HealthEdge® Named in the Gartner® Hype Cycle™ for US Healthcare Payers, 2023

Company recognized as a Sample Vendor in three categories of July 2023 report

Next-generation healthcare SaaS company HealthEdge® is recognized in three categories of the Gartner® Hype Cycle™ for U.S. Healthcare Payers, 2023 report. The report names HealthEdge a Sample Vendor for Next-Gen Core Administrative Processing Solutions, Prospective Payment Integrity Solutions and AI-Enabled Fraud Detection. According to the report, “U.S. healthcare payer chief information officers (CIOs) should use this to plan new and manage existing investments for business optimization and transformation.”

The July 2023 report marks the 13^th consecutive year in which HealthEdge has been named a Sample Vendor for Next-Gen Core Administrative Processing Solutions (CAPS). “HealthEdge’s flagship solution, HealthRules® Payer, enables health plans to embrace new business models, adapt to changing regulations and expand into new markets with ease,” said Alan Stein, chief commercial officer of HealthEdge. “The modern platform creates unparalleled flexibility and provides the real-time data, transparency and transaction processing plans need to compete in today’s healthcare landscape.” According to the report, “CAPS modernization is a top strategic imperative that delivers operational improvements and administrative cost savings through increased efficiency and accuracy, freeing funds and resources for innovation.” With HealthRules Payer, “Advanced automation puts accuracy and efficiency at the core of every process and workflow,” said Stein.

This Hype Cycle marks the 5^th year in a row naming HealthEdge* a Sample Vendor in Prospective Payment Integrity (PPI) Solutions. The company’s cloud-native pricing and editing platform, Source, enables plans to pay claims quickly, accurately and comprehensively from the start — saving payers the time, expense and headache of recovering overpayments. “Source identifies issues at the root cause, giving plans the power to stop the endless pay-and-chase cycle,” said Ryan Mooney, Source’s executive vice president and general manager. “Paying claims right the first time reduces costs not only for health plans — it drives down the cost of care for everyone.”

According to the report, “PPI solutions mitigate a broad range of potentially improper claims payment activities by identifying, and correcting for, claims inaccuracies prior to claims payment. PPI solutions could reduce payer (and taxpayer) burden, such as the $1.7 billion in fraud recovered retrospectively by the U.S. Department of Justice in 2022.” In addition to thwarting fraud, prospective payment integrity raises member and provider satisfaction levels, lowers appeals rates, and decreases claims spend. “Cost avoidance from PPI solutions and practices represents a larger benefit opportunity than revenue recovery. Between 3% and 7% of all healthcare claims are paid inaccurately — and only a fraction of those claims payments are later corrected,” the reports states.

Source also shines in bringing multiple, traditionally fragmented processes together in one dynamic solution. According to the report, “Few payers have an enterprise payment integrity program that provides governance and oversight across all regions, products, provider networks, capabilities and vendors. Fragmented procurement and operations of PPI solutions diminish the return on investment (ROI) of cost avoidance or, at least, hinder accurate aggregation of savings realized across the organization and provider networks.” Source provides real-time analytics, a centralized audit trail with rich data and reporting, and claims modeling that predicts the impact of edits before plans put them into production. The report recommends that payers “Prioritize solutions that support real-time updates to policies and employ advanced analytics, automation and artificial intelligence (AI). These features will help you quantify and optimize cost avoidance, and remain compliant with the Centers for Medicare & Medicaid Services (CMS) and other regulatory updates.”

The report names HealthEdge a Gartner Hype Cycle Sample Vendor in a new category: AI-Enabled Fraud Detection. HealthEdge’s report generation and case integration capabilities help fight fraudulent claims that raise costs and lower the quality of care across the healthcare ecosystem. The U.S. Department of Justice estimates that healthcare fraud, waste and abuse may exceed $100 billion each year. According to the report, “AI-enabled fraud solutions are beginning to address this considerable cost by identifying fraudulent claims more accurately, compared to their rule-based predecessors.” Mooney explained, “HealthEdge solutions seamlessly integrate with AI and machine-learning engines that detect fraud. On our future roadmap, partner integrations in development will provide HealthEdge customers with built-in fraud detection technology.”

*HealthEdge was recognized as Burgess Group from 2019 to 2021 in the Prospective Payment Integrity (PPI) Solutions category. HealthEdge acquired Burgess Group in August 2020.

Gartner, Hype Cycle for U.S. Healthcare Payers, 2023, Mandi Bishop, Connie Salgy, Austynn Eubank, 10 July 2023.

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About HealthEdge

Innovating a world where healthcare can focus on people, HealthEdge® is driving a digital transformation through transaction automation and real-time business and clinical engagement among payers, providers and patients. The next-generation healthcare SaaS company provides an integrated ecosystem of advanced solutions for core administration (HealthRules® Payer), payment integrity (Source), care management (GuidingCare®) and member experience (Wellframe) that empower health plans to accelerate business, reduce costs and improve outcomes. Follow HealthEdge on Twitter or LinkedIn.

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