Case Study: a large non-profit health plan improves claims audit and reimbursement accuracy with HealthEdge Source

Regional Non-Profit - Leveraging Source for Efficient Claims Audit & Inquiry

A large non-profit health plan in the northeast faced challenges with its aging technology platform, which struggled to integrate with its legacy systems. They also needed a modern solution to handle complex provider payment arrangements and to efficiently audit claims and address retroactive payment inquiries from providers. To overcome this, they partnered with HealthEdge to implement its Source payment integrity platform.

The implementation of HealthEdge Source was successful, achieving seamless integration with the health plan's legacy core administration system and accommodating their complex hierarchical pricing rules. This resulted in a measurable improvement, increasing their first-pass claims adjudication rate from 80% to 98%. The solution provided powerful audit features that allowed the team to efficiently investigate and resolve dispersed claims complaints, significantly improving their manual inquiry and adjustment processes.