Future-Proof Your Claims-Payment Capabilities: Insights from Gartner® for Health Plans

In the ever-evolving landscape of health insurance, claims editors play a pivotal role as the first line of defense against inaccurate claim submissions. These editors are vital for the success of payment integrity programs as well as the pursuit of real-time claims processing environments of the future.

According to Gartner, “At a minimum, claims editors are meant to reduce appeals, decrease payment inaccuracies and ensure compliance. Additionally, changes within your lines of business and future needs can lead to more extensive requirements and expectations of claims editors. Situations that can point to growing complexity in claims editing include:

• Increasingly complex value-based payment agreements.
• Providers’ growing use of alternative coding methods for revenue cycle gain.
• Self-funded employers’ demands for greater transparency.”

At HealthEdge^® Source, we help health plans navigate these claims editing and payment complexities with our modern Source Editing solution. Now is the time for health plan CIOs to re-evaluate existing claims editing technologies to ensure they are prepared to meet the future demands of real-time claims processing.

Evaluation Considerations for Future-Proof Claims Editing Solutions

In addition to the core capabilities of claims editing solutions, it is essential for claims editing solutions to support customized edits. Source not only delivers out-of-the-box edits, but the solution also supports the ability for users to customize edits that meet their unique contract and business requirements.

It is also essential for users to have clear visibility into the edits applied to different groups through user-friendly dashboards. Source delivers edit results via dashboards through its Audit Trail and Retroactive Change Manager capabilities. This transparency reduces dependencies on editing vendors, minimizes contingency fees, and empowers health plans to eliminate recurring errors.

In a future-proof claims editing solution, users should also be able to perform proactive reviews of edits before placing them into production. With Source, health plans can process claims in Monitor Mode to run what-if scenarios and better understand the impact of edits.

As more health plans transition from legacy core administrative processing systems (CAPS) to more modern, cloud-based platforms, claims editing solutions must be able to keep pace with the higher levels of interoperability these CAPS can facilitate. Source integrates with virtually every major CAPS on the market today. Plus, the new Payer-Source solution, which is the productized integration between HealthEdge’s CAPS (HealthRules Payer) and HealthEdge Source, delivers seamless integration, a more consolidated vendor stack, a single source for customer support, and a more unified long-term vision.

The Future of Real-Time Claims Processing

At Source, we are disrupting the mature space of claims editing by providing pricing and editing in a single call to deliver more comprehensive, accurate results. We are enabling payers to resolve issues further upstream for continuous improvements and significant savings on contingency fees from claims editing vendors.

By ensuring your claims editor aligns with your current and future needs, you can mitigate the risks of inaccurate claims processing, streamline operations, and provide better experiences for members and providers alike.

For further thought on the topic of future-proofing your claims editing solutions, download your complimentary copy of the 2023 Gartner How U.S. Healthcare Payer CIOs Can Future-Proof Claims Editing report today.

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. and/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 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.