eBooks: A Checklist for Enabling Real-Time Claims Editing and Payments

Enabling Real-Time Claims Processing for Healthcare Payers

In an evolving healthcare landscape, where complexity and demand for transparency are increasing, modernizing core administrative processing systems (CAPS) is no longer optional for payers. A critical aspect of this modernization is transitioning to real-time claims processing, which can significantly reduce costs, streamline workflows, and enhance relations with both members and providers.

However, achieving real-time claims processing requires the deployment of effective claims editing solutions to ensure accuracy before claims are processed. According to a Gartner report, reevaluating the performance of current claims editors is essential in meeting new business requirements and focusing on real-time operations and interoperability.

The Current State of Payment Accuracy

The 2023 Gartner Hype Cycle™ for U.S. Healthcare Payers highlights that between 3% and 7% of all healthcare claims are paid inaccurately, with only a fraction corrected later. Traditional approaches to claims accuracy focus on payment recovery through multiple claims editing solutions, rather than ensuring payment accuracy from the start. This results in data silos, limited insights into root causes of errors, and escalating costs due to secondary and tertiary claims editors.

Modernizing Claims Editing Solutions

HealthEdge Source™ offers a comprehensive claims editing solution designed to support real-time claims processing. It covers multiple lines of business, integrates with various CAPS, and supports cost avoidance. With capabilities like AI/ML integration, customizable edits, and detailed reporting, Source addresses the limitations of traditional claims editing methods.

Key Features of HealthEdge Source:

• Coverage: Supports multiple lines of business including Medicare, Medicaid, and Commercial.
• Integration: Pre-built integrations with major CAPS and third-party specialty content solutions.
• History Capabilities: Maintains 39 months of claims history to identify and prevent improper payments.
• Customization: Intuitive user interface for easy customization of edits and pricing algorithms.
• Guidelines: Utilizes resources from CMS, state Medicaid programs, and other authoritative bodies.
• Reporting: Comprehensive audit trails, historical claims data, and flexible reporting capabilities.
• Analytics: Real-time analytics module for continuous monitoring and comparison with benchmarks.

Conclusion

To truly benefit from real-time claims processing, healthcare payers must adopt modern, enterprise-scale claims editing solutions. HealthEdge Source delivers these capabilities, ensuring accuracy, efficiency, and significant cost savings. By transitioning to such advanced solutions, payers can not only improve their operational workflows but also foster better member and provider relations.