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Data Sheet: Enhancing Healthcare Payer Efficiency with HealthEdge Source™ Advanced Custom Edits and Analytics Integration

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This use case demonstrates the significant benefits of integrating the Advanced Custom Edits module with Analytics for healthcare payers.

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For healthcare payers seeking to optimize payment accuracy and streamline operations, integrating the HealthEdge Source™ Advanced Custom Edits module with Analytics offers a strategic advantage. This integration provides a robust framework for building, testing, and verifying the impact of new policies before deployment. By leveraging these advanced capabilities, health plans can achieve significant cost avoidance and enhance operational efficiency.

Operational Challenges in Payment Accuracy

Healthcare payers often face significant hurdles when managing customer interactions and policy implementations without integrated analytics. A specific use case involving "Healthcare Payer A" highlights three critical challenges addressed by HealthEdge Source™ Advanced Custom Edits:

  1. Demonstrating Value: Without Analytics, it is difficult to quantify the value generated by custom edits, as the necessary reporting data is siloed or unavailable.
  2. Proving Policy Impact: Implementing new policies requires proving their impact for approval. Analytics is crucial for obtaining this detailed information.
  3. Resource Constraints: Without Analytics, the payer would miss out on modeling features, requiring them to recreate logic in their own system and involve development or analytics teams.

The Solution: Analytics Integration

The integration of HealthEdge Source™ Advanced Custom Edits with Analytics offers a comprehensive solution designed to eliminate post-payment work and enhance payer workflows. Key features include:

  • Monitor Mode: Allows building and testing edits before deploying them live.
  • Detailed Reporting: Delivers the specific reporting metrics required to demonstrate the tangible value generated by the module.
  • Modeling Features: Frees up development or analytics teams to focus on other tasks.
  • Cost-Avoidance: By incorporating edits into the payer’s workstream, the solution eliminates the need for post-payment work typically handled by additional vendors.

Strategic Benefits for Healthcare Payers

Adopting this integrated approach delivers measurable improvements in efficiency and financial performance:

  • Efficiency: The only effective way to assess the impact of edits before activation is through Analytics with HealthEdge Source or internal reporting resources.
  • Cost Savings: This approach reduces costs by avoiding post-payment work handled by external vendors, saving both time and money.
  • Continuous Improvement: HealthEdge Source also constantly enhances its Real-Time Analytics (RTA) service, leading to ongoing improvements in the Advanced Custom Edits module.

Future Vision: Innovation in Cost Containment

HealthEdge continues to innovate within the payment accuracy landscape. Future enhancements include:

  • Bundling and Unbundling: Dedicated cost containment edits organized in a separate library, available as a licensable feature.
  • Native Edits: Empowering end users to build edits internally and publish them across relevant customer bases.
  • Custom Edit Libraries: Continued support for customer-specific needs through importable custom edit libraries.
  • Ongoing Optimization: Continuous improvement of edits that support cost containment strategies.