Ensuring accurate claims payments can be difficult and fixing errors can be costly. And health plans face challenges throughout the payment process. Multiple rounds of editing, pricing, and review leave payment integrity pitfalls for your organization to fall into. A billion-dollar market has been built around detecting payment inaccuracies—and it continues to grow.
59% of organizations listed “in-sourcing payment integrity functionality” as a . While outsourcing aspects of payment integrity can help organizations scale their operations, it can also lead to loss of data visibility, increased operating costs, and reliance on contingency vendors.
How can your organization promote greater payment accuracy while reducing costs?
Here are three ways a payment integrity solution like HealthEdge Source can impact your health plan.
1. Combine pricing and editing capabilities in one place.
75% of organizations said it would be “very valuable” to Consolidating solutions can help improve efficiency by bringing key information together, rather than taking extra time gathering fee schedules from multiple locations.
HealthEdge Source users, for example, can leverage native content including CMS, Medicaid, and AMA policies in one place—without the need for additional integrations. Having third-party best-of-breed content available within a single resource enables health plans to gain greater visibility into the payment process and organizational inefficiencies.
2. Improve visibility and analytics
Enable analytics by bringing pricing and editing information—for claims across all lines of business—into one place. See top providers, DRGs, CPT codes, and other insights that make it easier to understand how new policies could impact your claims.
It can be easy to fall into a pattern of relying on a vendor to detect certain issues and patterns without diving deeper into why these errors occur. Leveraging a single solution can reduce administrative burden and reduce the opportunity for mistakes, such as inputting incorrect fee schedules. Instead of trying to pull data from multiple cap systems and present it together, your organization could gain visibility into the root causes of inaccurate payments.
3. Reduce IT burden
Some organizations have reported spending up to a week updating fee schedules in 6 or more places. Each of these platforms has different upload requirements and requires IT support. If IT can’t deliver help in time and there’s an error, then you’d have to rely on a vendor solution to catch it later in the workflow.
This is where bringing pricing and policies together is important. If your team is managing fewer solutions, they’re able to work more efficiently and with a deeper knowledge of the platforms they’re using. There will also be less demand for IT and other internal stakeholders to keep software and other technology up to date.
This is not to say contingency vendors can be beneficial. However, eliminating more straightforward issues like reoccurring overpayments can open the door for vendors to focus on solutions for new and more complex issues. Once your health plan has a single solution in place, your teams can identify leakage in the workflow, understand why it’s happening, and move that information upstream to the primary editing space to ensure more accurate reimbursements.
Shifting from multiple solutions to a single platform doesn’t have to happen all at once. To learn more about the HealthEdge Source payment integrity solution, visit our guide, “Beyond the Basics: The Modern Approach to Payment Integrity Vendors With HealthEdge Source.”