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High-Speed Payment Accuracy: Take a Proactive Approach with HealthEdge Source

Health plans today face significant challenges in managing payment integrity. Operations are often hindered by fragmented systems and slow, ticket-based processes for implementing policy edits. These inefficiencies create a lag in responsiveness, delaying potential savings by weeks or even months, which directly impacts budgets and operational agility.

This guide outlines a transformative path forward using HealthEdge Source. By moving away from disjointed legacy systems toward a modernized, integrated platform, health plans can transition from ideation to production savings with unprecedented speed and accuracy. The following sections detail the current industry challenges, the strategic shift toward user-driven configuration, and the technical workflows necessary to take direct control of payment policies—from creation and testing to deployment and retrospective analysis.

The Challenge with Traditional Payment Integrity

The conventional approach to payment integrity typically relies on a complex web of disparate systems, multiple vendors, and manual ticketing processes. This "spaghetti" model creates numerous points of friction that prevent health plans from harnessing the full power of their data.

Key inefficiencies in the traditional model include:

  • Extended Timelines: Moving a new payment policy edit from concept to production often takes months. During this lag time, incorrect payments continue to process, leading to recoverable but administratively burdensome overpayments.

  • Vendor Dependency: Health plans frequently rely on external vendor engineering teams and rigid release schedules, limiting their control over the pacing of critical updates.

  • Increased Costs: Managing multiple providers and paying various fees for configuration changes adds significant administrative overhead to the bottom line.

  • Lack of Agility: The inability to respond quickly to new billing trends, regulatory updates, or contractual changes compromises a health plan's ability to manage costs effectively.

 

A Modernized Approach: User-Driven Edit Configuration

To overcome these barriers, health plans require a suite of integrated tools designed to centralize control over payment integrity strategies. HealthEdge Source facilitates this by combining long-standing configuration capabilities with powerful new modules. This platform empowers users to build, test, and deploy complex edits directly within the user interface—no engineering change orders required.

The core of this modernized approach is enabling data-driven decision-making. Rather than relying on intuition or vendor timelines, the platform provides the insights and functionality necessary to:

  • Validate policies against real-world data.

  • Forecast financial impact before implementation.

  • Implement changes with confidence and precision.

 

The Virtuous Cycle: A Four-Step Workflow

HealthEdge Source integrates several powerful modules into a cohesive workflow, creating a "virtuous cycle" of ideation, testing, implementation, and analysis. This end-to-end process ensures accuracy while dramatically increasing the speed of deployment.

1. Test and Validate with What-If Modeling (SWIM)

Before deploying a new edit, the Source What-If Modeling (SWIM) tool allows teams to forecast impact using historical data. This predictive capability enables health plans to:

  • Create a Data Snapshot: Define a universe of historical claims for analysis (e.g., all lab claims from the last 90 days).

  • Run a Data Study: Process the snapshot against different configurations—comparing current production setups against new proposed edits.

  • Analyze the Impact: Review exactly which claims would have been impacted and calculate potential savings. This provides the concrete data needed to gain internal approval and refine logic before going live.

2. Collect Real-Time Data with Monitor Mode

Once an edit is built, it can be activated in Monitor Mode. This feature runs the edit passively on live production claims without affecting final payment adjudication.

  • Process: The claim processes first with standard production edits, then runs a second time with monitored edits applied.

  • Strategic Value: This allows teams to collect real-time performance data and continuously track the financial impact of policies not yet fully implemented. It builds confidence in the edit's accuracy through live-fire testing without financial risk.

3. Educate Providers with Informational Edits

To minimize provider abrasion and encourage correct billing behavior, users can temporarily set an edit's disposition to informational.

  • Provider Notification: During a set period (e.g., a 90-day notification window), the edit fires on claims and returns a message on the Explanation of Benefits (EOB) explaining the new policy.

  • Behavioral Change: This proactively educates providers, giving them time to adjust billing systems (e.g., including required therapy modifiers) before the edit impacts reimbursement.

4. Automate Retrospective Analysis with RCM

After an edit goes live, the Retroactive Change Management (RCM) tool automates the identification of claims paid incorrectly prior to the change. This is critical for backdating policies or implementing contract updates.

  • Automated Rework: RCM re-processes a defined period of historical claims against the new configuration.

  • Comprehensive Reporting: It generates dashboards detailing overpayments and underpayments, providing a clear net difference for each provider.

  • Reduced Abrasion: Consolidated analysis streamlines recovery and facilitates transparent communication with providers regarding backdated changes.

 

Technical Implementation: Building Custom Payment Policies

The Advanced Custom Edit tool is the engine behind this agility. It allows payment integrity teams to design and implement highly specific policies tailored to unique plan requirements via an intuitive, point-and-click interface.

The Logic Framework

Building an edit involves three key components:

  1. Current Claim Criteria: Defines attributes of the incoming claim that qualify it for the edit.

  2. History Criteria: Defines specific patterns or codes to look for in a member's claim history.

  3. Relational Criteria: Establishes the logic for how the current claim and historical claims interact to trigger a denial or flag.

Key Use Cases

Use Case

The Problem

The Solution within Source

Lab Duplicates

A facility bills for collecting a sample, and an independent lab also bills for the test, resulting in double payment.

Create an edit that identifies a facility lab claim and searches the member's history for a matching service from an independent lab (Place of Service 81) on the same date.

Therapy Frequency Limits

Over-utilization of therapy services (e.g., physical, occupational) leads to waste and unnecessary costs.

Build an edit using a Code Collection of therapy codes. The logic sums units of therapy services within a calendar week, grouped by modifier, and denies units exceeding the plan's weekly limit.

E&M Downcoding

A facility bills a high-level emergency room code, but the physician claim indicates a low-level service.

Construct a cross-provider edit that flags a high-level facility E&M claim and denies it if a low-level physician E&M claim exists for the same date of service, indicating potential upcoding.

 

 

By adopting a modernized, user-driven approach to payment integrity, health plans can break down the boundaries that prevent efficient cost management. The integration of advanced custom editing, predictive modeling, and automated retrospective analysis creates a robust framework for success.

HealthEdge Source empowers plans to shorten implementation cycles, ensure billing accuracy, and maximize savings. This shift from reactive, vendor-dependent models to proactive, data-driven operations positions health plans to be nimble enough to address future industry changes while delivering superior financial and operational outcomes today.