Case Study: Elderplan uses HealthRules® Payer to Lower Administrative Costs
Today’s health plans have less money to reinvest in critical areas such as innovation, member satisfaction, care coordination, and new lines of business.
Challenges Faced by Elderplan
Elderplan, a not-for-profit health plan organization based in Brooklyn, New York, faced significant challenges in managing administrative costs and operational inefficiencies. Manually processing tens of thousands of claims each month strained resources and hindered the organization's ability to reinvest in crucial areas such as innovation, member satisfaction, and care coordination.
Implementing HealthRules® Payer for Lowered Administrative Costs
To address these issues and achieve lowered administrative costs, Elderplan implemented HealthEdge’s HealthRules® Payer solution in 2016. This advanced platform enabled the organization to automate key processes, significantly reducing the need for manual claim adjudication and resulting in critical administrative savings. By leveraging the patented HealthRules Language™, Elderplan could quickly configure benefits and adapt to market changes without requiring programmers, thus maximizing operational efficiency and enhancing productivity.
The adoption of HealthRules Payer led to remarkable outcomes for Elderplan:
- Lowered Administrative Costs: Achieved over $1.6 million in savings by automating processes and reducing staff needs.
- Increased Revenue: Transitioned from a $28 million loss in 2014 to a $20 million gain in 2017.
- Enhanced Claims Processing: Achieved a 96% increase in auto-adjudication rates for Medicare claims and a 21% increase for Homefirst Managed Long-Term Care claims.
- Improved Claims Management: Reduced pending claims by 95% and ensured 0 claims aged over 15 days monthly, with a 99% accuracy in claims payment.
Additionally, HealthRules Payer proved instrumental during the COVID-19 pandemic, allowing Elderplan to swiftly adapt to regulatory changes and maintain focus on member well-being. The ability to configure benefit plans within two weeks showcased the system's resilience and flexibility.
Elderplan's successful integration of HealthRules Payer underscores the value of advanced AI-driven solutions in lowering administrative costs and driving efficiency in the healthcare industry. The organization’s experience highlights how technology can empower health plans to overcome challenges, improve member outcomes, and stay resilient in the face of change.
Learn more about how HealthRules Payer can transform your health plan operations and drive substantial savings by visiting HealthEdge.
