Case Study: a large non-profit health plan improves claims pricing efficiency with HealthEdge Source

Managing Payment Complexity to Improve Operational Efficiency

A large non-profit health plan in the northeast region faced the challenge of accurately and efficiently paying claims from non-contracted providers. With nearly four million members, these out-of-network claims were complex to price without negotiated rates, requiring intricate configurations aligned with CMS fee schedules and ongoing policy updates. To manage this complexity, the health plan turned to HealthEdge and its Source payment integrity platform.

The Source platform from HealthEdge provided a comprehensive solution, handling the plan's 75 different rate configurations and enabling accurate pricing for non-participating provider claims. HealthEdge delivered automatic updates to keep the plan compliant with policy changes and provided expert support to configure unique payment arrangements. This resulted in improved operational efficiency, reduced administrative burden, and confidence in the accuracy of their claims payments.