Brochure: A Health Plan on a Payment Integrity Journey

In the evolving landscape of healthcare, enterprise-level payment integrity has emerged as a critical priority for health plans. BlueHealth, a fictional representation of real-world challenges, highlights the complexities faced by health plans due to payment inaccuracies and the high cost of third-party vendors. This scenario mirrors the widespread struggles within the industry to streamline payment processes while maintaining transparency and accuracy.

Key Challenges Faced by BlueHealth

BlueHealth has received a national mandate to reduce payment errors and demonstrate plan savings. However, the organization grapples with growing provider and member dissatisfaction due to payment inaccuracies. The lack of transparency and the burdensome costs of third-party solutions further complicate their efforts to implement effective payment integrity measures.

The narrative follows Thom, Raj, Ana, Kelly, and Erika, key leaders at BlueHealth, as they confront payment integrity challenges. Thom’s team faces limited visibility into third-party systems, resulting in manual resolution of payment errors. Raj anticipates additional resource requests, stretching the IT team's capacity. Ana identifies technology gaps, while Kelly recognizes the need for an enterprise-wide strategy. Erika, the CEO, establishes a Payment Integrity Enterprise workgroup to address these systemic issues.

The Expertise of HealthEdge Source

With over 15 years of working with health plans, offering home and host capabilities, HealthEdge Source (Source) offers a robust solution designed to address these pressing issues. Source has partnered with 13 health plans, including multi-state and national plans, to provide integrated and efficient payment integrity solutions. The platform supports a sustained, enterprise-wide approach to ensure accurate and transparent payment processes.

Source Solution and Benefits

Source by HealthEdge emerges as the ideal partner for BlueHealth, offering comprehensive capabilities such as:

• Primary and Secondary Editing: Seamless integration with existing health plan products and solutions.
• Customizable Edit Libraries: Enables health plans to add proprietary edits while providing transparency into ongoing payment errors.
• Modeling Capabilities: Allows plans to anticipate financial outcomes of new edits, minimizing risks.
• Cloud-Based Platform: Automated upgrades reduce IT burdens and ensure up-to-date content.
• Comprehensive Reporting: Dashboards and reports help monitor savings and identify new opportunities.

Outcome for BlueHealth

By leveraging Source, BlueHealth can significantly reduce manual payment corrections, achieve higher accuracy in claims payments, and align departmental KPIs for a unified payment integrity strategy. The integration of Source promises not just cost savings but also enhanced operational efficiency and improved member satisfaction.

For health plans seeking to transform their payment integrity processes and achieve sustained enterprise-wide solutions, Source by HealthEdge offers a path forward. Explore how Source can help your organization reduce payment inaccuracies and improve operational efficiency.