Case Study: Managing Payment Complexity to Improve Operational Efficiency

Managing payment complexity is crucial for improving operational efficiency in health plans. Not all claims come from contracted providers with negotiated rates, making accurate pricing and payment essential. HealthEdge Source™ (Source) is a comprehensive payment integrity platform that supports health plans with enterprise-wide payment integrity strategies and foundational pricing for both participating and non-participating providers.

Challenges Faced by Non-Profit Health Plan

A large non-profit health plan in the Northeast region faced significant challenges with non-participating provider claims. With nearly four million members and multiple lines of business, the health plan often received claims from providers outside their network. To ensure accurate and efficient payments, the health plan leveraged the Centers for Medicare and Medicaid Services (CMS) fee schedules, which list maximum fees for various services.

Importance of CMS Fee Schedules

CMS fee schedules are vital for both government and commercial lines of business. They simplify payment arrangements but require tailored configurations and claims-payment messaging to account for varied provider characteristics. HealthEdge’s Source platform helps health plans stay compliant with ongoing policy updates and retroactive change mandates, ensuring accurate claims processing.

The Solution Provided by Source

Source platform facilitates many configurations and specific messaging, reducing the complexity associated with different provider types and locations. HealthEdge's quick deployment of updates and built-in edits streamline the validation and testing process, offering a significant advantage over other vendors.

Key Benefits

• Accurate Payment: Ensures precise payments for non-participating providers, maintaining member care access even beyond home regions.
• Efficient Operations: Reduces the number of payment arrangements while facilitating necessary configurations.
• Compliance: Keeps plans updated with automatic policy changes, minimizing resource demands.
• Automation: Optimizes automation and accuracy, enhancing overall operational efficiency.

Conclusion

Investing in the HealthEdge Source platform allows health plans to manage payment complexities effectively, ensuring accurate and efficient operations. By leveraging CMS fee schedules and automated updates, health plans can focus on providing high-quality care while maintaining financial integrity.