Case Study: Modernizing Care Management and Operations with HealthEdge® Solutions
The rapidly growing health plan’s strategy included expansion into a new line of business that would serve the Highly Integrated Dual Eligible (HIDE) and Fully Integrated Dual Eligible (FIDE)...
Modernizing Care Management and Operations with HealthEdge® Solutions
In the evolving landscape of healthcare, HealthEdge® Solutions empowers health plans to modernize their care management and operational strategies. This case study highlights how a rapidly growing health plan successfully expanded into serving the Highly Integrated Dual Eligible (HIDE) and Fully Integrated Dual Eligible (FIDE) populations by adopting HealthEdge's advanced platforms.
The Situation
The health plan faced significant challenges with their existing technology systems, which were inadequate for handling the complex clinical and social care needs of HIDE/FIDE populations and the rigorous compliance reporting requirements. To support their expansion and ensure operational success, they needed a modern care management solution.
Solution Selection
After thorough evaluation, the health plan chose HealthEdge’s GuidingCare® for care management and HealthEdge Source™ for payment integrity. The decision leveraged their existing relationship with HealthEdge's HealthRules Payer® core administrative processing system (CAPS), ensuring seamless integration and numerous benefits:
- Seamless User Experience: Single sign-on capabilities enhance security and user convenience.
- Real-time Data Sharing: Supports informed care management decisions.
- Reduced IT/Administrative Challenges: Simplifies system synchronization and vendor management.
Health Plan Overview
- Non-profit HMO
- 230k members
- 1,800+ primary care practitioners
- 5,100+ specialists
- 5,000+ behavioral health providers
Key Benefits
By integrating HealthEdge solutions, the health plan achieved:
- Increased Payment Accuracy: Automatically updated pricing and editing content libraries.
- Reduced IT Burden: Out-of-the-box integration minimizes resource strain and lowers risk.
- Improved Payment Integrity: Enhanced through comprehensive access to claims history and proactive business intelligence.
Top Challenges Addressed
The health plan overcame several critical challenges to modernize care management:
- Complex Care Needs of HIDE/FIDE Members: Ensured comprehensive and coordinated care.
- Regulatory Requirements: Adhered to intricate federal and state regulations.
- Prospective Payment Integrity: Reduced savings leakage and managed multiple vendors efficiently.
- Reporting Capabilities: Integrated sophisticated systems for precise and timely reporting.
- Utilization Management (UM) and Care Management (CM) Inefficiencies: Streamlined authorization lifecycle and improved stakeholder coordination.
- User Experience: Enhanced efficiency and compliance for medical management teams.
- Legacy System Sunset: Adopted next-generation solutions integrated with CAPS.
- Reducing Maintenance Costs: Improved interoperability and reduced costs with pre-integrated solutions.
Why HealthEdge?
The health plan’s choice of HealthEdge was driven by:
- GuidingCare Integration: Continuous management of member care and core administrative processes.
- Successful Demonstrations: Proven performance in sandbox environments.
- Third-Party Recognition: Validation from analysts like Gartner.
- Trust in HealthEdge: Long-standing customer relationship and confidence in HealthEdge’s support services.
Overview of Selected Solutions
HealthRules Payer
A next-generation CAPS designed for health plans of all sizes, offering:
- Transformative Capabilities: Quick adaptation to market opportunities.
- Member and Provider Satisfaction: Enhanced through automation.
- Cost Reduction: Lowered administrative costs.
GuidingCare Care Management
A comprehensive suite supporting person-centered care with features like:
- Streamlined Coordination: Across care spectrum.
- Automation: For care and service planning.
- Targeting High-Risk Populations: Management of clinical and behavioral health needs.
HealthEdge Source
A leading digital prospective payment integrity solution providing:
- Claim Payment Automation: Combined with proactive business intelligence.
- Enhanced Provider Relationships: Reduced waste and improved financial performance.
With integrated HealthEdge solutions, the health plan built a modern technology foundation to support its expansion into new lines of business while adhering to regulatory requirements and enhancing operational efficiencies. By increasing automation and improving accuracy, the plan is now better positioned to serve the HIDE/FIDE population and its current members effectively.
Visit HealthEdge or follow HealthEdge on Twitter and LinkedIn to stay updated on the latest innovations in healthcare technology.
