced analytics and AI,” notes the Gartner report.

According to the 2024 Hype Cycle, PPI solutions are “early mainstream,” which in our opinion means that many health plans are still evaluating these solutions. This isn’t surprising, given the cost pressure health plans face, and the difficulty in qualifying cost-avoidance savings. Factors such as counterfactual analysis, indirect costs, and data limitations can make it challenging to accurately measure savings. Despite these challenges, PPI solutions are still considered valuable investments for health plans looking to improve operational efficiency. Reducing the percentage of claims that require rework and limiting the manual effort involved are key strategies that health plan leaders believe can help achieve their efficiency goals.

HealthEdge Source challenges the traditional approach to payment integrity by offering a single platform for accessing and leveraging all data for true payment accountability. This platform approach empowers payers to identify the root causes of payment inaccuracy and correct the issues early on, leading to greater efficiency and lower contingency fees. By streamlining workflows and automating processes, Source enables health plans to insource more functionality, reducing reliance on third-party vendors for overpayment and underpayment recovery. This not only saves time and money, but also provides greater control over the claim’s payment process.

Real-World Case Studies: Cost Savings vs. Cost Recoveries

Source’s Data Study team collaborates with health plans to measure the potential savings when implementing the Source payment integrity solution. Here are a few examples of what those savings can be:

• Mid-sized Regional Health Plan (Medicare Advantage):
• Claims Analyzed: 1.7 million claims
• Total Spend: $648 million
• Incremental Savings: 1.6%, or $11.1 million
• Regional Health Plan (Medicaid):
• Claims Analyzed: 2.1 million claims
• Total Spend: $571 million
• Incremental Savings: 1.6%, or $9.1 million
• National Health Plan (All Lines of Business):
• Claims Analyzed: 5.1 million claims from Medicaid and Dual Eligible members
• Total Spend: $790 million
• Incremental Savings: 1.1%, or $8.7 million

(1) Gartner, Hype Cycle for U.S. Healthcare Payers, 2024. Mandi Bishop, Austynn Eubank, Connie Salgy, 29 July 2024

GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally, and HYPE CYCLE is a registered trademark of Gartner, Inc. and/or its affiliates and are used herein

Gartner does not endorse any vendor, product or service depicted in its research publications, and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

To learn more about what Source prospective payment integrity solution can do for your organization, visit www.healthedge.com.

Healthcare is experiencing a significant digital transformation, and the HealthRules® Payer Machine Readable Files (MRF) Suite is at the forefront of this revolution. This innovative software suite, developed for HealthRules® Payer, is an industry game-changer, offering a superior solution to manage and publish Machine Readable Files (MRF) of negotiated rates and allowed amounts.

What is the HealthRules® Payer Machine Readable Files Suite?

The HealthRules Payer Machine Readable Files (MRF) Suite is a cloud-based SaaS application specifically designed to help health plans streamline the process of calculating and publishing rates.

With the Machine Readable Files suite, health plans can create accurate, comprehensive MRF files swiftly and efficiently via a user-friendly web interface. Users can also manage, track, and establish operational processes to publish multiple MRF files as needed to maintain compliance. This cutting-edge solution is an essential tool for complying with the mandate from the Centers for Medicare & Medicaid Services (CMS) for Transparency in Coverage and MRF Requirements.

Benefits of using the HealthRules® Payer Machine Readable Files Suite

What do health plans get with the HealthRules Payer Machine Readable Files Suite? Using this innovative offering, our customers gain access to benefits such as:

Industry-Leading Accuracy: The MRF Suite calculates negotiated rates based on Supplier Contract Agreements and historical billing code combinations through a partial adjudication process to help ensure highly accurate results.

Faster Execution Time: Intelligent rate processing features significantly reduce redundant processing and increase billing code coverage.

Flexible and Intuitive Configuration: The solution features an easy-to-navigate, web-based user interface that makes it easier to configure, manage, and track MRF generation.

CMS-Compliant Files: With the MRF Suite, users can produce files compliant with the CMS schema for negotiated rates, allowed rates table of content files

Key Features of the HealthRules® Payer Machine Readable Files Suite

How are our customers achieving these critical business goals? By leveraging MRF Suite features such as:

Intelligent Rate Processing

With the MRF Suite, users can calculate negotiated rates for up to 4.8 million provider billing code combinations daily. The solution also uses historical negotiated rates and shorter runs to refresh changing rates as configured. Plus, users can reuse and map existing negotiated rates.

Flexible Web-based UI

The MRF suite offers an intuitive user interface (UI) that facilitates file configuration, management, and tracking—including asynchronous initiation and monitoring. Users can access flexible configuration options to generate different MRF files according to their unique needs. Health plans can also use the solution to monitor the status of MRF processing runs with a live throughput and count of the claims’ combinations. And, as an added bonus, users can download intermediate files generated in the MRF pricing process.

Data Optimization and Processing

MRF suite users can reduce processing and execution time by storing and reusing generated data. Automated data cleanup and re-evaluation helps to ensure data accuracy and storage optimization, and scheduled incremental runs more easily update negotiated rates. Health plans can adhere to compliance rules and make sure their files are published on time.

Next-Generation Performance

Avoid rate reprocessing rates in case of MRF run failures. Incremental rate updates in the MRF suite generate more comprehensive billing code sets. The web-based UI simplifies and automates monthly operational tasks and monitoring for faster completion—and a 70% time reduction with incremental runs.

Enhance Performance with Machine Readable Files

The latest version of the MRF Suite enhances value for health plans with a 25% reduction in execution time and a 40% improvement in performance—while helping maintain accuracy and storage optimization. It also facilitates more timely publishing of on-demand MRF to improve compliance and reduce operational costs.

Health plans utilizing the MRF Suite have witnessed substantive improvements in performance and compliance. With the updated MRF suite, users see a 40% average increase in daily provider billing code rates throughput and a 28% faster execution time. And the inclusion of incremental runs leads to a 70% reduction in execution time and a larger coverage of billing codes.

HealthEdge is on a mission to drive digital transformation in healthcare, connecting health plans, providers, and members with cutting-edge technology solutions. Our end-to-end digital technology solutions support rapid member growth, new business models, and improved health outcomes.

If you’re looking to transform your health plans’ MRF publishing processes, the HealthRules® Payer Machine Readable Files could be the solution you’ve been waiting for. To find out more or to schedule a demo, watch our videos:

Video part one and video part two.

A modern care management business intelligence (BI) platform can play a crucial role for health plans. Business intelligence tools help support quality initiatives, manage population health, and optimize resource allocation for healthcare payers. Payers can utilize integrated reporting capabilities to mitigate risk as well as improve clinical and financial outcomes. In addition, the right business intelligence platform can enable health plans to effectively analyze vast quantities of data and deliver high-quality value-based care.

Though there are many benefits to adopting a care management business intelligence platform, health plans may face several common challenges. Many care management solutions lack depth in reporting and analytics, leading to expensive ad hoc solutions. They also tend to fail to integrate clinical and claims data. By using outdated or legacy solutions, health plans often struggle with data overload and limited analytical capabilities, making it challenging to derive meaningful insights from business intelligence.

Today, a new standard in the business intelligence space is necessary to improve healthcare outcomes and operational efficiency.

Key Capabilities for Care Management Business Intelligence Platforms

These challenges can be overcome with health plans requiring business intelligence solutions that are technologically advanced and user-centric. When evaluating care management solutions, health plan leaders should look for platforms that include business intelligence capabilities, which can help:

• Maximize efficiency and minimize costs with powerful, out-of-the-box, and user-friendly reports ready from the moment the solution goes live.
• Provide regulatory support and expertise, including support for regulatory and custom reports to help health plans meet state and federal requirements.
• Leverage data and insights from multiple modules in an end-to-end digital payer solution so that business intelligence can develop a full-picture view of the member, not just the data in the care management system.

Next-Generation Care Management Business intelligence: HealthEdge® GuidingCare®

The Business intelligence Module within the GuidingCare® care management platform from HealthEdge® is a state-of-the-art solution that empowers health plans to elevate their performance. The GuidingCare Business intelligence Module provides a comprehensive view of key information, transforming data into actionable intelligence that payers can use to optimize care delivery and operational efficiency.

GuidingCare Business Intelligence Module

The core Business intelligence Module is a component of the GuidingCare Bundle, supporting health plans to measure outcomes, manage operations, and maintain compliance with ease. The comprehensive reporting and dashboarding solution transforms health plan operations through clinical and operational insights, including capabilities such as:

Standard Reports

• 12 interactive reports covering utilization management, care management, and appeals and grievances use cases.
• Includes operational, trending, and turnaround time data views
• Data and reports can be downloaded in PDF, Excel, and PPT formats

Regulatory Reports

• 20+ Centers for Medicare and Medicaid Services (CMS) regulatory reports covering Organization Determinations, Appeals, and Grievances (ODAG), Coverage Determinations, Appeals, and Grievances (CDAG), and Part C/D needs
• Updated with the latest CMS requirements to support audit and annual reporting needs
• Automatically published to customer environments

Self-Service Reports

• Pre-defined data sources available for self-service report creation
• Robust front-end, database, and data source documentation
• User training provided as part of the Implementation

Advanced Business Intelligence Offerings for the GuidingCare Solution

There are additional premium offerings available so health plans can establish a system according to their unique business needs:

Accreditation Report Suite

Accreditation reporting incorporates HealthEdge’s NCQA expertise, the health plan’s workflow and configuration considerations, and frequently added new reports and enhancements.

• A suite of pre-built reports to support health plan accreditation.
• Includes National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC) accreditation reports.
• NCQA package that includes 15 reports, updates required per NCQA, minor custom changes, and thorough documentation of business requirements

Premium Report Suite

This reporting suite offers trending reports to help payers make informed business decisions, advanced reports to help tailor services to meet member needs, and additional reports that are frequently updated based on market changes and GuidingCare platform enhancements. A suit of 80+ pre-built and interactive operational dashboards support areas like:

• Care management
• Utilization management and appeals & grievances
• Population health management
• Systems reports

Additional Business intelligence Report Offerings

• Custom Reports and Data Sets: Based on the health plan’s unique reporting requirements, the business intelligence team builds custom reports using their expertise in data modeling and Tableau visualizations.
• Product Training: Our experts provide additional training for health plans on best practices for the self-service tool and in-depth review of the standard report analysis in your environment.
• Additional User Licenses: Purchase additional Publisher and Viewer licenses to expand access to data and insights.

How GuidingCare Business Intelligence Is Different

The GuidingCare Business Intelligence Module stands out with its unmatched standard features and integration of data into actionable reports and analyses. Alternative solutions fail to integrate clinical and claims data seamlessly, and competitor’s standard reports typically lack depth, resulting in a need for ad hoc solutions to bridge these gaps. GuidingCare addresses the complexities of modern health plans’ business by providing a comprehensive solution.

Comprehensive Reporting 

GuidingCare offers comprehensive standard reports that help health plans operate more efficiently and reduce business intelligence costs. These reports include quality improvement, preventive, operational, productivity, and trending reports, which provide transparency across the organization. GuidingCare also delivers clinical insights that show changes in risk scores, intervention success rates, and readmission rates by diagnosis-related group, care plan triggers, targeting populations, and program outcomes. By providing insights into gaps in care and the best interventions, GuidingCare helps improve member care and experience.

Seamless Cross-Module Integration and 360 View of Members

GuidingCare has a unique capability that enables seamless integration across various modules such as claims, utilization management, appeals and grievances, care management, and risk management. Unlike other solutions that only report on a specific module, GuidingCare combines all available data into a single comprehensive dashboard. This integration provides a complete view of the authorization process and patient journey, which assists payers in making more informed decisions and improving patient outcomes.

Team of Business intelligence Experts for Support and Customization

The GuidingCare Business intelligence team is a dedicated, certified team that offers premium services in managing, visualizing, and reporting data. The team comprises certified Tableau experts who provide expert technical and domain knowledge to support health plans. They specialize in rapidly creating and testing custom reports with advanced visualizations and ensure that these reports work seamlessly—including when significant system upgrades occur. The Business Intelligence team takes a proactive approach to product improvement and collaborates closely with clinical subject matter experts to ensure data is seamlessly captured and incorporated into workflows.

Operational Efficiency and Compliance

GuidingCare is designed to bridge gaps in care management through prebuilt reports that help health plans improve from day one. Over 20 CMS regulatory reports ensure compliance and aid successful audits. The solution’s self-service capabilities allow quick turnaround times and flexible reporting, further improving operational efficiency.

For more information from a third party on HealthEdge and care management, please see the 2023 Gartner Market Guide for U.S. Healthcare Payer Care Management Workflow Applications.

The Benefits of Next-Generation Business intelligence

Business intelligence in care management is a transformative force that drives strategic decision-making to optimize care and efficiency. Here’s how a GuidingCare Business Intelligence delivers a return on investment for health plans:

Business Impact

• Better insight through analysis of quality initiatives, health management, and allocation of resources.
• Improved decision-making by converting complex data into visualizations showing essential trends and patterns.
• Enhanced care management through population health analytics.

Operational Impact

• Reduce internal business intelligence costs and resource strain with ready-to-use reports at go-live.
• Increase transparency into business insights.
• Improve decision-making and operational efficiencies by helping to identify future and immediate needs.

Regulatory Impact

• Reduce internal resource effort to adapt to regulatory change and support audits with our pre-built CMS regulatory reports available at go-live.
• Reporting is available for review and validation throughout the year.
• Reduced resource needs by having updated reports based on requirement changes.

Modernize Your Business with GuidingCare Business Intelligence

As the healthcare industry becomes increasingly complex, incorporating an advanced care management business intelligence platform is no longer just an advantage but a necessity. GuidingCare Business Intelligence can unlock a new era of efficiency, compliance, and member-focused care. With the right business intelligence capabilities, health plans are better positioned to lead the charge toward a more sustainable, outcome-focused future, ensuring that every decision is data-driven and every care strategy is optimized for success.

To learn more about how GuidingCare Business Intelligence can accelerate your care management transformation, visit our VillageCare case study: Leveraging Business Intelligence to Accelerate Digital Transformation.