Prospective
Payment
Integrity

Prospective payment integrity focuses on preventing errors like overpayments, underpayments, or fraud before payments are made, rather than correcting the issues afterwards. This proactive approach reduces waste, minimizes administrative burdens, and enhances the overall accuracy of payment systems.

HealthEdge Source redefines what a payment integrity solution can achieve by addressing systemic challenges at their core. Our solution empowers health plans to understand both what went wrong and why, using advanced analytics and real-time insights to identify overpayments, underpayments, and claim denials. By automating processes and equipping in-house teams with powerful tools, we reduce reliance on third-party services, improve operational control, and cut long-term costs. Through innovation and a deep understanding of healthcare complexities, HealthEdge Source prepares your organization for today’s demands and tomorrow’s opportunities.

HealthEdge Source simplifies claims editing with integrated pre-pay and post-pay solutions, removing the need for multiple vendors. By centralizing claims processing, it improves workflows, enhances accuracy, and lowers administrative overhead—helping your organization achieve better outcomes with greater efficiency.

HealthEdge Source is built to work with any Core Administration Platform Solutions (CAPS). It integrates directly with HealthRules Payer to enable more efficient claims processing, payment management, and data exchange. Additionally, it can connect with any CAPS solution through a single API, offering flexibility and smooth integration.

The Center for Medicare and Medicaid Services (CMS) frequently enforces retroactive changes to fee schedules, edits, and pricer logic, creating significant challenges for health plans. Traditional approaches rely on manual efforts or third-party vendors to recover over- and underpayments, which often take months after the changes occur. This leads to high administrative costs, inefficiencies, and strained provider relationships. HealthEdge Source Retroactive Change Manager (RCM) automatically and proactively monitors for retroactive changes. This enables payers to accurately reprice and adjust over-and-underpayments with full transparency into the changes, generate variance reports to identify claims that require adjustments, and reconcile inaccurate claims immediately to improve compliance.

Payment integrity solutions improves claims processes, reducing delays, errors, and disputes. They ensure claims are processed accurately, with clear explanations for changes or denials to help providers understand. Automation speeds up payments and minimizes mistakes, while addressing issues early to prevent bigger problems down the line, making the whole process easier for everyone involved.