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Today’s Complexities Demand a Future of Flexibility: Claims Pricing Solutions

“Healthcare organizations face increasing complexity in reimbursing care with value-based payments, self-funded business and more; however, claims-pricing software remains largely stagnant. U.S. healthcare payer CIOs need to procure claims-pricing software that addresses this complexity.”

— Gartner® “How U.S. Healthcare Payer CIOs Handle Effective Claims Pricing” Austynn Eubank, 5 December 2023

Complexity can be found everywhere you look in the healthcare industry today. But never before has there been so much pressure on payers to respond to providers’ rising expectations for timely and accurate payments while also addressing members’ rising expectations for more personalized and flexible benefit plans. 

When you combine these pressure points with the industry’s shift toward value-based care models, the growth in self-funded employer contracts, and evolving Medicare Advantage Star Ratings criteria, it’s easy to see how payers can become overwhelmed by the complexities of accurate and timely payments.   

In an attempt to address these challenges, payers have stacked claims editing and pricing solutions on top of each other, but many have found that their antiquated systems are creating more problems than solutions. In fact, in a HealthEdge research report, 90% of payers depend on two or more payment vendors. However, many of these systems do not afford the flexibility that is necessary to support payers’ ability to meet rapidly evolving provider and member demands.   

It’s Time to Reevaluate Claims Pricers 

“U.S. healthcare payer CIOs advancing healthcare digital optimization and modernization should: Build flexibility and efficiencies into the claims adjudication process by leveraging modular, cloud-native and API-first platforms for claims processing, pricing and editing that support members’ and providers’ needs.” — Gartner® “How U.S. Healthcare Payer CIOs Handle Effective Claims Pricing” Austynn Eubank, 5 December 2023 

Flexibility is the name of the game, especially for payers with multiple, state-managed Medicaid contracts, unique self-funded arrangements, or wide provider networks that require more flexibility and fee scheduling capabilities.  

HealthEdge Source™ delivers the flexibility today’s payers need to address complex provider contracts and multiple fee schedules, ensuring that payers can meet the needs of their providers while also optimizing operational efficiencies.  

How it Works 

With Source, payers can combine dynamic configuration capabilities with a smart hierarchy structure to reduce the overhead of maintaining and updating contracts. Source also automatically supports the consistency of terms across provider contracts without jeopardizing the unique requirements of each contract.  

Several health plans that have implemented Source have benefited from a 90% reduction in the number of managed configurations, leading to faster times to contract, more accurate payments, and less provider abrasion.  

A Flexible Future For Claims Pricing Solutions

As payers work to implement more flexible claims pricing solutions that can accommodate today’s fee schedule complexities and rising provider demands for more timely and accurate payments, Source delivers a modular, cloud-based solution supported by a robust set of APIs that can connect to any existing CAPS via a single instance. As a result, payers can develop more collaborative and trusting relationships with their provider networks that ultimately lead to better member outcomes and lower operating costs.  

To learn more about how HealthEdge Source can help your organization meet the evolving demands for more timely and accurate claims payments, visit  

1Source: “How U.S. Healthcare Payer CIOs Handle Effective Claims Pricing” Austynn Eubank, 5 December 2023.  

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