Case Study: Modernizing with HealthEdge® to Drive Expansion
Learn how a health plan leveraged HealthEdge to modernize its core administrative processing system, driving expansion and 90% auto-adjudication.
A not-for-profit health plan serving Medicare beneficiaries found its growth potential severely limited by a legacy core administrative processing system. The inflexibility of their outdated technology and reliance on manual processes created significant barriers to entering new markets and expanding their lines of business, particularly into Medicare Advantage.
Key Challenges of the Legacy System
The health plan's aging infrastructure resulted in several critical operational and financial challenges that hindered its long-term sustainability and performance.
|
Challenge Area |
Description |
|---|---|
|
Agility and Speed to Market |
The existing system lacked the flexibility required to launch new products or enter new markets efficiently. |
|
Maintenance Costs |
Managing multiple vendors for various functions led to excessively high maintenance and operational costs. |
|
Auto-Adjudication Rates |
A high volume of claims required manual processing, resulting in poor auto-adjudication rates, increased errors, and higher labor costs. |
|
Vendor Management |
A fragmented vendor ecosystem complicated management and inflated costs, highlighting the need for a consolidated system. |
|
Prospective Payment Integrity |
The plan lacked proactive payment integrity, struggling with cumbersome policy updates, an inflexible configuration layer, and decentralized audit processes. |
To overcome these obstacles and ensure future growth, the health plan required a new, modern core administrative processing system.
The Solution: Implementing HealthEdge's Next-Generation Platform
The health plan selected a suite of HealthEdge solutions to modernize its technology stack, automate key processes, and build a foundation for scalable growth.
HealthRules Payer: A Modern Core Administrative Processing System
HealthRules Payer is an end-to-end core administrative processing system designed for real-time automation and operational efficiency across all lines of business. Its key capabilities include:
- Real-time Automation: Delivers immediate processing for claims, enrollment, and billing functions.
- Improved Auto-Adjudication: Automates up to 90% of claims, significantly reducing manual intervention and errors.
- Flexible Configuration: Supports all payment models and allows for rapid adaptation to new market requirements.
HealthEdge Source™: Integrated Prospective Payment Integrity
HealthEdge Source™ integrates payment integrity directly into the claims workflow before adjudication. This solution uses a powerful, plan-configurable rules engine to drive automation and accuracy. Key benefits are:
- Upstream Integration: Embeds payment integrity checks into the claim flow, preventing incorrect payments before they happen.
- Expanded Capabilities: Supports full clinical validation for Medicare and other complex lines of business.
- Streamlined Audits: Eliminates decentralized audit processes by integrating policy and coding updates directly into claims processing.
The Result: Modernizing for Scalability and Future Growth
By implementing HealthEdge's integrated solutions, the health plan successfully modernized its core administrative processing system. This transformation provided the robust functionality and scalability needed to support its strategic objectives. The plan is now empowered to:
- Increase auto-adjudication rates and operational efficiency.
- Enter new markets with greater speed and agility.
- Expand into new lines of business, including Medicare Advantage.
- Reduce maintenance costs through a simplified vendor structure.
- Enhance financial performance with prospective payment integrity.
