From Cost Pressure to Proven Financial Results for Blues Health Plans
Your HealthEdge investment demonstrates a commitment to operational excellence. HealthRules Payer® extends that investment to claims administration — delivering the cost predictability, administrative efficiency, and MLR and ALR optimization that finance leadership requires.
"States are looking at how efficiently we process claims. As we transitioned, we began to see improvements, with auto-adjudication rates increasing. Today, we’ve been able to push those rates up into the top quartile, significantly impacting administrative savings.
The accuracy of claims processed also increased dramatically, correcting over- and underpayments."
— Blue Plan, SVP of Operations
Your HealthEdge Foundation
You've established a foundation with modern healthcare technology. Completing the integrated platform with HealthRules Payer enables measurable improvements in financial performance.
90%+
First-Pass Auto-Adjudication Rates Achieved by HealthEdge Customers
99%+
Claims Financial Accuracy Rate Achieved by HealthEdge Customers
HealthEdge: A Platform Engineered for Financial Performance
As an existing HealthEdge partner, we understand your current investment position — and the remaining optimization opportunity. HealthRules Payer bridges the gap between your current administrative cost structure and the financial performance a fully integrated platform enables.
MLR Optimization
Pre-pay payment integrity and automated adjudication reduce administrative expenditure and overpayment exposure — directly improving Medical Loss Ratio (MLR) and Administrative Loss Ratio (ALR) performance while minimizing rebate risk.
Real-Time Financial Intelligence
HealthRules Answers delivers real-time claims, financial, and membership analytics — enabling finance leadership to monitor operational performance and respond to cost trends without dependency on monthly reporting cycles.
Reduced Maintenance Expenditure
HealthRules Payer's configurable architecture eliminates custom code requirements for regulatory changes and new product launches — reducing IT maintenance costs that impact administrative budgets.
Predictable Platform Investment
HealthEdge's outcome-based commercial models establish a direct correlation between platform investment and operational results — providing finance leadership with cost predictability and performance accountability that traditional licensing models cannot deliver.
From Cost Pressure to Proven Financial Results
HealthRules Payer provides a direct pathway to reduced administrative costs, enhanced budget predictability, and optimized MLR performance.
CURRENT STATE
Elevated Administrative Cost Ratio from Legacy Claims Operations
Legacy claims systems inflate administrative expenditure through costly maintenance contracts, manual adjudication processes, and expensive custom development for benefit modifications and regulatory compliance. These costs lack predictability and cannot be reduced without platform modernization.
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INTEGRATED ECOSYSTEM SOLUTION
Automated Adjudication + Pre-Pay Accuracy via HealthRules Payer & HealthEdge SourceTM
HealthRules Payer's advanced auto-adjudication capabilities minimize manual intervention per claim. Pre-pay payment integrity through HealthEdge Source prevents overpayments before disbursement — eliminating costlier post-pay recovery processes.
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OUTCOME
Reduced manual claim processing, minimized overpayment exposure, and a lower administrative cost ratio — with direct correlation between platform investment and claims cost savings.
CURRENT STATE
Staffing Overhead Driven by Manual Workarounds
When claims systems cannot auto-adjudicate complex claims, efficiently process regulatory changes, or deliver actionable real-time data, organizations compensate with additional personnel. This creates staffing cost volatility and dependence on institutional knowledge that is difficult to budget or scale.
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INTEGRATED ECOSYSTEM SOLUTION
HealthRules Language™ Configuration + HealthRules Answers Business Intelligence
Business analysts — not IT developers — configure benefit plans, update provider contracts, and implement regulatory changes using HealthRules Language. HealthRules Answers provides real-time operational dashboards that eliminate ad hoc reporting requirements and enable data-driven staffing optimization.
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OUTCOME
Reduced dependency on specialized IT resources for routine updates, enhanced operational data for staffing decisions, and administrative staff redeployed to higher-value strategic initiatives.
CURRENT STATE
Fragmented Vendor Contracts With Unpredictable Total Cost of Ownership
Managing disparate contracts for claims processing, care management, payment integrity, and member engagement creates overlapping costs, complex TCO calculations, and limited leverage for contract negotiations or operational guarantees.
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INTEGRATED ECOSYSTEM SOLUTION
Consolidated HealthEdge Platform + Outcome-Based Commercial Models
Consolidating on the HealthEdge integrated ecosystem reduces vendor relationships, simplifies TCO analysis, and provides finance leadership with a unified platform investment to evaluate against operational outcomes. HealthEdge's outcome-based commercial models align costs with proven administrative performance metrics.
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OUTCOME
Streamlined vendor portfolio, transparent total cost of ownership, and a commercial structure that correlates platform costs with the operational savings your organization achieves.
Additional Resources for your Blues Plan