eBooks: Beyond the Basics - The Modern Approach to Payment Integrity Vendors With HealthEdge Source

Challenges in Claims Payment

In the evolving healthcare landscape, accurately paying claims has become increasingly complex, posing significant challenges for payers. To address these issues, many payers have segmented their organizations to tackle different pain points, leading to fragmented infrastructures and specialized teams with unique workflows, technology stacks, and vendor solutions. This segmentation has created intricate IT ecosystems that struggle to adapt to the influx of data, market demands, and regulatory requirements.

Shift Towards Digital Strategy

The traditional approach to claims payments is becoming obsolete as health plans shift towards a digital strategy. Prospective Payment Integrity (PPI) represents this shift by moving information and processes upstream in the adjudication process, ensuring accurate payments and cost avoidance. While the return on investment for PPI solutions is challenging to measure, the benefits of cost avoidance outweigh those of revenue recovery.

Reevaluating Fragmented Approaches for Payment Integrity Vendors

Payers are reevaluating their fragmented approaches, seeking holistic solutions for claims payment accuracy. The market offers two primary categories of Payment Integrity vendors:

1. Single Vendor with Multiple Disparate Claims Payment Applications:

• These traditional solutions offer multiple independent modules from a single vendor.
• This approach often leads to hidden costs, inconsistent processes, siloed data sets, and IT burdens.
• Many of these solutions are not designed for cloud environments, adding to their complexity.

2. Single Payment Integrity Platform with Multiple Interoperable Solutions:

• This modern approach allows payers to choose products and vendors that best fit their needs without additional IT burdens.
• Platforms like HealthEdge Source operate in cloud-based environments, handling pricing, editing, and claims analysis in a single pass.
• This model provides a comprehensive view of claims payments, improving accuracy and reducing costs

Key Evaluation Criteria

Key evaluation criteria for these solutions include infrastructure and updates, customization capabilities, content, interoperability, and total cost of ownership. The single-platform approach offers significant advantages over traditional methods, including seamless integration, reduced IT maintenance, and comprehensive content updates.

In conclusion, as payers strive for more efficient and accurate claims payments, choosing the right payment integrity vendor is crucial. Business and IT leaders must collaborate to evaluate solutions that offer long-term success and improved payment accuracy.