Case Study: Large, National Health Insurer

National Health Insurer Payment Integrity Transformation

A leading national health insurer, already ranked among the top 15 insurance companies with over 6 million members, set out on an ambitious growth plan. To expand their government business and streamline operations, the insurer faced challenges with their outdated claims system. This system needed to adapt to the complexities of innovative government programs, highlighting the need for a fully automated claims reimbursement process.

Transition to Modern Payment Solutions

We collaborated with operations and IT leaders to create a multi-stage plan for migrating payment operations to HealthEdge Source's advanced systems. Our solution offers:

• Automatic Updates: Ensuring data consistency and up-to-date information.
• Increased Auto-Adjudication: Reducing manual claims processing and rework.
• Enhanced Compliance: Meeting regulatory requirements more efficiently.

Initial Success and Expansion

The initial implementation proved successful, particularly for their Medicare Advantage business. This success led to expanded use across other federal services, dual-eligible programs, and Medicaid in multiple states.

Long-Term Impact

Over a 23+ year partnership, Source has become a vital resource for over 1,000 employees across various departments, including claims operations, configuration, provider relations, medical economics, and management. The automated systems now handle over 1,000,000 claims per month, saving millions of dollars annually. The insurer has significantly reduced operational overhead, increased first-pass payment accuracy, and strengthened relationships with providers nationwide.

Conclusion

The implementation of Source's payment integrity tools has enabled the insurer to accurately handle complex reimbursement scenarios. This includes using custom payment formulas and fee schedules. This integration not only improves efficiency and accuracy but also establishes the insurer as a forward-thinking leader in the healthcare industry. Through this partnership, the insurer aims to enhance its competitive advantage by leveraging AI-driven solutions to maintain excellence in payment integrity.