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HealthRules® Payer Horizons: Enabling Health Plan Automation With Integration

To stay ahead in the constantly evolving healthcare sector, payers are adopting digital solutions that put automation and accuracy at the core of every workflow. It’s critical that your Core Administrative Processing System (CAPS) delivers the most up-to-date data available so you can improve automation rates and streamline processes. Our five-part blog series, titled HealthRules® Payer Horizons, demonstrates how our CAPS solution empowers payers to adapt to meet new market opportunities.

Read the entire series at the links below:

Take advantage of end-to-end automation with HealthRules® Payer

In today’s healthcare landscape, the pressure to reduce costs and simultaneously enhance operational efficiency is more intense than ever for health plan leaders. Amidst this complex industry, automation emerges not just as a solution but as a strategic imperative for health plans seeking to invest in. HealthRules Payer is a platform uniquely designed to leverage the power of end-to-end automation to streamline operations and improve efficiency.

By harnessing the automation capabilities of HealthRules Payer, health plans can dramatically reduce administrative burden, streamline redundant processes, and optimize resource utilization. Equally critical is maintaining regulatory compliance in a strict and shifting environment. Through regular, automated updates, HealthRules Payer ensures that health plans remain compliant—significantly mitigating the risk of costly resubmissions.

Leveraging advanced automation will also let your plan reallocate manual resources toward higher-value work.

For health plan executives, the message is clear: leveraging end-to-end automation with HealthRules Payer not only addresses the immediate challenge of cost pressures but also unlocks the potential for strategic growth and sustainability.

1. Improve operational efficiency  

Streamline workflows and create efficiencies by automating the claims adjudication process and saving manual reviews for what matters most. With HealthRules Payer, our health plan partners regularly achieve auto-adjudication rates over 90%, and claims accuracy of 99%.

For one metropolitan non-profit health plan, leveraging HealthRules Payer led to:

  • 96% increase in auto-adjudication rate for Medicare claims processing
  • 95% decrease in pending claims
  • 0 claims aged over 15 days on a monthly basis

2. Increase productivity and transparency

By automating more of the claims review process, your health plan can reduce complexities and administrative burdens associated with manual reviews. Plus, the HealthRules Payer platform is regularly updated with the latest payment regulations to reduce repayments and adjustments—saving time and money. For one customer, automating key processes led to savings of more than $1.6M.

3. Leverage auto reprocessing capabilities

The HealthRules Manager feature within HealthRules Payer allows your health plan to make adjustments based on your specific criteria to reduce reprocessing times. HealthRules Manager also allows users to manage membership, providers, billing and commissions, pricing, cost estimators, pricing transparency, and integrations with care and utilization management tools.

4. Support remote operations with hyper-automation

Accelerate payment accuracy and advanced configurations with integrated end-to-end system automation—what we call hyper-automation. By bringing disparate systems together and controlling information processing this way, your health plan can adapt more easily to industry demands and shifting payment guidelines. HealthRules Payer can integrate with your existing technology suite, as well as HealthEdge Source for payment integrity, GuidingCare® for care management, and Wellframe for member engagement.

Do you want to learn more about how HealthRules Payer can lower production time, reduce errors, and easily build audits across claims environments? 

Read our Case Study, “HealthRules® Promote Empowers Medica Health Plan to Streamline Processes” to see how our solution empowers customers to drive efficiency and quality.”