Case Study: Medica achieves faster, more accurate claims processing with HealthEdge HealthRules Payer

How HealthEdge®’s HealthRules® Payer Helped Medica Transform Claims Operations through Strategic Automation

Medica, a Minnesota-based nonprofit health plan, faced significant challenges due to rising healthcare utilization and intense administrative cost pressures, which strained the accuracy and efficiency of its claims operations. To address this, the company partnered with vendor HealthEdge to implement its core administrative processing system, HealthRules Payer, as the foundation for a strategic automation initiative.

By leveraging HealthEdge's HealthRules Payer platform to automate workflows, Medica dramatically increased its claims processing efficiency. The results included an 800% increase in automation volume, leading to administrative savings of $1.2 million in the first year and an additional $1.6 million the next. HealthEdge’s solution also enabled Medica to achieve a 99.5% auto-adjudication rate and process 99.5% of claims within 30 days, greatly improving accuracy and speed.

Medica

Stacy Chalupsky

Vice President for Claims Operations and Payment Integrity