Data Sheet: HealthEdge Source™ Medicaid - New York
A prospective payment integrity solution that manages accurate and compliant pricing data, so health plans can focus on optimizing member outcomes instead of claims editing and re-work.
As regulatory environments become increasingly complex, health plans face significant challenges in maintaining accuracy and compliance. With CMS estimating $132 billion in annual improper payments—over 60% of which stem from Medicaid programs—the need for a robust, prospective solution is critical. Source provides a comprehensive New York Medicaid payment integrity solution that manages accurate and compliant pricing data, allowing health plans to focus on optimizing member outcomes rather than claims editing and re-work.
The Complexity of New York Medicaid
New York Medicaid reimburses qualified medical expenses based on intricate eligibility criteria determined by the NY Department of Social Services (DSS). This complexity is evident in Ambulatory Surgery Center (ASC) reimbursements, where over 2.4 million surgery services are performed annually. These services utilize Enhanced Ambulatory Patient Groups (EAPGs), requiring specific rate codes and relative weight adjustments for accurate payment.
Source addresses these challenges by delivering in-depth, NY-specific content that includes fee schedules and payment policies across a wide range of facility and professional provider types.
Strategic Advantages of Source
Leveraging a cloud-supported infrastructure and Agile development methodologies, Source delivers the following strategic benefits to health plans:
- Proven Expertise: Backed by 10+ years of experience providing Medicaid support to some of New York’s largest and most progressive health plans.
- Automated Accuracy: Hands-off, automatic delivery of Medicaid policy updates every two weeks, maintained by a dedicated team of subject matter experts.
- Operational Efficiency: A single API requires only one call from a single source for all NY-specific fee data, eliminating manual updates and reducing IT burden.
- Flexible Configuration: Customization capabilities accommodate even the most complex payment arrangements.
- Audit Readiness: Improved transparency within a single system supports audits and strengthens provider relations.
Quantifiable ROI and Workflow Improvements
Deploying Source as a New York Medicaid payment integrity solution drives measurable operational improvements and cost savings:
- 40% reduction in claims needing to be re-keyed due to improved workflow.
- 5-8% of total claims identified with inaccuracies are corrected pre-payment.
- $5 in savings per identified claim resulting from improved accuracy.
- 25% time savings over previous manual processes.
Conclusion
To navigate the evolving landscape of healthcare reimbursement, health plans must adopt modern technology solutions that create business agility. Source empowers organizations to pay claims accurately, quickly, and comprehensively, transforming compliance challenges into opportunities for efficiency and growth.
