Improve Data Security & Compliance with a Prospective Payment Integrity System
The healthcare industry has long been a primary target for cyberattacks due to the vast amount of sensitive data it handles. The increasing prevalence of cyber incidents, combined with ever-evolving regulatory frameworks, has made security and compliance top priorities for health plans.
According to the Annual Payer Market Planning Report 2025 by HealthEdge, which surveyed more than 450 health plan leaders, 46% of respondents indicated that security is their primary concern. This is followed closely by concerns about regulatory compliance, with many health plans struggling to keep pace with regulations from the Centers for Medicare and Medicaid Services (CMS) like the No Surprises Act and the Transparency in Coverage.
The Growing Importance of Data Security in Healthcare
In general, the healthcare industry has witnessed a series of high-profile cyberattacks in recent years, highlighting the critical need for robust data security. In 2024, incidents like the February breach affecting Change Healthcare and the August data breach at National Public Data exposed vulnerabilities in the healthcare system.
As a result, data security in technology and data science has quickly become the top technology concerns for health plans.
Leaders are seeking ways to protect member data while ensuring compliance with HIPAA regulations and other data privacy standards. HealthEdge Source™ (Source), HealthEdge’s prospective payment integrity platform, offers health plans a clear path to data security by incorporating security and scalability at the beginning and consistently throughout the software development process.
In fact, Source was recently recognized as a Sample Vendor in the 2024 Gartner® Hype Cycle™ for U.S. Healthcare Payers in two categories: Prospective Payment Integrity Solutions and AI-Enabled Fraud Detection. Source incorporates AI capabilities, allowing health plans to leverage AI-driven insights for improved security and compliance.
How HealthEdge Source
Helps Automate Compliance
Navigating the complex web of healthcare regulations is another major challenge for health plans. Non-compliance can lead to penalties, reputational damage, and potential legal issues. Health plans must continually monitor CMS changes, update their policies and procedures, and ensure that staff members are well-versed in the evolving regulations.
According to the Market Planning Report, managing CMS fee schedules and staying compliant with evolving regulations are among the most significant pain points for health plans. More specifically, the report outlines leaders’ top 3 biggest challenges when it comes to maintaining CMS compliance:
- Managing Fee Schedules (55%)
- Lack of technology partners to ensure regulatory compliance (54%)
- Lack of staff/resources to make necessary changes (50%)
The Source solutions empower health plans to address these challenges in multiple ways.
Compliance Monitoring
The Source team of regulatory compliance experts monitor and maintain CMS fee and policy changes daily. They are dedicated and well-versed in tracking the changes and helping health plans interpret and implement the necessary changes to maintain compliance. The platform continuously monitors compliance with CMS fee schedules and policy changes and generates reports, enabling health plans to stay on top of their obligations and avoid penalties.
Automated Fee Schedule Management
Keeping up with CMS fee schedule updates can be daunting, but Source simplifies this by automatically uploading fee schedule updates every two weeks. This ensures that health plans always work with the latest data and remain compliant with CMS payment regulations.
Claims Auto-Adjudication
Compliance with CMS payment rules requires accurate and timely claims processing. Source’s auto-adjudication feature reduces the risk of human error, ensuring that claims are processed in accordance with the latest regulatory standards. This helps health plans meet the strict timelines required by CMS, such as the 7-day turnaround for prior authorization decisions.
Preparing for Future Regulatory Changes
Another key finding from the report addresses compliance readiness. The bottom line: Many health plans do not feel adequately prepared for upcoming regulatory changes, particularly regarding the Payer-to-Payer Data Exchange and Advanced Explanation of Benefits. Less than half of respondents report being ready for these regulations.
HealthEdge Source helps health plans stay ahead of regulatory changes by offering:
- Scalable Compliance Solutions: The platform is designed to scale with evolving regulations, ensuring that health plans can easily adapt to new requirements without needing significant system overhauls.
- Regular Updates: Source continuously updates its platform to stay compliant with the latest CMS rules and regulatory guidelines, reducing the burden on health plans to manually track and implement changes.
HealthEdge Source: Your Strategic Partner in Data Security and Compliance
As health plans navigate the complexities of data security, regulatory compliance, and technology modernization, it is clear that having the right technology platform is critical to success. Source addresses these challenges by offering a comprehensive, integrated payment integrity platform that enhances security, automates compliance, and drives long-term operational efficiency.
Learn more about how Source can help your organization not only stay compliant but also turn regulatory challenges into opportunities for innovation. Watch a demo of the Source solution.
