Take a Proactive Approach to High-Speed Payment Accuracy with HealthEdge Source™ 

Across the healthcare industry, organizations are making do with a payment integrity process that relies on a complex web of disparate systems, multiple vendors, and manual ticketing processes. This fragmentation creates administrative bottlenecks and leads to friction with members and providers.

When payment integrity operations are based on disconnected tools, health plans can find themselves stuck in a “pay and chase” cycle. In these cases, the lag between identifying a necessary policy change and actually implementing it can span months. Meanwhile, health plans are still processing incorrect claims, leading to burdensome adjustments. To meet industry demands and manage rising costs, health plans must shift away from this reactive approach.

Advanced payment integrity solutions like HealthEdge Source™ can enable health plans to centralize payment policies and integrate disjointed workflows, delivering production savings with unprecedented accuracy and efficiency.

The High Costs of Legacy Payment Integrity Systems

Current industry models for managing payment integrity are often inefficient. They were not built to handle today’s complex billing guidelines, or the speed required for modern claims processing. Legacy payment systems can prevent health plans from achieving true payment accountability in a few key ways, including:

1. Extended Edit Timelines

Moving a new payment policy edit from concept to production can take several weeks. Operations teams must wait for vendor engineering cycles or navigate internal IT backlogs. But claims continue to be invoiced and paid incorrectly in the meantime, requiring time-consuming and costly repayments.

2. Vendor Dependency

Health plans frequently rely on external vendor engineering teams and rigid release schedules across multiple, disparate systems. This limits a health plan’s control over the launch of critical payment updates.

3. Inflated Operational Costs

Managing multiple vendors and paying unanticipated fees for configuration changes can add significant administrative overhead for health plans, in addition to the time it takes to reconcile the data in each system.

4. Lack of Agility

The inability to respond quickly to new billing trends, regulatory updates, or contractual changes compromises a health plan’s ability to manage costs effectively. In a rapidly changing healthcare landscape, flexibility is a requirement, not a luxury.

User-Driven Configuration: The Future of Payment Integrity

To overcome traditional barriers to payment accuracy, health plans need access to integrated digital solutions that centralize processes and improve control. HealthEdge Source delivers robust configuration capabilities that empower users to build, test, and deploy complex edits immediately—no engineering change orders required. This shift puts control back in the hands of health plan leaders and facilitates data-driven decision-making.

With HealthEdge Source, teams can validate policies against real-world data, forecast financial impacts before deploying into production, and implement changes with precision.

The Four-Step Payment Integrity Workflow

HealthEdge Source integrates several powerful modules into a cohesive workflow known as the “virtuous cycle.” This end-to-end process covers ideation, testing, implementation, and analysis, ensuring accuracy while dramatically increasing the speed of deployment.

1. Test and Validate with What-If Modeling  

Before deploying a new edit, the Source What-If Modeling tool allows payers to forecast the impact of potential contract configurations using historical data. This predictive capability helps health plans create a data snapshot, run a data study to process the snapshot against different configurations, and analyze the outcome before going live.

2. Collect Real-Time Data with Monitor Mode 

Once an edit is built within HealthEdge Source, it can be activated in Monitor Mode. This feature runs the edit passively on live production claims without affecting final payment adjudication. The claim processes first with standard production edits, then runs a second time with monitored edits applied.

This allows teams to collect real-time performance data and continuously track the financial impacts of policies, building confidence in the accuracy of the edit through live-fire testing without financial risk.

3. Educate Providers with Informational Edits 

To minimize provider abrasion and encourage proper billing, HealthEdge Source users can temporarily set the disposition of an edit to “informational.” During a set period, such as a 90-day notification window, the edit returns a message on the Explanation of Benefits explaining the new policy.

This proactively educates providers on new guidelines, giving them time to adjust billing systems before the edit impacts reimbursement.

4. Automate Retrospective Analysis with Retroactive Change Management 

After an edit goes live, the Retroactive Change Management tool automates the identification of claims paid incorrectly prior to the change, which is critical for backdating policies or implementing contract updates.

The Retroactive Change Management tool can re-process historical claims against the new configuration and generate dashboards detailing overpayments and underpayments. This consolidated analysis streamlines recovery and facilitates transparent communication with providers regarding backdated changes.

Build Custom Payment Policies with Precision

The Advanced Custom Edit tool from HealthEdge Source allows payment integrity teams to design and implement highly specific policies tailored to unique plan requirements via an intuitive, point-and-click interface.

Building an edit requires three key components:

• Current Claim Criteria: Defines attributes of the incoming claim that qualify it for the edit.
• History Criteria: Defines specific patterns or codes to look for in a member’s claim history.
• Relational Criteria: Establishes the logic for how the current claim and historical claims interact to trigger a denial or flag.

For example, a plan could easily address “Lab Duplicates” where a facility bills for collecting a sample and an independent lab also bills for the test. The user can create an edit that identifies a facility lab claim and searches the member’s history for a matching service from an independent lab on the same date.

Future-Proofing Your Payment Integrity Strategy

Digital innovation isn’t about adopting new tools just for the sake of change. It’s about recognizing that health plans need a nimble digital ecosystem that can help payers adapt to change quickly, proactively avoid errors, and address root-cause issues quickly and easily.

HealthEdge Source enables an enterprise payment accountability approach, shifting focus from post-payment recovery to proactive cost avoidance. With the ability to continually adapt to both competitive market demands and evolving regulatory requirements, health plans can set new standards in transparency, accountability, and operational excellence.

Transforming your claims process starts with taking control of your data. By adopting high-speed, proactive payment integrity solutions, your organization positions itself for long-term success and industry leadership.

Watch the full webinar on-demand to learn more: “High-Speed Payment Accuracy: Take a Proactive Approach with HealthEdge Source.”