Data Sheet: HealthEdge Source™ Medicaid - Florida

Managing the complexities of state-specific healthcare regulations requires a sophisticated, data-driven approach. Source provides a comprehensive Florida Medicaid payment integrity solution designed to manage accurate and compliant pricing data, eliminating the need for health plans to handle these intricate processes internally.

By leveraging a cloud-supported infrastructure and prospective payment integrity capabilities, Source ensures health plans can pay claims accurately, quickly, and comprehensively while navigating the specific nuances of Florida’s regulatory landscape.

Core Capabilities and Infrastructure

Source delivers a hands-off, automated experience that improves time-to-value through a single API and cloud-based architecture. Our solution creates a single source of truth for fee schedules and payment policies, supported by:

• 10+ years of experience developing and delivering state-specific Medicaid support.
• In-depth Florida Medicaid content, including fee schedules and policies across a wide range of facility and professional provider types.
• Automatic delivery of Medicaid policy every two weeks, built and maintained by Source Subject Matter Experts (SMEs) to remove internal IT burdens.
• Customization capabilities to meet complex payment arrangements and improve transparency for audit and provider relations.

Comprehensive Coverage for Florida Medicaid

Source enables accurate reimbursement by evaluating claims against Medicaid fee-for-service pricing formulas and rates. Our solution covers a diverse array of facilities and services, including:

• Ambulance and Suppliers (DME)
• Ambulatory Surgery Centers (ASC) and End-Stage Renal Disease (ESRD)
• Home Health Agencies, Hospice, and Nursing Facilities
• Hospital Inpatient and Outpatient Departments
• Professional Services

Furthermore, Source manages core payment policies such as modifier appropriateness, outliers, specialty adjustments, multiple surgery reductions, bilateral procedures, and Maximum Daily Units.

Technical Precision in Action: Nursing Facility Reserve Bed Pricing

Source’s unique content offering supports compliance standards based on accuracy, speed, and reliability. A prime example includes our handling of Florida Nursing Facility Reserve Bed Pricing (Revenue Code 0182).

• History-Enabled Logic: Source looks across a patient's past claims to determine when annual thresholds are reached (e.g., the 16-unit maximum per fiscal year).
• Automated Adjustment: Instead of producing a denial when a claim exceeds limits, Source evaluates the line and adjusts the unit pricing (e.g., adjusting 17 units down to 16).
• Reduced Abrasion: This precise adjustment reduces claim resubmissions, provider over/under payments, and member abrasion.

Proven Impact and ROI

With CMS estimating $132 billion in annual improper payments—over 60% of which stem from Medicaid—Source delivers measurable financial and operational improvements:

• $5 savings per identified claim from improved accuracy.
• 5-8% of total claims identified with inaccuracies.
• 40% reduction in claims needing to be re-keyed due to improved workflows.
• 25% time savings over previous manual processes.