Case Study: Health Plan for Large Metropolitan Area Transforms Care and Operations with HealthEdge® Solutions

A prominent health plan serving over 700,000 members in a large metropolitan area faced significant operational hurdles due to outdated legacy systems. The plan, which manages a diverse portfolio including Medicare Advantage, Medicaid, and complex state employee health plans, required a digital transformation to support its growth, manage costs, and meet stringent regulatory requirements.

By implementing an integrated solution from HealthEdge, the organization successfully modernized its core administrative and care management functions. This strategic shift enabled the automation of manual processes, reduced IT burdens, and provided a holistic view of member data, ultimately transforming its ability to deliver high-quality care efficiently.

The Challenge: Overcoming Legacy System Limitations

The health plan's existing infrastructure presented several interconnected challenges that hindered its performance and scalability.

Outdated Legacy Claims Management

The organization relied on a rigid, rules-based legacy claims processing system that was difficult to maintain and could not adapt to evolving business needs. This resulted in inefficient manual workarounds, increased administrative costs, and delays in processing claims for its network of over 34,000 providers.

Inefficient Manual Processes

Critical tasks in care management and claims processing were performed manually, leading to operational inefficiencies, a higher risk of errors, and a lack of real-time visibility. These manual dependencies limited the plan's capacity to scale operations in line with its growing membership.

Significant IT Burden

The IT department was consumed with supporting and maintaining disparate legacy systems. Data was siloed across these platforms, preventing the creation of a comprehensive, 360-degree view of member information and care activities, which is critical for effective population health management.

Complex State Regulatory Requirements

As a government contractor, the health plan must adhere to unique and complex state mandates for care management. The legacy systems struggled to meet these requirements, posing significant compliance risks and the potential for financial penalties.

The Solution: An Integrated Platform from HealthEdge

The health plan selected HealthEdge as its strategic partner to deploy a modern, integrated platform. The decision was based on HealthEdge's ability to deliver a holistic solution that addressed both core administrative and clinical needs.

Key factors for choosing HealthEdge included:

• Proven Automation: A track record of increasing auto-adjudication rates and payment accuracy.
• System Flexibility: Advanced automation and flexibility for benefit plan configuration and updates.
• Seamless Integration: Ease of integration with the plan's existing technology ecosystem.
• Unified Platform: Support for all lines of business on a single system, eliminating the need for multiple platforms.
• Natively Integrated Data: A complete view of the member's healthcare journey by leveraging data across products for advanced reporting.

The deployed solution consisted of two key components:

HealthRules Payer® for Core Administrative Processing

HealthRules Payer is a next-generation Core Administrative Processing System (CAPS) that empowers health plans to adapt to market changes, improve member and provider satisfaction, and lower administrative costs. Recognized as "Best in KLAS" for three consecutive years, its flexible and robust architecture is designed for intuitive use and operational excellence.

GuidingCare® for Comprehensive Care Management

The GuidingCare platform is a comprehensive suite designed to support person-centered care. It provides robust tools for:

• Care and utilization management
• Provider authorizations
• Appeals and grievances
• Population health management
• Business intelligence

With certifications such as HITRUST and NCQA for HEDIS® Measures, GuidingCare ensures compliance and quality in modern healthcare management.

Key Results and Business Outcomes

The integrated HealthRules Payer and GuidingCare solution enabled the health plan to modernize its operations and achieve significant improvements across the organization.

By modernizing with HealthEdge, the health plan is now positioned to operate more efficiently, manage growth effectively, and deliver superior care to its members. To learn more about how HealthEdge drives digital transformation in healthcare, visit healthedge.com.