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Healthcare Rules and Regulations are Constantly Changing, But Your Payment Accuracy Doesn’t Have To

Healthcare is unique in so many ways – services are customized to each person, experience is impacted heavily by the provider, and quality of care is affected by your coverage. Paying for healthcare services is also unique. Where else do you go to a place of business for a service, pay a co-pay (or not) at the time of service, and then a few weeks later receive a bill outlining how much that service cost, how much your insurance will cover, and how much you’ll be paying out of pocket? And, woven throughout that whole scenario are rules and regulations that play a significant role in the calculation of what the health plan pays and what you pay.

These past few years, payers have been challenged more than ever to keep up with volatile market dynamics and comply with regulatory requirements. It’s not an easy feat to accomplish. The health insurance industry must comply with federal regulations from the Department of Health and Human Services (HHS) and Centers for Medicare and Medicaid (CMS), as well as each state’s health departments. There’s the Medicare physician fee schedule adjusted by location and updated yearly, and the ever-evolving rules brought on by the pandemic, which in some cases were even changing on a weekly basis. And, with each new presidential administration, comes another new set of rules and regulations.

In these unique times, it’s critical to have technology in place that enables your organization to respond nimbly to rapidly changing regulatory mandates. Payers need to be able to ‘future proof’ their business and HealthEdge’s payment integrity solution, Source, is built for that purpose.

Source enables complete government compliance with first-pass payment accuracy. The unique two-week update cycle delivers all CMS and Medicaid regulatory updates automatically by a team of Medicaid and Medicare experts. Additionally, Source aims to streamline the workflow by removing the strain of manually loaded fee schedules.

One HealthEdge client, SummaCare, uses Source to manage regulatory updates and has realized significant process efficiencies saving their organization time and money. Join us for a more in-depth look at how Source helps SummaCare navigate the ever-changing regulatory cycles. Register for the upcoming AHIP webinar on May 5th.