Set the Bar for Payment Integrity with Enterprise Payment Accountability

To stay ahead of complex payment models and billing guidelines, healthcare payers are turning to integrated digital solutions that can help streamline operations to achieve key business goals. Approaching payment integrity using disparate systems often results in unnecessary reworks and higher administrative costs. With an enterprise payment accountability approach, health plans can avoid improper payments and reduce recovery fees.

A Proactive Approach to Payment Integrity

Payment Accountability® from HealthEdge Source™ shifts the focus from post-payment recovery to proactive cost avoidance practices. By integrating claims processing workflows and optimizing pre-pay processes, health plans can reduce processing times and strengthen financial performance.

A Comprehensive Solution for Greater Control

HealthEdge Source Platform Access empowers health plans to enhance payment integrity at every level. Advanced analytics, custom editing tools, and real-time insights give payers more control over their payment processes, and achieve key benefits such as:

• Root-cause detection: By analyzing historical claims data, health plans can uncover policy gaps, identify outliers, and detect configuration issues before they lead to costly errors.
• Quick & easy adjustments: Advanced Custom Editing lets health plans quickly create and customize edits and analyze past claims for increased accuracy. This simplified process eliminates delays and reduces dependence on external vendors for execution and maintenance.
• Enhanced transparency and control: With a centralized platform, health plans gain real-time visibility into their payment integrity processes—helping ensure payment accuracy and regulatory compliance.

Our integrated technology, combined with our consultative partnership, helps health plans proactively manage claims processing and payments. HealthEdge  Source platform gives health plans greater control over their intellectual property, addresses root cause issues, and eliminates recurring administrative waste to support enterprise payment accountability.

Payer-Source Integration

The Payer-Source integration between HealthEdge Source and  HealthRules® Payer will be another pivotal step towards achieving an enterprise approach to payment integrity. By connecting all claims processing functions through a single platform, HealthEdge Source empowers health plans to manage their payment integrity programs more effectively. This effort enhances transparency between core platform and payment integrity functions.

By aligning disparate functions into a unified system, health plans can benefit from:

• Improved Payment Accuracy: Libraries of pricing and editing data, updated biweekly, lay the groundwork for industry-leading accuracy.
• Holistic Claims Adjudication: Editing can be applied effectively at multiple stages of the workflow, minimizing errors and reducing redundancies.

This centralized approach creates a bottom-line impact for enterprises, improving productivity while reducing overhead costs associated with fragmented systems.

Real-World Impact: Transforming a National Health Plan 

A major national health plan partnered with HealthEdge Source to address key challenges with achieving payment accuracy and workflow efficiency. The health plan leveraged the HealthEdge solution suite to streamline claims processing and payment management across the organization.

After adopting the integrated HealthEdge Source solution, the health plan accomplished notable improvements across performance and financial goals. Key achievements include:

• 30-40% reduction in resource-intensive contract maintenance
• Managed 70% self-funded business on a single platform
• Eliminated processing delays and improved claims transparency

• “The flexibility, configurability, and transparency of HealthEdge Source have been pivotal in our journey, resulting in measurable savings and operational improvements,” the payer’s VP of Operations shared. “This partnership has truly transformed our approach to payment accuracy and operational efficiency.”

With the abilities to continually adapt to both competitive market demands and evolving regulatory requirements, the organization’s enterprise-wide payment integrity transformation positions it for long-term success and industry leadership.

Opportunities in Payment Accountability

Disruption isn’t just about changing for the sake of change. It’s about understanding that yesterday’s systems weren’t built to handle tomorrow’s demands. Health plans should recognize the need to challenge outdated norms in favor of strategies that position them for long-term success.

By embracing a coordinated, technology-driven approach to payment integrity, health plans can move beyond cost savings to set new standards in transparency, accountability, and operational excellence—ensuring they are ready for the challenges of tomorrow.

See how a provider-owned health plan leveraged the HealthEdge Source Payment Integrity solution to streamline operations, improve accuracy, and enhance provider transparency. Read the case study: SummaCare’s Secret to Payment Integrity Success