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HealthRules® Payer Horizons: Automating regulatory compliance and accuracy

To remain competitive, payers are increasingly adopting integrated digital technologies that help improve efficiency and reduce costs. Make sure your Core Administrative Processing System (CAPS) is providing the real-time information your health plan needs to maintain accuracy and compliance. This 5-part blog series, entitled HealthRules® Payer Horizons, highlights a few of the key ways our CAPS solution is empowering payers to take full advantage of market opportunities.

Read the entire series at the links below:

Simplify regulatory compliance with HealthRules® Payer

Healthcare payers are facing pressure from all sides, with high member expectations, regulatory changes, staffing shortages, and rising costs among the top challenges. Many health plans are turning to digital transformation to gain a competitive advantage and better serve their members. A Core Administrative Processing System (CAPS) that meets these needs is one of the most significant investments your health plan can make.

HealthRules® Payer (HRP) is a modern CAPS solution that automates compliance regulation, enabling you to streamline existing workflows and respond to new opportunities in real-time. Using HealthRules Payer, your teams will spend less time manually adjusting payments—streamlining the claims editing process and making it easier to save money on retroactive changes. Regulatory compliance can also improve Star ratings, with 4.5-star health plans having a 5% revenue advantage over 3.5-star plans.

As an organization, HealthEdge® is dedicated to simplifying regulatory compliance and transparency through innovative solutions. For HealthRules Payer, that includes features payers need to maintain efficiency while satisfying the demands of members, providers, and regulators.

1. State and federal legislation monitoring 

HealthRules Payer continually monitors federal and state-level legislation across Medicare, Medicaid, and Commercial lines of business. This information is automatically updated within the system to ensure regulatory compliance and reduce the need for manual editing and resubmission. HRP customers regularly achieve auto-adjudication rates of more than 90%—and financial accuracy up to 99%.

Healthcare payers rely on HRP to automate regulatory compliance so they can focus on larger organizational goals.

2. Compliance-based strategic planning 

The intentional design of HealthRules Payer makes it easy for users to access the information they need to develop a comprehensive strategy. Customers can leverage controlled and comprehensive modeling of new product designs and provider pricing methodologies based on specific business rules and compliance programs. With HRP, health plans can establish modeling during employer negotiations, leading to quicker turnaround of new product offerings, better customer service, and increased sales.

3. Reliable collaboration and support 

Customers working with HealthRules Payer receive personalized support. Health plans can vet their support strategies with the HRP Steering Committee, as well as hold monthly meetings to assess progress toward key business goals.

For the third year in a row, HealthRules Payer was named “Best in KLAS®” for Claims & Administration Platforms. In the KLAS survey of existing HRP customers, 100% of respondents said HealthEdge solutions are part of their long-term plans.

4. Cloud-based delivery model 

A cloud-based repository makes it possible for health plans to communicate strategy and compliance artifacts within HealthRules Payer while tracking an annual+ roadmap of compliance initiatives. Cloud-based solutions also facilitate real-time integrations with third-party systems, leading to more cost-effective and lower-risk IT ecosystem maintenance. In addition, they offer continuous monitoring, remediation, and patching to free internal IT teams to focus on higher-value objectives.

Companies using cloud services are held to rigorous security and confidentiality standards, meaning member protected health information (PHI) and sensitive payer data are guarded.

Do you want to learn more about how HealthRules Payer can help your health plan stay compliant with the No Surprises Act and other regulations? 

Read our data sheet, “Navigating the No Surprises Act: The Right Tools for Health Plan Success” to see how our solution empowers customers to increase auto-adjudication, give members personalized cost-sharing information, easily configure out-of-network services, and more.


About the Author

Maggie Brown has over 30 years of leadership experience in healthcare and insurance marketplace. Maggie transitioned from health plan management roles to implementing core business solutions for numerous health plans around the country. With the enactment of HIPAA, the Balanced Budget Act, and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 she focused on how to ensure a health plan could implement key technology solutions, meeting the needs of their members, while being compliant in a rapidly changing regulatory environment. Maggie has led implementations for government programs at both new and established managed care companies. Maggie holds a Doctor of Religious Arts degree with a major in Pastoral Psychology.