Case Study: SummaCare's Secret to Payment Integrity Success

SummaCare, a provider-owned health plan in Akron, Ohio, faced significant challenges in its payment processes due to a mix of manual and automated systems, leading to inefficiencies and high costs. The adoption of HealthEdge Source™, a payment integrity solution, transformed these processes, streamlined operations, and resulted in substantial cost savings.

Before implementing HealthEdge Source, SummaCare struggled with manual fee schedule downloads, complex inpatient and facility claim pricing, and outdated CMS fee schedules, which caused frequent claims rework. They needed a solution that provided timely updates, reduced administrative burdens, and improved payment accuracy. HealthEdge Source met these needs with unmatched solutions.

With HealthEdge Source, SummaCare consolidated from three editing solutions to one, streamlined processes, reduced manual intervention, and centralized pricing operations. This brought transparency and flexibility to their contracting process, resulting in a 500% increase in savings and over $1 million in edits.

A key success factor was the collaborative relationship between SummaCare and HealthEdge. SummaCare actively optimized the solution’s capabilities and beta-tested new features, including analytics tools and the Retroactive Change Manager.

HealthEdge Source also enhanced provider transparency and reduced provider abrasions. Its flexibility for integration with any claims system prepares SummaCare for a potential transition to a new core administrative processing platform.

SummaCare's success with HealthEdge Source demonstrates how the right technology partner can improve payment integrity, operational efficiency, and secure significant cost savings.