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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.

When it comes to claims processing, it’s easy to look at an error rate of 3-7% and be satisfied with your progress. But if you dig deeper, you may see a different, more concerning picture. Every year, health plans lose an estimated $86.49 billion dollars due to incorrect payments. Don’t get stuck spending valuable resources on just managing and reconciling data.

Ensuring payment integrity in healthcare is essential, but the process is full of hurdles and can be costly. You might find your health plan fighting against outdated or inaccurate edits, depending too heavily on external vendors, held back by a lack of customization and flexibility in your payment processes, and stuck in slow development cycles. These issues aren’t just annoying—they can lead to mistakes, inefficiencies, compliance risks, and a lot of frustration for both your members and providers.

Common Claims Editing Challenges for Health Plans

In a recent webinar, a HealthEdge® expert discussed how health plans can take control of business rules and create their own edits to improve claims processing. During the webinar, our audience reported that some of their biggest challenges include: relying on external partners, billing errors, and keeping up with regulatory changes.

These responses demonstrate health plan needs for more adaptable solutions, less reliance on third-party vendors, and staying up-to-date with regulatory changes.

We also found that 84% of the webinar participants heavily depend on external partners for managing intellectual property (IP). Relying on third-party vendors for important tasks like editing and rule creation can lock health plans into external systems and processes—making it more difficult to adapt to meet new regulations or adopt new systems.

Involved third-party partnerships can also become less cooperative, leading to external vendors benefiting from recurring problems instead of working together to solve them. Plus, depending on external vendors can be more expensive and introduce security risks over time.

 

 The Advanced Custom Edits (ACE) solution from HealthEdge Source™ puts the power back in your hands by offering an advantage over traditional approaches to payment integrity. With ACE, your health plan can create edits that are tailored to specific organizational policies and data. This means you won’t have to wait through lengthy development cycles or use more of your budget for external help. Plus, you have complete control over the final product, ensuring it aligns perfectly with your plan’s unique needs.

No one knows your data and policies better than your team. The ACE solution recognizes this and provides the efficiency and flexibility your plan needs to take ownership of your payment integrity processes. By empowering your team to create their own edits, ACE fosters a more collaborative and solution-oriented approach that leads to greater accuracy, efficiency, and cost savings.

Benefits of Advanced Custom Edits from HealthEdge Source™

HealthEdge Source™ is the ultimate solution for payment integrity. It seamlessly integrates with existing adjudication systems, providing a centralized platform to manage all your health plan’s editing requirements. Whether you require standard, custom, or third-party edits, Source efficiently handles them all with speed, accuracy, and transparency. Additionally, Source offers powerful analytics and reporting features to monitor your payment integrity performance.

Advanced Custom Edits are accessible through the Source user interface, equipped with all the familiar functionalities of Custom Edits. This point-and-click tool allows you to effortlessly create complex edits in the user interface, test the edits, and activate them in just minutes. Whether you need to rectify billing errors, modifier abuse, frequency limits, duplicate claims, downcoding, or any other payment integrity issue, you can accomplish it all with ACE.

The Advanced Custom Edits tool is here to put control back in your health plan’s hands. Some of the primary benefits of leveraging ACE include:

• Build edits based on your specific policies and data without waiting on external vendors or paying hefty fees.
• Create and update edits in minutes, without involving IT resources, to keep pace with changing regulations and policies.
• Ensure your edits are tailored to your health plan’s exact needs, minimizing errors and ensuring compliance.
• Prevent overpayments, underpayments, and fraud, saving you time and money.
• Easily understand how your edits work and share them with your team for better collaboration.

Benefits of Advanced Custom Edits from HealthEdge Source™

While there are many benefits of leveraging Advanced Custom Edits, we gathered three of the most valuable ways the tool impacts payment integrity processes for our health plan customers.

Reduce Duplicate Claims

Duplicate claims occur when the same service is billed more than once, either by the same or different providers. This can happen due to errors, miscommunication, or fraud and cause issues like overpayments, underpayments, or unnecessary costs.

With Advanced Custom Edits, health plans can create a duplicate edit that checks or compares any selected field, such as date of service, provider, CPT codes, modifiers, charges, and more. Users can also deny, adjust, and append claims as well as make a simple or complex duplicate edit.

Create Frequency Limits

Frequency limits restrict the number of units, visits, or services that a member can receive in a certain time period. They are based on medical necessity, clinical guidelines, or contractual agreements and can prevent overutilization, waste, or abuse.

With ACE, you can create a frequency edit to identify claims that exceed your frequency limits based on internal policy and data. Users can filter by fields such as CPT codes, modifiers, revenue codes, and providers, in addition to using different operators, such as equals, less than, greater than, etc.

Identify Downcoding

Downcoding is a practice where a provider bills a lower level of service than what was actually provided, or what was documented in the medical record. It can happen due to errors or misunderstanding. It can result in underpayments, compliance issues, or quality concerns.

With ACE, you can create a downcoding edit that detects claims that have a mismatch between the facility and the physician level of service, based on your policy and data. Like with Frequency Limits, users can filter by CPT codes, modifiers, type of bill, providers, as well as operators like equals, less than, or greater than.

Frequently Asked Questions about Advanced Custom Edits

How do users test the edits that you create with ACE?

Users can test the edits in several ways:

• Monitor Mode: Observe how your edits perform on live claims without affecting the adjudication process.
• Batch Processing: Run claims against your edits in bulk.
• Manual Claim Portal: Enter claims manually to see the results.
• Analytics and Reporting: Track and measure the impact of your edits.

How do users document or share the edits you create with ACE?

Use the notes feature within the tool to document or share edits:

• Add Notes: Include links, references, or any other relevant information.
• View Notes: See notes added by other users, including the date and user name.
• Audit Trail: Create a detailed audit trail and collaborate with team members and stakeholders.

Are there limitations or special permissions needed to access ACE?

There are no specific limitations or special permissions required to access Advanced Custom Edits. It is designed to empower teams to manage their own content and intellectual property.

Can you provide more information on how advanced custom edits can help reduce dependency on external partners?

The ACE tool reduces dependency on external vendors by allowing teams to enact their own policies, create custom edits specific to their needs, and centralize the payment integrity process by eliminating the need for new editing and post-pay vendor solutions.

Is ACE a replacement for existing custom edits or a new separate feature?

Advanced Custom Edits is a new feature developed to provide advanced custom editing capabilities. It enhances existing custom edits by offering more control and customization.

The recent HealthEdge webinar provides valuable insights for health plans seeking to improve payment integrity and reduce dependence on external vendors. The session provided information on payment integrity topics vital to many health plans, such as billing errors, modifier abuse, frequency limits, duplicate claims, and downcoding.

To discover how ACE can benefit your health plan’s payment integrity efforts, watch the webinar recording.

The traditional post-pay model has long been the standard in healthcare claims adjudication. However, it can result in significant administrative burdens and increased costs for healthcare payers. Providers are left to deal with the impacts, such as claim rejections that lead to financial setbacks and strained relationships.

A pre-pay model offers a solution by resolving errors before claims are paid. This proactive approach reduces costs and enhances the experience for payers and providers. By streamlining workflows and implementing robust pre-payment processes, health plans can expedite claims processing while reducing unnecessary payments and appeals.

Industry Trends Driving the Shift to Pre-Pay Review

As an industry, the increased focus on care quality and efficiency is changing how health plans deliver and reimburse for care services. As payers and providers strive to improve outcomes without increasing costs, 4 key components have emerged as most influential in supporting pre-pay initiatives.

• Value-Based Care: The shift toward value-based care models from fee-for-service highlights the need for accurate and timely payments. Pre-pay review supports this trend by making sure that providers are fairly compensated for the value of the care they deliver—thereby helping improve outcomes while controlling costs.
• Risk Adjustment: Risk adjustment models are becoming increasingly complex, making accurate coding and documentation crucial for maximizing revenue. Pre-pay review helps identify and correct coding errors before claims are submitted.
• Advanced Analytics: The availability of data and advanced analytics tools allows health plans to identify potential issues with claims more efficiently. This powers predictive models that can flag high-risk claims for pre-pay review, enabling health plans to address problems before they escalate. This proactive approach reduces the likelihood of claim denials and rework.
• Regulatory Compliance: Healthcare payers operate within a complex regulatory environment. Pre-pay review helps health plans ensure compliance with fraud, waste, and abuse regulations. By addressing issues upfront, health plans can avoid costly penalties and maintain a high standard of integrity.

Benefits of a Pre-Pay Model

A pre-pay model facilitates accurate claims reimbursements, helping payers accelerate transactions, identify root causes of incorrect payments, and decrease claim denial rates. It is a step forward in creating a more optimized and cost-effective payment ecosystem. Primary advantages of a pre-pay model include:

• Claim Accuracy: Reduces errors and denials by proactively verifying eligibility, medical necessity, and authorizations before payment.
• Administrative Efficiency: Minimizes manual intervention and risk of rework by identifying and addressing issues before claim submission.
• Cost Control: Prevents unnecessary services and detects fraud early, which can lead to substantial cost savings.
• Provider Relationships: Timely claim payments, fewer denials, and transparent communication foster trust and build strong provider relationships[AM2] . Health plans that prioritize accuracy and efficiency in claims processing are more likely to retain high-quality provider networks.

Challenges with Implementing a Pre-Pay Model

Implementing new processes and solutions can be complicated. From earning team buy-in and managing expectations to training and adoption, there are several hurdles health plans might face. But the right technology partner should be able to answer your questions and support your organization throughout the implementation process.

Data Integration

Integrating different data sources can be a major obstacle in implementing a pre-pay model. Health plans often rely on outdated systems that struggle to communicate with each other, impacting the accuracy and speed of pre-payment claim reviews. Leveraging an integrated payment integrity solution can facilitate data-sharing and claims processing.

Technical Barriers

Setting up and configuring new systems can be cumbersome and time-consuming. Upgrading infrastructure, implementing advanced analytics, and retraining staff require significant financial and time investments. Organizational buy-in is crucial to overcome adoption roadblocks.

Financial Considerations

Shifting to pre-payment requires upfront capital for new systems and ongoing operational costs. Despite the promising long-term benefits of a pre-pay model, health plans must carefully consider the financial implications of such a transition and prioritize their adoption timelines accordingly.

Cultural Transformation

Implementing a pre-pay model requires a cultural transformation within the organization. Employees must adapt to new roles and responsibilities, and health plans must foster a culture of continuous improvement and innovation. Effective change management strategies from the beginning of the process are vital for maintaining long-term commitment.

Prospective Payment Integrity Solution for Pre-Pay Accuracy

To make this transition easier, we have designed HealthEdge Source™, an integrated prospective payment integrity solution. Source can support payers across all lines of business, providing real-time claims audits and analytics while addressing common challenges associated with pre-pay implementation.

The Source platform can enable the transition to a pre-pay model through:

• Data Integration and Standardization: Leverage up-to-date information from claims, members, providers, and contracts—all seamlessly combined and standardized accurate analysis.
• Comprehensive Content Library: Access the latest clinical, coding, and payer guidelines, updated bi-weekly to ensure claim accuracy. This comprehensive content library helps health plans stay current with industry standards and best practices.
• Advanced Automation: Accelerate claim processing through real-time, cloud-based editing and pricing features that reduce manual intervention.
• Robust Analytics: Identify trends, patterns, and anomalies across your payments data to inform data-driven decisions and workflow optimization.
• Flexible Configuration: Adapt to your health plan’s unique needs with flexible and user-friendly configuration options.
• Reduced Vendor Dependency: Manage edits in-house and increase how much control your plan has over payment integrity.

How HealthEdge Source Supports Pre-Pay Review

Identifying Potential Issues Early

By applying comprehensive edits and analytics, Source can flag claims with potential errors before payment is issued. This early identification helps prevent costly mistakes and reduces the need for rework.

Improving Claim Accuracy

Addressing upfront issues helps reduce claim denials, appeals, and rework, leading to increased claim accuracy. Health plans can ensure that claims are processed correctly the first time, enhancing overall efficiency.

Enhancing Operational Efficiency

Automation and streamlined workflows contribute to faster claim processing and reduced administrative costs. Health plans can allocate resources more effectively, focusing on strategic initiatives rather than manual claim reviews.

Supporting Data-Driven Decision-Making

Source provides valuable insights into claim trends and performance metrics, enabling data-driven improvements to the pre-pay review process. Health plans can use this information to continually refine their processes and achieve better outcomes.

Adopting a new payment model comes with distinct challenges, but your health plan doesn’t have to do it alone. HealthEdge Source offers more than just a solution for payment integrity—it helps drive enterprise-wide transformation. By optimizing workflows and establishing strong pre-payment processes, health plans can expedite claims processing while minimizing unnecessary payments and appeals.

To learn more about how a regional health plan partnered with Source to improve efficiency and reduce payment complexity, visit our case study.

In a dynamic marketplace, member engagement helps strengthen healthcare market competitiveness for healthcare payers. Health plans that leverage digital engagement solutions can enhance their appeal to employer groups and members across lines of business while achieving substantial cost savings. 

According to the 2024 HealthEdge® Consumer Survey, one-third of health plan members are “very likely” or “likely” to switch insurance plans in the next year. Personalization, transparency, and convenience topped the list of factors most influencing member satisfaction.  

Use Member Engagement for Marketplace Differentiation 

Digital solutions like Wellframe can amplify the impact of healthcare interventions, increasing workflow efficiency and broadening member reach. Wellframe enables health plans to distinguish themselves in a crowded market by offering an integrated, enhancing healthcare market competitiveness by offering an integrated whole-person platform that streamlines workflows and reduces reliance on point solutions. Members can directly engage with their health plan and providers, simplifying the user experience and improving benefits access. 

Health plans that utilize Wellframe have reported significant improvements in member satisfaction, engagement, and clinical outcomes—which contribute to higher retention rates and a stronger market position. Plus, payers can leverage their integrated Wellframe offerings as a value proposition during the RFP process and open enrollment to attract new business. 

Deliver Comprehensive Benefits for Employer Groups 

Employers are increasingly looking to provide their employees with comprehensive benefits that directly affect health and wellness. Wellframe addresses this need through a range of accessible features designed to help health plans achieve organizational goals, such as cost savings, improving satisfaction rates, and reducing vendor reliance. 

Cost savings: Coordinated care management drives cost savings, reducing overall healthcare expenses. The Wellframe solution offers up-to-date information on members’ unique health needs, making it easier for care managers to prioritize outreach and deliver proactive support that lowers long-term care costs. 

High satisfaction rates: Wellframe’s staff dashboard offers tools that enable decision support and facilitate member engagement. Care managers receive alerts based on member risk data, and a HIPAA-compliant chat feature allows them to send messages for members to respond to on their own time. By offering an intuitive and accessible platform, Wellframe increases member satisfaction and engagement with their health benefits.  

Vendor Reduction: Managing multiple vendor relationships and coordinating between multiple systems can be a logistical challenge for employer groups. With more than 70 digital care programs, Wellframe eliminates the need for distinct point solutions by providing an integrated platform that supports a broad spectrum of acute and chronic conditions. The Wellframe solution streamlines administration and reduces the complexity of managing employee health benefits. 

Retain and Win New Members Across Lines of Business  

Wellframe’s platform provides a strategic advantage for retaining and attracting new members across lines of business, including Medicare, Medicaid, and Commercial populations. 

Government Lines of Business 

Achieving high member satisfaction is critical for favorable Consumer Assessment of Healthcare Providers & Systems (CAHPS) scores, which, in turn, contribute to a plan’s Star Rating. Improved Star Ratings not only enhance a plan’s reputation but also lead to increased federal bonus payments and boosted member enrollment. Wellframe’s digital engagement solutions help health plans improve CAHPS scores by providing personalized, consistent support to high-risk and rising-risk members. 

Commercial  

For commercial populations, high rates of member satisfaction can be a powerful marketing tool for attracting new members and retaining existing ones. Offering Wellframe as a solution positions health plans as modern partners in member engagement and satisfaction. Potential members will also compare health plan offerings during open enrollment to find the best fit. A member engagement solution with demonstrated results can drive interest and increase enrollment. 

It’s easier to engage members in their health by providing value upfront with easy-to-access resources and communication tools. This proactive approach significantly improves member experiences and satisfaction, leading to high rates of member retention as well as boosting healthcare market competitiveness. 

In an increasingly competitive healthcare market, member engagement and satisfaction are crucial for success. Wellframe’s digital health management platform offers a comprehensive, unified solution that enhances member satisfaction, reduces costs, and improves Star Ratings. By leveraging the Wellframe solution, health plans can differentiate their offerings, provide superior benefits to employer groups, and retain and attract members across lines of business. 

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To learn more about how the Wellframe solution can help your health plan drive member engagement and satisfaction, watch the webinar on-demand: “Using Digital Care Management to Meet Members & Care Managers Where They Are.” 

Hear about the strategies other health plans use to integrate digital engagement solutions into care management workflows and meet members across the risk pyramid.