Critical Criteria for Future-Proofing Claims Editing Software

As the U.S. healthcare system is undergoing rapid transformation, many health plans are looking to modernize their core administrative processing systems (CAPS). In fact, according to the 2023 Gartner® How U.S. Healthcare Payer CIOs Can Future-Proof Claims Editing report¹, “Increasing member expectations and operational demands are pushing payer CIOs to modernize their core administration systems.” A recent Gartner survey shows that:

• 60% of respondents are moving their core administration system from on-premises to the cloud.
• 34% are consolidating to a common platform.
• 26% are replacing proprietary solutions with commercial off-the-shelf (COTS) solutions.
• 17% are re-platforming to a modern architecture.”

However, the report also warns that the business goals associated with transitioning to more real-time claims processing are in jeopardy if CIOs do not simultaneously consider the capabilities of their claims editing solutions.

“With the modernization of claims administrative processing systems (CAPS), new business requirements and a heightened focus on real-time operations and interoperability, you need to reevaluate your claims editor’s performance.”¹

This report provides detailed questions CIOs should use to evaluate claims editing solutions and ensure they can be prepared for the future. The Source team offers these answers in response to the Gartner proposed evaluation criteria.

Modern Claims Editing Solution

Core Capabilities of Source Editing Solution

• Supports all lines of business in a single platform,
• Seamlessly integrates with virtually every major CAP system and offers complete interoperability with its sister product, HealthRules Payer (Payer-Source).
• Cloud-based solution means all maintenance and support costs are included in the monthly subscription fee, and all pricing and policy updates are proactively applied every two weeks, reducing IT and administrative burdens.
• Clients average a 30+% increase in first-pass adjudications.
• Clients find cost savings through many different edits, including validation, reimbursement, payment and billing guidelines, and medical necessity.
• Supports 39 months of claims history to help identify improper payments.
• Clients can easily customize any existing edit in Source libraries or build a custom edit in minutes.
• And much more!

Advanced Capabilities of Source Editing Solution to Support Future-Proof Initiatives

• By design, Source includes a real-time Analytics module that models claims after the editing, pricing, and audit processes occur for our client’s core claims adjudication. Source real-time analytics are run continuously and automatically.
• Source features a centralized advanced audit trail with rich data and reporting to provide complete transparency for audit and provider relations teams.
• Source allows users to set an edit to Monitor Mode to review its impact before it is put into production.
• All new edits/policies are delivered to the non-production environment where they can be tested, promoted to production in the “off” mode, and then instantaneously turned on through the system and published by the end user as needed for their required timelines.
• And much more!

Claims editing solutions’ critical role in enabling a real-time claims processing environment cannot be overstated. But even if organizations are not undergoing massive system transformations, the Source Editing solution can deliver powerful savings without changing anything in the existing editing stack.

For example, in recent data studies conducted by the Source team, millions of dollars in savings were identified when Source was placed in front of third-party editing solutions.

• 7M Medicare Advantage claims spend $648M, resulting in a $11.1M savings opportunity for a mid-size regional health plan
• 1M Medicaid claims spend $571M, resulting in a $9.1M savings opportunity for a large regional health plan
• 1M Medicaid and Dual Eligible claims spend $790M, resulting in a $8.7M savings opportunity for a national health plan

¹ Source: Gartner, How U.S. Healthcare Payer CIOs Can Future-Proof Claims Editing. Austynn Eubank, 20 April 2023. GARTNER is a registered trademark and service mark of Gartner, Inc. or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved. 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’s 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.