From Guessing Game to Proactive Process: Payment Integrity with HealthEdge Source™ 

Managing payments for a health plan is not as simple as it was a few decades ago. Updated billing models, new compliance mandates, and complex provider networks can make it challenging for payers to align their processes and effectively manage payments.

In this blog, we unpack three common barriers to payment efficiency and what to look for in a payment integrity solution.

3 Key Barriers to Healthcare Payment Integrity

1. Disparate vendor network

To deal with complex healthcare payments, health plans often work with multiple vendors and disparate solutions. Often, each vendor focuses on one part of the process, like pricing, policies, or reviewing payments after they’ve been made. While this approach offers specialized support, it can lead to a tangled system where similar tasks are repeated by different partners. This setup makes it hard for health plans to make changes quickly or respond to new challenges.

2. Disconnected data sources

When each vendor keeps data within their own systems, information is siloed and hard for health plans to piece together in a meaningful way. In addition, any errors in the process are often handled on an individual basis, making it difficult to see bigger trends or identify recurring problems. This can lead to health plans taking action without a clear, unified view of the process.

3. Workflow inefficiency and payment errors

Most existing payment integrity systems work backwards: They try to find and recover funds from incorrect payments after the payment request is sent. This means health plans pay third-party vendors to track down mistakes that were made in-house – and likely could have been avoided. The payment recovery process can also be slow and expensive, leading to wasted resources and frustration.

A Unified Approach to Health Plan Payment Integrity

The team behind HealthEdge Source™ recognized that healthcare payers didn’t need another third-party editor or another pricing tool. Instead, health plans needed a way to integrate and streamline claims processing.

With the HealthEdge Source payment integrity solution, health plans have access to custom configuration, editing, and advanced analytics tools all in one place for greater visibility and catch errors before payments are sent.

4 Key Features of HealthEdge Source

• Easy Edit Building: HealthEdge Source includes a no-code edit builder, allowing users to create and update payment edits without special requests from engineering teams. An edit can be built and published in minutes.
• Automatic Updates: The platform automatically incorporates new rules based on regulatory changes from agencies, like the Centers for Medicare and Medicaid Services (CMS). New rules are built in every two weeks, with no manual work for your team.
• Test Before Going Live: A built-in Monitor Mode allows users to test new edits on real claims without affecting actual payments. This allows teams to see the impact of a new rule before fully implementing it.
• Clear Tracking and Analytics: Every claim is tracked with a detailed audit trail, and the system offers advanced analytics to help health plans spot trends, track performance, and make better decisions.

By uniting these tools in a single solution, HealthEdge Source helps turn payment accuracy from a guessing game into a straightforward, proactive process.

Innovations in Payment Integrity: Edit Management Enhancements

The HealthEdge Source team is always working on new solution enhancements based on user feedback and changes in the industry. Recently, we implemented two key improvements to make managing edits even more efficient.

1. Simplified Edit Configuration

Managing edits used to mean navigating multiple screens and manually updating rules for each provider type—a tedious and error-prone process. Now, HealthEdge Source offers a single, consolidated interface where all configurations happen in one place.

For example, if a health plan wants to require prior authorization for high-cost imaging services, this can be enabled with a single click for every relevant facility or provider group. If there’s a need for an exception, such as excluding emergency services, it takes only a few seconds to adjust.

This approach to configurations helps improve efficiency for policy management. Health plan teams can view, enable, adjust, or turn off edits for different provider types using simple checkboxes across the same dashboard, rather than tracking changes across separate screens. Centralizing these functions saves time while reducing the risk of manual errors and helps ensure updates are reflected in the proper places.

2. Global Edit Exceptions

With global edit exceptions, users can create exception rules in one central location, then apply them across as many edits as needed. If a particular provider, like a large hospital network, should be exempt from certain claim edits, a health plan only has to set up their tax ID or configuration details once. This rule can then be linked to every relevant edit, instead of repeating the same exclusion logic each time. This centralized approach reduces duplicate work and makes it easier to standardize processes across the organization.

When a contract changes or another provider needs a similar exception, users simply update the global exception in the central library, and the change automatically applies to the connected edits. This helps reduce the risk of missing updates or implementing inconsistent rules across a single system. For example, if a health plan wants to adjust exclusion criteria for a set of specialty providers, those updates can be handled quickly and accurately by revising a single rule, rather than searching for and editing each instance individually.

Ultimately, this approach helps deliver a stable, scalable foundation for managing edits, empowering health plans to manage regulatory shifts and network changes as a controlled process.

Watch our on-demand webinar, “Edit Smarter Not Harder with HealthEdge Source™” to get an inside look at how connected, automated payment integrity can work day to day.