How to Simplify Claims Audits with the HealthEdge Source™ Payment Integrity Solution

Health plan leaders are juggling multiple responsibilities and facing pressures from all sides. Navigating complex provider reimbursement models, meeting the growing demand for fair and accurate claims processing, retroactive pricing updates, and audits can all put a significant strain on day-to-day operations. Having a clear and efficient process for claims audits and inquiries isn’t just a nice-to-have for payers—it’s a must-have. 

Legacy core administration processing systems (CAPS) are still prevalent among health plans. While these solutions may have gotten payers this far, continuing to rely on outdated systems can come with risks including greater need for manual rework, audit delays, and lack of integration capabilities. 

Payment integrity solutions like HealthEdge Source™ help bridge this gap with pre-built integrations and smarter pricing logic. For instance, a large non-profit health plan in the Northeast transitioned from an older payment integrity platform to HealthEdge Source. In doing so, the payer was able to improve their first-pass adjudication rates from 80% to 98%. That’s a major leap in accuracy and efficiency! 

Learn more about how this health plan successfully implemented the solution and how an advanced payment integrity solution improved the payer's claims management, audit, and inquiry processes.  

Case Study: Northeast Regional Non-Profit Health Plan 

HealthEdge’s collaboration with this health plan began with an in-depth analysis of their operational challenges. The conversation focused on two key challenges: 

1. Modernizing outdated systems while ensuring seamless integration 

The plan’s existing tech stack featured a legacy CAPS system that was outdated yet deeply ingrained within their workflows. Transitioning to a new, cloud-based platform was necessary but daunting due to integration concerns. 

2. Managing retroactive claims audits and complex reimbursement models 

The reimbursement team needed a more effective way to manage claims audits and handle retroactive updates, especially with the intricate, hierarchical configurations of provider payment arrangements. 

The HealthEdge Source Approach to Implementation 

The health plan began with a phased implementation process as they sunset an older payment and pricing platform and upgraded to HealthEdge Source. Change management within a legacy-heavy technology environment can be an uphill battle for health plans. In this case, however, it was a seamless process due to the HealthEdge Source solution’s pre-built integration capabilities. 

HealthEdge Source is compatible with more than 10 major claims systems, which helps mitigate typical integration hiccups. Even with the complexity of this health plan’s hierarchical provider payment arrangements, the transition stayed on course. 

Breaking Down Hierarchical Pricing and CMS Complexity 

Managing hierarchical pricing can be messy, especially when the Centers for Medicare and Medicaid Services (CMS)—or non-CMS—fee schedules are involved. Fee schedules often demand intricate, layered rules and configurations that can be labor-intensive to manage manually. 

For this health plan, HealthEdge Source introduced hierarchical edit capabilities, enabling the creation of enterprise-level configurations with ease. These capabilities helped ensure seamless operations across the diverse pricing scenarios the team encountered every day, streamlining processes and reducing operational complexity. 

Addressing Retroactive Adjustments 

Every time CMS introduces retroactive updates, it creates a ripple effect through claims systems. For this particular health plan, the challenge was no exception. These policy updates often lead to dispersed claims issues, triggering manual audits and adjustments. Before HealthEdge Source, the plan grappled with inefficiency and a lack of clarity in tracing and managing these updates. 

With HealthEdge Source’s robust audit feature, the plan’s reimbursement team transformed their approach to proactively manage retroactive claims inquiries. The solution allowed for detailed, side-by-side comparisons of claims, enabling swift identification of discrepancies. For example, the team successfully addressed a series of complaints tied to CMS fee schedules by leveraging the solution’s audit capabilities. What once was a reactive process became a structured, efficient workflow, minimizing delays and enhancing accuracy. 

“There are a lot of things we can do in HealthEdge Source now that we couldn’t do before.” 

– Health Plan Reimbursement Initiatives Manager 

 Automating Updates and Enhancing Team Efficiency 

One of the platform’s key features is its bi-weekly automated updates. These updates proved to be very useful for the team, enabling them to proactively manage retroactive claims inquiries and reduce the manual burden related to CMS policy changes. 

For example, the Reimbursement Initiatives Manager efficiently used HealthEdge Source’s audit feature to pinpoint relevant claims, filter by ambulance codes, and provide a detailed explanation of CMS reimbursement practices for these high-cost services. 

By automating previously manual tasks, the team could focus on higher-value activities, further amplifying the accuracy of their reimbursement processes. 

Key Benefits of Adopting HealthEdge Source:  

The health plan’s adoption of HealthEdge Source led to measurable improvements across their operations: 

• First-pass adjudication rates improved from 80% to 98%, enhancing accuracy and efficiency 
• Enabled 6 enterprise-level configurations overlaying mapping rules for 75 distinct rate configurations, including CMS fee schedules 
• Audit processes were simplified and expedited, reducing manual rework and processing delays 

“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 

Pave the Way for Payment Integrity Automation 

HealthEdge Source supports health plans at every stage, helping teams manage retroactive claims inquiries and audits, while paving the way for more automated solutions. With technology built specifically for healthcare, HealthEdge empowers plans to navigate the complexities of diverse pricing and provider arrangements. 

By partnering with an industry-specific technology partner, health plans can enhance automation, streamline workflows, and increase accuracy for long-term success in a constantly evolving industry. The right tools don’t just solve today’s problems—they set you up for long-term success in an industry that’s always evolving. 

Want to learn more about how a nonprofit health plan from the Northeast leveraged HealthEdge Source to increase audit and inquiry efficiency? Read our case study.