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HealthEdge Source™ Horizons: Ensure Regulatory Compliance & Cost Transparency

Healthcare payers are turning to innovative digital solutions to maintain payment integrity. But ever-shifting guidelines can make it challenging to pay claims accurately the first time—costing time and money. It’s critical that your Prospective Payment Integrity solution operates using the most up-to-date regulatory information available so you can streamline workflows and improve accuracy. Our five-part blog series, titled HealthEdge Source Horizons, demonstrates how our Prospective Payment Integrity solution empowers health plans to remain compliant with ever-shifting regulations.

Read the entire series at the links below:

As we move through 2024, the healthcare landscape is undergoing a significant transformation. Regulations such as the Transparency in Coverage (TiC) mandate and the No Surprises Act (NSA) are reshaping how payers interact with members and providers.

The Transparency Imperative

The Transparency in Coverage mandate represents a major shift in communication between payers and members. It demands unprecedented levels of clarity regarding cost and coverage, empowering consumers to make informed decisions–with the goal of fostering a more competitive and cost-effective healthcare market.

Protecting Patients from Surprise Bills

The No Surprises Act protects patients from unexpected bills for out-of-network services. Additionally, it establishes a new process for resolving billing disputes and eliminates “gag clauses” that prevent providers from discussing costs with patients.

While each regulation brings its own set of challenges, the underlying goal is clear: to promote transparency, efficiency, and patient empowerment within the healthcare system. For your health plan, navigating compliance with these regulations presents an opportunity to redefine your role and positively impact the healthcare continuum.

How HealthEdge Source™ Enables Payers to Remain Compliant

At HealthEdge Source, we understand the challenges and opportunities arising from the TiC mandate and NSA. We’re committed to empowering health plans and their members through data and pricing transparency.

Simplifying Transparency in Coverage

Maintaining compliance with the TiC mandate can be an ongoing challenge. This regulation necessitates that health plans make healthcare price information readily available to members before they receive services or incur any charges. The initial phase requires this data to be shared in a Machine-Readable File (MRF).

HealthEdge Source solution adheres to Centers for Medicare & Medicaid Services (CMS) mandates while accommodating your specific needs and system capabilities. With this platform, your health plan can:

  • Generate MRFs containing specific rates based on your configurations within the HealthEdge Source system.
  • Conveniently schedule and produce MRFs through a user-friendly interface (UI).
  • Offer both monthly (as required) and on-demand scheduling choices.
  • Calculate rates based on specific services and modifiers, going beyond configuration-based data.
  • Incorporate data dictionary updates alongside MRFs to ensure clear data comprehension.

No More Surprises

Price transparency is at the core of our commitment to empowering both you and your members. Our Price Comparison Tool, seamlessly integrated with HealthRules® Payer, allows you to provide members with personalized cost estimates for various services and treatments. This promotes informed decision-making and compliance with both the NSA and TiC regulations.

Furthermore, we simplify compliance with the NSA through the Trial Claims functionality within HealthRules Payer. This feature enables you to deliver required pricing information to members through various channels, guaranteeing transparency and meeting all regulatory requirements.

Introducing the Retroactive Change Manager

As you navigate the evolving healthcare landscape shaped by regulations like the TiC mandate and NSA, ensuring accurate claims processing and compliance remains a top priority. At HealthEdge Source, we tackle these challenges head-on with our groundbreaking tool, the Retroactive Change Manager.

This revolutionary tool streamlines claims processing by automating critical tasks like monitoring, reconciliation, and repricing. This eliminates the risk of missed adjustments and guarantees accurate payments to providers. Additionally, the tool proactively identifies and corrects underpayments and overpayments, minimizing your audit risk.

With a user-friendly single API for managing all aspects of claim pricing, editing, configuration, and policy updates, the Retroactive Change Manager eliminates the need to toggle between multiple systems. This streamlines workflows and minimizes human errors.

By automating critical tasks and ensuring compliance with ever-changing regulations, the Retroactive Change Manager empowers you to focus on what truly matters – delivering exceptional healthcare experiences for both providers and members.

Embracing transparency, efficiency, and automation can make it easier for your health plan to navigate the changing healthcare landscape with confidence. HealthEdge Source is here to partner with you every step of the way. By leveraging our solutions, you can build trust with your members, foster informed decision-making, and achieve compliance with evolving regulations.

About the Author

Diana Nguyen is an experienced Product Marketing Manager at HealthEdge, based in Denver, Colorado. With over 2 years at HealthEdge, Diana has held various roles, including Market Research Marketing Manager, Partner & Services Marketing Manager, and Channel Marketing Manager. She currently focuses on driving market awareness and adoption of HealthEdge Source™, the industry-leading payment integrity solution that empowers payers to optimize claims accuracy, minimize errors, and maximize cost savings.

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