Our Solutions

Dual-Eligibles

Health plans serving Dual-Eligible populations must provide high-quality care at every stage, deliver positive health outcomes, and keep costs low. 

HeatlhEdge's integrated next-generation, cloud-based solution suite enhances claims processing with software-driven payment integrity and feeds data to an end-to-end care management solution. Together, these solutions enable regulatory compliance, lower costs, higher quality care, and improved patient outcomes.

Administrative cost pressures weigh heavily on health plans serving Dual-Eligible members. HealthRules® Payor enables plans to maximize operational efficiency and realize cost savings through automating key processes while caring for even the highest risk members. The next-generation core administrative platform also offers the flexibility to respond to changing regulatory requirements and seamlessly connects everyone in the healthcare delivery cycle to improve patient outcomes. It also provides the agility to understand how Medicare and Medicaid coverage is accurately applied to an individual in combination.

Elderplan Case Study
Lower Administrative Costs, Maximize Operational Efficiency & Be Resilient to Change

For nearly 30 years, Elderplan has served the needs of Medicare, Medicaid, and Dual-Eligible individuals. The not-for-profit leverages HealthRules Payor to maximize their operational efficiency, control administrative costs and embrace an evolving business model that promotes the delivery of high-quality care for improved patient outcomes.

Elderplan Case Study Icon

Health plans with Dual-Eligible members must stay compliant with changing regulations while serving a population with complex health needs. Burgess Source® automatically delivers up-to-date Medicare and Medicaid policies and fee schedules, resulting in lower administrative costs, increased operational efficiency, and improved compliance.

eBook
7 Reasons to Choose an Integrated Ecosystem

Burgess Source provides an integrated ecosystem designed to ensure all aspects of the payment process work together. Our seven unique features and capabilities offer health plans serving Dual-Eligible members the opportunity to modernize claims processing resulting in big savings with improved workflow automation.

Integrated Ecosystem

GuidingCare® supports care management and population health services for health plans serving Dual-Eligible members in Medicare and Medicaid, the most vulnerable population in the United States. Offering a 360-degree view of the member and incorporating social determinants of health data, GuidingCare increases collaboration between all stakeholders in member care for maximum coordination, engagement, and improved health outcomes.

 

Working together, HealthRules Payor, Burgess Source, and GuidingCare enable health plans serving Dual-Eligible members tackle critical imperatives including:

  • Enroll and reconcile members efficiently and accurately
  • Identify and provide care to high-risk populations and members with high utilization
  • Track and report on critical quality and compliance measures
  • Achieve and maintain regulatory compliance as new rules emerge
  • Deliver transparency of information for superior customer experience
  • Lower administrative costs
  • Coordinate individuals' healthcare and support services effectively
  • Innovate new product lines