Gartner Hype Cycles provide a graphic representation of the maturity and adoption of technologies and applications, and how they are potentially relevant to solving real business problems and exploiting new opportunities. Gartner Hype Cycle methodology gives you a view of how a technology or application will evolve over time, providing a sound source of insight to manage its deployment within the context of your specific business goals.**
In the Gartner Hype Cycle for U.S. Healthcare Payers, 20231 report, HealthEdge was mentioned as a Sample Vendor in three major categories. This blog dives into each of these trends and presents a more detailed description of HealthEdge’s representative solutions in each of these innovation areas.
1. Next-generation core administrative processing solutions (CAPS):
According to the report, “Next-generation CAPS enable payers to manage their enrollment, premium billing, claims processing and payment operations more nimbly than with legacy applications. Solutions must meet the following criteria: support cloud delivery models; allow clients to configure policies and processing rules without IT; decouple modular business functions and support third-party module integrations; enable value-based payment; and provide configurable interfaces.”
HealthEdge offers HealthRules® Payer as its next-generation CAPS, supporting plans of all types and sizes. For more than 10 years, health plans implementing HealthRules Payer have been able to quickly address market opportunities and stay ahead of their competition. They have done this with high levels of customer and provider satisfaction and transparency by providing accurate, real-time information to everyone involved in the care continuum. Simultaneously, those health plans have also significantly lowered administrative costs by automating their critical manual business processes, resulting in an enhanced bottom line.
2. Prospective Payment Integrity (PPI):
According to the report, “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. They incorporate claims editing, data mining and complex clinical review, as well as advanced analytics and AI. PPI solutions mitigate a broad range of potentially improper claims payment activities by identifying, and correcting for, claims inaccuracies prior to claims payment.”
HealthEdge’s PPI solution, HealthEdge Source™, offers the ability for payers to unlock transformation at the reimbursement, payment integrity, and enterprise level. Our Reimbursement Transformation features Medicare and Medicaid content coupled with flexible contract configuration capabilities for Commercial and Government lines of business. Payment Integrity Transformation includes rich editing libraries with history-based capabilities, easy development of customized edits, and improved transparency to reduce vendor dependency and increase control. As a complete solution, clients can achieve Enterprise Transformation, where root-cause issues are identified and addressed upstream, and all aspects of claims operations are centralized for comprehensive business intelligence.
3. AI-enabled fraud detection:
Gartner introduced this innovation for the first time in 2023. According to the report, “Fraudulent claims affect the entire healthcare ecosystem negatively, add to the rising cost of healthcare and decrease the quality of care for patients. AI-enabled fraud detection solutions employ AI algorithms and machine learning (ML) capabilities to identify, predict and prioritize suspicious claims, providers, and even patients or members. They go beyond traditional rule-based approaches to model and act on emerging and increasingly sophisticated fraud schemes.”
HealthEdge’s report generation and case integration capabilities help fight fraudulent claims that raise costs and lower the quality of care across the entire healthcare ecosystem. HealthEdge solutions seamlessly integrate with AI and machine-learning engines that detect fraud. On the company’s future roadmap, partner integrations in development will provide HealthEdge customers with built-in fraud detection technology.
In addition, HealthEdge Source is working to apply AI to the process of analyzing the impact of Medicare payment policy changes, many of which are retroactive to a previous date. With the upcoming AI enhancements, business leaders can augment the existing solution and unlock insights within their data to analyze the impact those changes will have on specific providers, regions, configurations and contracts.
For more information on HealthEdge’s leading-edge solutions that are represented in the Gartner Hype Cycle for U.S. Healthcare Payers, 2023, visit www.healthedge.com.
Source: **Gartner Research Methodologies, " Gartner Hype Cycle", "September 1 2023", https://www.gartner.com/en/research/methodologies/gartner-hype-cycle
1Gartner, Hype Cycle for U.S. Healthcare Payers, 2023. Mandi Bishop, Connie Salgy, Austynn Eubank, 10 July 2023.
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