Systems That Easily Integrate Necessary For Improving Claims Accuracy Rates

Once a health plan finalizes a claim, they do not want to go back and fix it retroactively. Claims accuracy rates improve productivity, reduce errors, and are critical to a health plan's success.

In order to improve claims accuracy rates, health plans need a technology that integrates easily with all of the systems in your IT ecosystem and infrastructure and allows data exchange in real-time. Real-time data enables a payer to match the members to the right benefit plan and the providers to the right contract provisions to ensure the correct payment is applied to every claim. Without the proper tools, data matching can drain a payer's time and resources and adversely impact the bottom line.

I worked with a Mid-West health plan that had clear key performance indicators they were looking to improve. They needed technology that integrated with their entire ecosystem and shared data to track their success metrics. They specifically needed a technology that could integrate with trading partners for eligibility, medical claims editing, grouping and reimbursement, repricing entities, provider credentialing, and more. They also needed a way to enhance member and provider matching, standardize USPS requirements and format, and provide latitude/longitude coordinates, among other things.

Their existing legacy technology could not configure or integrate their systems to track the necessary data. Their only options were a mixed-bag of technology to cover basic functionality and custom code to resolve integration gaps. Maintaining the integration was cumbersome, and upgrades required custom remediation. Furthermore, extending benefit information to external systems required interpretation of legacy table data, increasing the chance for error.

The health plan needed a next-generation system that worked in harmony with all other solutions in their IT ecosystem to achieve their business goals.

With next-generation technology, health plans can be self-sufficient. This enables implementations and ongoing maintenance of your IT infrastructure to be lower cost and lower risk than with a legacy solution.

About the Author

David Nesbitt

David Nesbitt, Vice President, Sales Operations

David is a senior executive responsible for sales operations across the HealthEdge solution suite. In his current role, he supports all HealthEdge sales activities including partner relationships. David has more than 25 years of healthcare payer experience and brings a broad background spanning software development, product management, professional services delivery and sales. He has been with HealthEdge for more than 13 years. During this time, David has served as Product Manager designing HealthRules Payor functionality as well as Senior Director of Business Services managing the business consultants and education services in Professional Services. Prior to his tenure at HealthEdge, David held product management and delivery roles at NaviNet and Verisk Analytics. His early healthcare experience was in the role of software development at Healthsource/CIGNA. 

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HealthEdge recognizes the importance of reliable integrations. The HealthRules® Solution Suite enables real-time transactional capabilities across the ecosystem to exchange data for improved throughput, reduced administrative resources, and business partner enablement.

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