HealthRules Payer Case Study with Presbyterian

Presbyterian Health Plan's Transformation with HealthRules® Payer

Presbyterian Health Plan, a pivotal healthcare provider covering over 725,000 lives across New Mexico, faced the challenge of managing the complexities of processing more than 9 million claims annually amid rapid expansion. The organization sought a more flexible Core Administrative Processing System (CAPS) to automate claims operations effectively and enhance claims accuracy while remaining responsive to changing market opportunities and competitive demands.

Key Drivers for Change:

• Rapid Business Expansion: The existing system was insufficient to support growing needs and required a shift to a more adaptable system.
• Enhanced Efficiency: A need for a configurable CAPS capable of handling all lines of business and supporting greater efficiencies in claims operations.

Migration to HealthRules® Payer:

• Successful Transition: The phased implementation approach allowed Presbyterian to gradually adapt to HealthRules® Payer, ensuring a smooth transition with guidance from HealthEdge experts.
• Business Transformation: Beyond software implementation, the shift was seen as a comprehensive business transformation, aligning processes with HealthRules® Payer's optimized operations.

Achieving Strategic Objectives:

• Cost Savings and Improved Access: HealthRules® Payer significantly contributed to cost savings, better access to care, and timely, accurate payments.
• Flexible Configuration: The ease of configuring benefit plans and introducing new packages ensured faster market readiness and improved regulatory compliance.

Notable Success Metrics (as of May 2023):

• Auto-Adjudication Rates: Improved by up to 25% across all product lines.
• Staff Productivity: Increased by up to 30%, measured by the number of claims processed per hour.
• Contract Benefits Configuration Efficiency: Improved by 40%.
• First-Call Resolution Rate: Greater than 90%.
• Claims Turnaround Time: Reduced to under 5 days.

Strong Partnership with HealthEdge:

• Collaborative Relationship: HealthEdge's openness to Presbyterian's input on the product roadmap and willingness to work on complex contracts fostered a strong, ongoing partnership.
• Adaptability during COVID-19: Quick adaptation to regulatory changes using HealthRules® Payer configuration tools demonstrated the system's flexibility and responsiveness.

Future Goals and Digital Transformation:

• System Flexibility: The ability to reconfigure the system without custom code allows Presbyterian to focus on optimization and efficiency.
• Data-Driven Decisions: Transitioning to a digital health plan emphasizes data sharing and informed decision-making.

Advice for Transitioning to a New CAPS:

• Comprehensive Approach: Ensure involvement from all business areas and maintain a collaborative partnership between IT, business, and product experts.
• Openness to Change: Be prepared for process changes and start with smaller business lines to gradually adjust to new systems.

Learn More: To discover how HealthRules® Payer can transform your organization's operations and achieve similar success, contact your HealthEdge representative or visit HealthEdge website.