Data Sheet: Automatically Manage Retroactive Policy and Pricing Changes

Healthcare policy changes demand that health plans actively manage retroactive components, often requiring internal teams and third-party vendors for claims recovery. This can result in over- and under-payments, provider dissatisfaction, and compliance risks. The current manual, fragmented approach also incurs significant costs and inefficiencies.

HealthEdge's payment integrity solution, HealthEdge Source, now includes the Retroactive Change Manager. This innovative tool is designed to automate the management of retroactive pricing changes. Integrated into the Source ecosystem, this solution uses advanced pricing and configuration capabilities to streamline the identification, assessment, and rectification of past claims.

Key functionalities include:

• Monitoring retroactive changes to ensure accuracy.
• Reconciling inaccurate claims to maintain financial integrity.
• Repricing claims automatically to reflect current policies.
• Generating variance reports for comprehensive oversight.
• Using a single API to manage all pricing, editing, and policy updates efficiently.

Retroactive Change Manager seamlessly integrates into existing claim adjudication processes without needing extra IT resources, allowing users to easily schedule and run reports. This innovative tool reduces overhead, minimizes manual effort, enhances provider relations, and ensures CMS audit compliance.

In a landscape where CMS updates lead to over 600 annual changes, Retroactive Change Manager excels with its comprehensive functionality, automation, and user empowerment. It moves away from the traditional contingency-based payment integrity model, granting payers greater control over claims processes and creating a more efficient, compliant environment.

By using Retroactive Change Manager, healthcare payers can quickly identify and address retroactive pricing changes, reducing risks, boosting provider satisfaction, and achieving significant cost savings.