Case Study: a leading health plan company modernizes care management and payment integrity with HealthEdge

Modernizing Care Management and Operations with HealthEdge® Solutions

A leading health plan company, a non-profit HMO serving at-risk populations, needed to modernize its technology to support an expansion into serving complex dual-eligible (HIDE/FIDE) members. Their legacy systems could not handle the rigorous clinical, operational, and regulatory demands of this new line of business, creating inefficiencies in care management and exposing them to savings leakage from claims inaccuracies. To solve this, the health plan turned to HealthEdge for its GuidingCare care management and Source prospective payment integrity solutions.

HealthEdge implemented its integrated GuidingCare platform to streamline care coordination and its Source payment integrity solution to improve claims accuracy. The result was a seamless, modern technology foundation that enabled the health plan's expansion. The integrated systems reduced administrative IT lift, improved payment accuracy, and provided the sophisticated reporting needed to meet strict regulatory requirements for their new member population.