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Case Study: Small Changes Lead to Big Impacts — A HealthEdge Case Study of BPaaS in Action

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Choosing the right transformation partner is critical for health plans striving to achieve operational excellence. Administrative inefficiencies are a significant driver of rising healthcare costs, stemming from fragmented processes and outdated technology. This case study explores how a strategic partnership with HealthEdge helped one health plan overcome these challenges, and achieve significant improvements through a modern Business Process as a Service (BPaaS) model.

The High Cost of Administrative Inefficiency

Administrative spending in U.S. healthcare represents a major opportunity for optimization. Current analyses reveal that these costs consume a significant portion of overall expenditures and often fail to contribute to better health outcomes.

  • Administrative Spending: Accounts for 15% to 30% of U.S. healthcare expenditures.

  • Wasteful Spending: At least half of this administrative spending is considered wasteful.

  • Annual Financial Impact: This translates to an estimated $285 billion to $570 billion annually that does not improve patient care.

Addressing these operational gaps is critical for reducing administrative burdens, lowering costs, and improving care quality through enhanced payer-provider coordination. This objective is a core component of payer financial modernization.

The Challenge: A Health Plan's Struggle with a Legacy Platform

One health plan faced significant operational challenges after struggling for nearly two years with a core administration platform that failed to meet its needs. This experience underscores a common industry issue: the need for a reliable partner capable of delivering measurable results. When they turned to HealthEdge, it was clear they had outgrown their legacy administration platform.

The plan was grappling with several critical issues. Organizational change was a major hurdle, as they required a strong advocate to drive transformation and address internal resistance to reducing inefficiencies. Their outdated legacy platform was another key problem, leading to fragmented processes and widespread inefficiencies throughout the organization. Additionally, operational complexity added to their struggles, with workflows becoming unnecessarily complicated and in need of a strategic overhaul to streamline processes and improve outcomes.

The Path to Transformation: A Strategic Partnership with HealthEdge

HealthEdge developed a decisive, strategic approach to address the client's challenges, focusing on two primary goals.

Goal 1: Migrating from a Legacy System Under Pressure

The most immediate challenge was transitioning the client from a partially implemented legacy system within a tight two-year renewal cycle. Missing this deadline would have triggered substantial financial penalties.

HealthEdge implemented a carefully phased migration approach with clear benchmarks. This strategy allowed the client to maintain business continuity, secure major contracts, and avoid penalties while transitioning to a more sustainable technological foundation. The project remains on schedule, setting the stage for long-term growth with a more streamlined and sustainable technological platform. (hyperlink) next-generation core administrative processing systems (CAPS).

Goal 2: Solving Complex Operational Challenges Through Change Management

Implementing new technology is not an instant solution. True success requires deep industry expertise and a collaborative approach to change management. By fostering a culture of innovation, HealthEdge helped the client embrace transformation at every level.

"Without cultivating change, processes won’t adapt, leading to delays and budget overruns."

— Chad Kauffman, Client Success Manager

This mindset shift enabled the client to adopt an operational problem-solving approach, ensuring smoother transitions and more effective outcomes. The partnership's success led to further engagements for other internal initiatives, including balance and controls and interface development.

The Outcome: Measurable Results and Dramatic Improvements

The strategic partnership delivered powerful results through steady, incremental improvements. Even when faced with a vendor cyberattack, HealthEdge's robust systems kept client data secure while adapting the implementation timeline. The most significant impact was to claim auto-adjudication rates, increasing from below 85% with frequent resubmissions to an impressive 99.8% after implementing HealthEdge's solutions.

This leap in automation reduced administrative costs, accelerated provider payments, and enhanced overall operational efficiency. Today, the partnership continues to exceed benchmarks and enable the client to:

  • Maintain seamless business operations.

  • Win significant new contracts.

  • Strengthen their market position.

  • Build a foundation for sustainable growth.

This success story exemplifies HealthEdge's commitment to unburdening health plans by delivering measurable improvements that drive long-term success. By modernizing health plan operations, organizations can achieve greater agility, efficiency, and innovation.