How Technology and Transparency Bring an Open Book to Payment Integrity

In a recent Becker’s podcast, Steve Krupa, CEO of HealthEdge, and Ryan Mooney, EVP and General Manager of Payment Integrity at HealthEdge, discussed the transformative role of technology and transparency in payment integrity practices. The leaders reviewed how traditional payment integrity solutions often operate retrospectively, identifying and recovering erroneous payments after they have been made. This reactive approach can lead to inefficiencies, provider friction, and higher costs.

In contrast, Krupa and Mooney revealed how HealthEdge’s prospective payment integrity solution, HealthEdge Source™, aims to correct errors before payments are made, emphasizing the importance of accuracy and efficiency from the outset. This forward-looking approach reduces the need for costly post-payment recoveries, minimizes provider abrasion, and improves payer-provider relationships.

From Black Box to Open Book

A key innovation of HealthEdge Source is its departure from the industry’s “black-box” methodology, where payment integrity processes are opaque, and solutions are proprietary, to an “open book” philosophy. This transparency lets payers see precisely where and how errors occur, facilitating root cause analysis.

The first solution to bring together contract configuration, reimbursement, editing, and analytics, HealthEdge Source provides the tools payers need to in-source capabilities to make real-time corrections—completing a virtuous cycle of payments.

This shift enhances operational efficiencies by empowering payers with the information they need to correct any process errors further upstream before the claim is paid. It also fosters a more collaborative environment between payers and providers, ultimately contributing to a more transparent and effective healthcare system.

The Payment Paradigm

• Post payment: You’ve already made a mistake, and the claim gets paid, leading to excessive recoupments and provider abrasion.
• Pre-payment: Let’s catch the mistake before it leaves the door, but its root cause is unknown.
• Prospective payment integrity: You can identify the root cause of the mistake and correct the issue to avoid the mistake entirely in the future.

The Solution to Payment Integrity: Payment Accountability®

Payment integrity transformation can inform various aspects of a payer’s organization enterprise wide. While traditional payment integrity solutions provide a quick fix to problems, HealthEdge Source delivers Payment Accountability with software that creates transparency to address root cause inaccuracies so payers can pay claims accurately, quickly, and comprehensively the first time.

With HealthEdge Source advanced analytics and machine learning algorithms, payers have the tools needed to identify and prevent payment errors. The cloud-based platform can quickly analyze large amounts of data from multiple sources to identify patterns and anomalies that may indicate payment errors and proactively correct them.

Here are a few examples of how HealthEdge Source also helps payers go beyond claims accuracy to gain greater insights and make more informed decisions.

• Retroactive change management identifies claims impacted by retroactive changes and reprocesses them, which helps improve provider satisfaction and performance during audits.
• Predictive Policy Modeling monitors any new payment policy edits before they are put into production to determine the impact prospectively. This enables health plans to make appropriate business decisions and improve provider-payer relationships.
• Contract Modeling enables a transparent analysis of the performance of contract changes or conversions to new contracted payment methodologies before implementation with a plan’s providers.

HealthEdge Source was recognized in the 2023 Gartner^®  Hype Cycle as a Representative Vendor for Prospective Payment Integrity Solution Category. From 2019 to 2021, HealthEdge was recognized as Burgess Group in the Gartner Hype Cycle for Payment Integrity (PPI) Solutions category. HealthEdge acquired Burgess Group in August 2020.

To learn more about how HealthEdge Source can help your organization get out of the black box and embrace an open-book approach to payment integrity, visit www.healthedge.com.

Gartner, Hype Cycle for U.S. Healthcare Payers, 2023, Mandi Bishop, Connie Salgy, Austynn Eubank, 10 July 2023

GARTNER and HYPE CYCLE are registered trademarks of Gartner, Inc. and/or its affiliates in the U.S. and internationally and are used herein with permission. All rights reserved. Gartner does not endorse any vendor, product or service depicted in its research publications, and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.