Case Study: Regional Non-Profit - Leveraging Source for Efficient Claims Audit & Inquiry
A large non-profit health plan in the northeast shared their positive experiences using the HealthEdge Source™ (Source) platform for provider reimbursement. This case study highlights the health plan’s successful replacement of an outdated platform with Source, detailing how this modern payment integrity solution integrates seamlessly with legacy components and enhances healthcare claims audit and inquiry processes.
Key Challenges and Solutions
The health plan faced two primary challenges:
- Platform Integration: The need to replace an older technology platform while ensuring compatibility with existing systems.
- Healthcare Claims Audit & Inquiry: The necessity for efficient auditing and handling ongoing retroactive claims inquiries.
Implementation and Benefits
In 2021, the health plan initiated a phased implementation of Source, overcoming integration challenges thanks to Source’s compatibility with over 10 claims systems. This integration led to a significant improvement in first-pass claims adjudication rates—from 80% to nearly 98%. The platform’s hierarchical edit capabilities also streamlined complex provider payment arrangements.
Enhanced Efficiency and Accuracy
Source’s robust features have optimized the health plan’s manual and resource-intensive processes. The automated bi-weekly updates and comprehensive audit tools enable the team to manage retroactive claims inquiries efficiently. For instance, the Reimbursement Initiatives Manager utilized Source’s audit feature to resolve dispersed claims complaints and provide detailed responses to leadership inquiries.
Conclusion
By leveraging HealthEdge’s Source platform, the non-profit health plan has significantly enhanced its operational efficiency, accuracy, and customer service capabilities. This case study demonstrates how Source can serve as a critical tool for health plans aiming to optimize their healthcare claims audit processes and drive better outcomes.
