Case Study: McLaren Health Plan

From 0% to 90% Auto-Adjudication Rate with HealthRules® Payer

Overview

McLaren Health Plan, a Michigan-based licensed Health Maintenance Organization (HMO) serving 260,000 members, faced significant operational challenges due to outdated technology. The 30-year-old legacy system led to a zero percent claims auto-adjudication rate, making it essential for McLaren to implement modern technology to stay competitive and efficient.

Challenges

• Outdated Technology: A 30-year-old system that was clunky, hard to configure, and not scalable.
• Zero Percent Claims Auto-Adjudication Rate: The manual process necessitated immediate change to ensure business viability.
• High Administrative Costs: Inefficiencies led to increased costs, reducing the funds available for reinvestment in critical business areas.

Solution

McLaren selected HealthEdge's HealthRules® Payer platform to address these challenges. The new system provided:

• Flexibility and Scalability: Enabling better response to industry changes and reducing manual data entry.
• Improved Efficiency: Automating claims processing to achieve over a 90% auto-adjudication rate.
• Enhanced Reporting: Faster and more accurate data retrieval.

Benefits

1. Rapid Response to Industry Changes: HealthRules® Payer allowed McLaren to adapt quickly to new regulations and market demands.
2. Cost Reduction and Efficiency: The new system decreased administrative costs and streamlined operations.
3. Competitive Edge: Leveraging the latest technology to outpace competitors.
4. Enhanced Customer Service: Providing quick and responsive service to members.
5. Resource Reallocation: Freed up human resources for other critical business areas.

Results

• New Membership and Business Expansion: McLaren's transition to HealthRules® Payer supported the acquisition of MDwise, growing their service base to over 620,000 members.
• Higher Auto-Adjudication Rates: Achieving over 90% auto-adjudication, significantly reducing the need for manual intervention.
• Operational Efficiency: Increased EDI submissions, rapid claims entry, and improved reporting capabilities.

Future Outlook

McLaren plans to continue leveraging HealthRules Payer to support new and evolving reimbursement models, enhancing their ability to serve a large and diverse membership effectively.

Conclusion

McLaren Health Plan's transition from a zero percent claims auto-adjudication rate to over 90% with HealthRules® Payer showcases the transformative power of modern technology in healthcare administration. This change not only improved operational efficiency but also positioned McLaren as a leader in the competitive healthcare landscape.

For more information, visit HealthEdge.