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Managing Payment Complexity to Improve Operational Efficiency

Health plans need to price and pay all claims accurately, even though not all of a health plan’s claims will come from contracted providers with negotiated payment rates. Source is a comprehensive payment integrity platform, able to support plans with everything from enterprise-wide payment integrity strategy to foundational pricing and reimbursement for participating and non-participating providers alike. The following case study highlights the ability of Source to help with the foundational, complex pricing for one plan’s non-participating provider claims.

Challenges of Non-Participating Provider Claims

A large, non-profit health plan has a robust network of contracted providers within the northeast region, facilitating local care access for their members. But, as health plan members seek care with non-contracted providers due to travel beyond the health plan region or for other logistic or personal reasons, the health plan receives claims from providers not contracted with their health plan. With multiple lines of business and almost four million members, these non-participating provider claims stack-up quickly and the health plan must be prepared to pay these claims accurately and efficiently, even without the benefit of contractually negotiated payment terms.

“We didn’t have many different pricing arrangements, but because of the differences in products and how those products wanted to message differently, it ended up being 75 different rate configurations for only six edit mapping rules.” – Health Plan Reimbursement Initiatives Manager

CMS Fee Schedules

The Centers for Medicare and Medicaid Services (CMS) maintains a fee schedule, which is a complete listing of maximum fees used to reimburse providers on a fee-for-service (FFS) basis. There are different fee schedules for:

  • physicians
  • ambulance service
  • clinical laboratory services
  • and more

Further, these fees can vary with modifications based on patient, provider and location factors; for example, urban, rural or low-density qualified areas.1

CMS fee schedules are not only important for Medicare and other government lines of business – they are also important for commercial lines of business. These fee schedules are often used by non-participating providers who submit claims using a percent of CMS FFS. Using CMS fee schedules can simplify the number of payment arrangements across these different provider types, but as this northeast health plan well knows, they still need to develop claims configurations and claims-payment messaging to account for varied provider characteristics. Configurations and messaging must be aligned with modifiers for government and commercial providers and in-network and out of network status. Further, the Plan must be able to edit these configurations to comply with ongoing policy updates, including retroactive change mandates.

“CMS pricing is not just a simple fee schedule. There are many different ways that CMS prices different types of claims, providers, bonuses, outliers and new technology payments. It’s very complicated and [to get claims right, we have to] understand the nuance.” – Health Plan Reimbursement Initiatives Manager

Solution = Source

Source was specifically designed as a single instance that connects with any claims system. Today, Source offers existing integration with over 10 claims systems, ensuring that implementation isn’t waylaid by key technology integration challenges. Source also supports the Plan with hierarchical edit capabilities to structure the six different enterprise-level configurations overlaying mapping rules for the 75 different rate configurations for the Plan’s commercial and Medicare Advantage products and lines of business using a percent of CMS FFS schedules.

“It’s helpful that updates are deployed so quickly. It’s helpful that HealthEdge puts edits right in [to the Source platform], so the brunt of validation and testing is already done in advance. This is a big advantage over other experiences that were not as positive – that we’ve had with other vendors.” – Health Plan Reimbursement Initiatives Manager

The Plan also faces provider-specific arrangements with non-participating providers whose pricing does not follow a percent of CMS schedule. As a true tech partner, Source was also able to help the Plan navigate this additional complexity. The Plan’s Reimbursement Initiatives Manager described reaching out to Source representatives who were able to show her how to configure pricing for these unique provider payment arrangements – leaving her confident in her ability to make other such configurations in the future.

“I have found the HealthEdge Source system to be very robust and flexible with regards to all of the different types of CMS and non-CMS based pricing methodologies that it offers.” – Health Plan Reimbursement Initiatives Manager


Non-participating providers are a critical extension of any plan’s network – and accurate and efficient payment despite the lack of contracted pricing, is an important component of effective health plan operations.

  • Non-participating providers play an important role in ensuring member care access in and out of their home region
  • Many non-participating providers use a percent of CMS FFS pricing
  • While CMS pricing offers a standardized base reducing the number of payment arrangements, plans still need a platform such as Source that facilitates many configurations and specific messaging based on provider type and other factors
  • Investing in a platform whose pricing includes ongoing, automatic updates keeps plans on-top of policy changes without additional resource demands
  • Choosing an industry-specific tech partner like HealthEdge gives plans the support they need to optimize automation and accuracy despite the complexity of provider arrangements