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Tools: From the Garage to Health Plan Administration

HealthRules Payer® gives plans the tools to succeed as the No Surprises Act and industry regulation evolves.

When it comes to home repair, there isn’t a lot of tool flexibility. A 1/8” Allen wrench cannot be substituted for a 3/16” Allen wrench and a Phillips head screwdriver won’t help with a flathead screw.  Every home renovation project seems to add another tool to your toolbox.

Digital tools, however, are a different story. Consider even a common tool like Microsoft Excel. While many of us use this software to perform basic calculations, we are barely scratching the surface of its capabilities. Excel is a powerhouse, and users who have taken the time to unlock more of the tool’s abilities are running advanced analytics and macros to feed critical business decisions.

From the health plan perspective, the constant evolution of health care practices, policies and communication standards can be much like the never-ending stream of repairs and renovations faced by homeowners. Health plans that invest wisely in their technology, however, can avoid an overflowing ‘toolbox’ and leverage the power and flexibility inherent in existing solutions – even as their operational and process renovation projects evolve.

The Challenge of Regulatory Evolution: The No Surprises Act

A particularly timely example is the No Surprises Act (NSA). This recent legislation requires significant revisions to the current administrative processes of most health plans, requiring plans to:

  • limit member cost-sharing responsibilities
  • manage out-of-network provider bills with federally regulated qualifying payment amounts
  • establish web-based provider directories and price comparison tools for healthcare services
  • prepare for anticipated guidelines around providing members with advanced explanations of benefits (AEOBs) detailing both pricing and individualized accumulator information

For some plans, this may feel like an overwhelming list of processes to develop and/or overhaul. But the tools for the job may already be at hand. For example, HealthRules Payer is a Core Administrative Processing Solution (CAPS) with existing technology to:

  • manage conditional payment structures
  • combine provider-level pricing information with individual level plan and accumulator data
  • generate accurate claims data after, or in advance of a scheduled service, without triggering a claims payment

These are the foundational functions underlying many of the NSA requirements, and many plans may not be aware of the functionality that already exists in their HealthRules Payer solution. For example, HealthRules Payer has Trial Claim feature, used to prospectively review various claims payment arrangements in a test environment. This same function can be used to populate price comparison data and accurately generate claims information in advance of scheduled services. In addition, HealthEdge is continuously adding new platform features.

HealthEdge is an industry-specific technology partner and is staffed by leaders passionate about technology and healthcare – including policy. The HealthEdge team is continually innovating, serving clients with new features and platform upgrades that occur automatically with no disruption to day-to-day operations. With the NSA top of mind across the industry, soon-to-be-released HealthRules Payer features will make it even easier for plans to succeed in the existing and evolving regulatory environment.

Building on Success

With a robust and flexible CAPS, payers can meet new regulatory requirements using existing and flexible features. And, much like complex home repair projects, it will pay off to have the right partner on board. HealthEdge clients have the benefit of our deep industry expertise and technical know-how at their fingertips, making it easy to nail regulatory compliance now and into the future.

What can HealthEdge do for you? See how in our No Surprises Act Data Sheet.

About HealthEdge

HealthEdge® is the health insurance industry’s first digital nervous system to provide automation and seamless connectivity between all parts of a payer’s administrative and clinical systems. HealthEdge provides modern, disruptive healthcare IT solutions that health insurers use to leverage new business models, improve outcomes, drastically reduce administrative costs, and connect everyone in the healthcare delivery cycle. Its next-generation enterprise solution suite is built on modern, patented technology and is delivered to customers via the HealthEdge Cloud or onsite deployment. In 2020, funds managed by Blackstone became the majority owner. HealthEdge and its portfolio of mission-critical technology assets for payers, including HealthRules Payer®, Source, GuidingCare® and Wellframe are collectively driving a digital transformation in healthcare. Follow HealthEdge on Twitter or LinkedIn.