Impact of HealthRules Payer on Healthcare Payer Operations

Healthcare organizations today face numerous challenges, including successfully managing health insurance-related issues and processing transactions that are within the scope of today’s regulatory environment. A vital component is having the optimal core administrative processing system (CAPS)—and, in 2023, HealthEdge HealthRules Payer earned the Best in KLAS designation for the second year in a row.

Expanding Requirements for CAPS

Although, at its core, the healthcare organizations’ CAPS must efficiently process insurance claim, the system must also be flexible and scalable to accommodate the organization’s changing needs. For example, if Medicare or plans under the Affordable Care Organization requirements change, the CAPS must be designed and implemented to rapidly be reconfigured—ensuring synchronization across all of the healthcare system’s portals. High-quality CAPs, like HealthEdge HealthRules Payer, allow for the evolution of complex payment/reimbursement systems while preserving data integrity and accuracy.

Features of HealthEdge HealthRules Payer

Key features of this modern CAPS include:

• HealthRules Language: This patented technology uses a conversational vernacular so that it’s easily understood by English speakers and allows users of HeathRules software to efficiently use the CAPS.
• HealthRules Answers: This business intelligence solution gives your organization access to CAPS’ operational data for reports and dashboards, allowing you to effectively make real-time, informed decisions.
• HealthRules Connector: This enterprise-class integration layer gives you batch access to data and functionality in real-time and allows you to integrate the application with third-party vendors and other platforms that can benefit from real-time data.
• HealthRules Promote: With this feature, your healthcare organization can benefit from enhanced automation. This simplifies processes, which lowers costs, and allows for improved data accuracy.
• HealthRules Home & Host Processing: Your organization will enjoy reduced levels of complexity with built-in capabilities to support the application. This feature also eliminates provider data duplication.

Another feature, the interoperable, cloud-based platform HealthEdge Source, provides advanced secondary claims editing to reduce the number of inappropriate claims before they’re paid. Health plans often use secondary claims editors, which aren’t usually integrated with CAPS—which means that manual steps are often added to the process and data silos are created that add to difficulties in determining the accuracy of claims data.

With HealthEdge HealthRules Payer, though, Source can serve as a secondary editor to streamline operational workflows, improve the accuracy of claims, lower the number of overpayments, and capture significant savings.

Benefits of HealthEdge HealthRules Payor

HealthRules software provides numerous benefits, including the following:

Operational Efficiency

Thanks to the easy to understand HealthRules Language that virtually eliminates human error, and the superior automation that helps to eliminate unplanned costs associated with manual processing, HealthEdge HealthRules Payer is an ultra-efficient CAPS. It’s easy to say that something is efficient, but HealthRules Payer provides quantified proof: HealthRules software provides 90 percent to 97 percent first-pass auto-adjudication rates with 99 percent accuracy. The application thereby reduces transaction costs and improves real-time data access in a streamlined structure that maximizes operational efficiency.

Resiliency to Change

Health plans must nimbly adapt to market demands, competitive pressures, opportunities for expansion, regulatory changes, and more—faster than ever before. When health plans associated with governmental programs fall out of compliance, they can be heavily sanctioned or even shut down—necessitating rapid changes on the part of the health plan providers. This, in turn, requires a rapid response from healthcare organizations. HealthRules Payer is the agile solution that allows organizations to smoothly configure their CAPS to meet virtually any challenge or complexity.

New Business Models

Modern architecture and design allows you to implement a benefit plan and its pricing methods in significantly less time at a reduced cost when compared to other CAPS. The same is true when adding a provider contact. This facilitates a faster speed to market, enhances customer satisfaction, and more while staying within regulatory compliance. Lower costs also exist with maintenance and testing because of the reuse of modules when reconfiguring. Overall, HealthEdge HealthRules Payer allows for a nearly endless amount of business model inclusion.

Integration Comes Easy

Entering the business needs of a particular payor into CAPS can lead to errors and delays—but not with HealthRules software. Integration flexibility allows you to configure the application with ease for an organization’s unique rules using language that’s easily understood by people who aren’t IT experts and with seamlessly clear business logic.

Actionable Insights

Gain real-time access to valuable data and analytics across the board—from member info to claims information to provider data—and access it seamlessly. This allows healthcare organizations to make informed decisions about products, lines of business, provider contracts, value-based contracts, and so forth. Tools like the benefit predictor and trial claim can allow you to get answers to “what-if” questions” to help with decision-making. Results can then be smoothly shared with key stakeholders.

Staff Augmentation Needs with HealthEdge HealthRules Payer

With HealthRules software, you can put complex custom coding and intricate system configurations in your rearview mirror, which can streamline your need for IT resources. That said, to gain the benefits described in this post, you will need expert management of the CAPS—and, in today’s times, having enough staff can be a real challenge in healthcare organizations.

When you choose HealthTECH Resources for HealthEdge HealthRules Payer staff augmentation solutions, you’re not just selecting a service—you can count on top-tier quality, rapid deployment, and a personalized touch. Our boutique-style EMR agency has more than twenty years of experience exclusively in the healthcare IT/EMR/EHR space.

HealthTECH Resources possesses an unparalleled network of the industry’s finest professionals. If your healthcare facility is in need of staff augmentation to manage your HealthRules software, please reach out. We respond quickly to requests for staff supplementation, even with the most stringent needs and timelines. We’re also here to help analyze your IT staff to determine where gaps can most effectively be filled.

Contact HealthTECH Resources

To discuss your specific needs, please contact us online or call us at (602) 903-7961.