Building a More Intelligent Payment Integrity Process: AI Enhancements in HealthEdge Source
In a recent webinar, our HealthEdge Source™ product leaders demonstrated how our teams are integrating artificial intelligence (AI) into our solutions to enhance experiences and outcomes for health plans. Their presentation delved into practical solutions to common health plan challenges—like using automation to streamline workflows and using advanced analytics to make claims operations more efficient.
At HealthEdge®, our goal is to create a smoother and more intelligent claims process using AI and machine learning. In this blog, we’re highlighting some of the key enhancements customers can expect from HealthEdge Source.
Using AI for Better Context in Retroactive Change Management
One of the most challenging aspects of healthcare claims management is discovering, often too late, that previous decisions or policy adjustments have led to a cascade of errors. The HealthEdge Source Retroactive Change Management (RCM) tool helps flag these issues. However, the current version of the solution only displays the dollar discrepancies without sufficient context.
This year, we plan to use large language models to enhance RCM outputs by explaining not just the what behind discrepancies, but the why. For example, instead of just noting that a claim amount differs post-adjustment, the tool will clarify the causes behind these changes, such as specific policy updates or edit rules. This added layer of clarity empowers users to address root causes more efficiently and reduces guesswork.
How AI Can Make Data Easier to Interact With
Reviewing and gleaning insights from vast datasets is a daunting task, especially when understanding claims and contracts requires complex queries and cross-checks. Our team is determined to simplify this process by integrating natural language processing (NLP) into the HealthEdge Source solution.
Through NLP, users will be able to interact with data more intuitively, asking direct questions about claims, payment trends, or configuration impacts with responses provided in user-friendly formats. Instead of navigating endless spreadsheets or relying heavily on IT teams to extract insights, this feature allows users to interact with our data conversationally, bridging the gap between questions and actionable answers.
Reducing Fraud, Waste, and Friction Through AI
The payment integrity lifecycle is known for its inefficiencies. Claims pass through multiple manual reviews and technology systems, creating opportunities for errors and delays. Over time, this not only increases costs, but also erodes trust between providers and payers.
By embedding AI in the HealthEdge Source, we aim to automate the process of identifying and preventing fraudulent claims. AI capabilities enable the solution to identify patterns within claims data, flag recurring issues, and even suggest corrective actions. This helps shift error detection earlier in the cycle, reducing the necessity for post-payment corrections. By proactively solving problems rather than reacting to them, HealthEdge hopes to minimize waste and inefficiencies for health plans.
The Next Frontier with Agentic AI
HealthEdge Source isn’t satisfied with small, incremental changes. Our goal is to fundamentally reshape the payment integrity ecosystem by applying advanced technologies like agentic AI to unlock what’s possible. With a system designed to accurately predict outcomes, safeguard clinical integrity, and minimize errors, it paves the way for a more effective and equitable payment process. The future holds even more exciting advancements as we refine and expand these technologies to deliver greater accuracy and scalability across the payment ecosystem.
Looking Ahead
Together, we’re building a more efficient, reliable, and equitable payment system that works for everyone. And this is just the start. Stay tuned as HealthEdge Source continues to lead the way.
To learn more about the ways HealthEdge is helping transform health plan operations through AI-powered solutions, read the data sheet: Transforming Operations and Care Delivery Through Advanced AI Capabilities.
