A typical complaint of health insurance companies is they don’t communicate with customers in “plain English.”

HealthEdge wants to be the translator, of sorts, by building a software platform that allows health plans to ditch their antiquated systems in favor of streamlined, customer-friendly, flexible and modern technology solutions.

“Our mission is to enable health plans to go out and compete and be successful in the new and ever-changing healthcare marketplace,” says Ray Desrochers, EVP of sales and marketing at HealthEdge. 

If we’re not helping physicians, then we’re not helping anyone.

Founded in 2004, the Burlington, Mass.-based HealthEdge defines the job to be done as improving health plan operations and using technology as the tool to do it.

The company offers health plans a complete and easy-to-use technology platform upon which they can run their administrative, financial and clinical processes more efficiently. That, in turn, enables health plans to better meet the needs of their customers. This is increasingly important in an era when health insurance products aren’t bundled together via employers but rather can be parsed and selected by individuals based on consumer-specific needs.

The Affordable Care Act – specifically the state-based health insurance exchanges and new payment models, such as accountable care organizations – offers an opportunity for insurers to create products that meet the individual needs of consumers. The problem is that, on the back end, technology systems weren’t built to handle these customized products.

“If you think about it, most of the software in the administrative and claims side of healthcare still uses 20-year-old COBOL [one of the earliest programming languages] and cumbersome table-based configuration,” Desrochers says. “Our software sits on top of modern Java technology and uses an English-like language. This allows business analysts within payor organizations to quickly and easily configure anything they can imagine.

When a customer – whether an individual or an employer – calls an insurer to ask about a claim, with HealthEdge technology, the answer is transparent. The service representative doesn’t have to hunt through various antiquated systems to find and cobble together the answer, Desrochers says. With more consumer-directed care and individual cost-sharing, this type of information is becoming more valuable to customers. Consumers are demanding accurate information on their health spending as they gain a greater financial stake.

“The example that I like to use is, what if you called your bank and asked them what your balance was and they told you, ‘It could be 50 bucks, might be $1,000—I don’t know, $500.  Call me in a month. I’ll send you a statement,’ you wouldn’t be too pleased,” Desrochers says. 

Along with better customer service, HealthEdge helps health plans improve efficiencies in claims processing.

A recent HealthEdge survey showed that 61% of health plan respondents are auto adjudicating less than 80% of claims, and more than half said they pay more than $6 per claim to manually adjudicate claims. HealthEdge technology boasts of being able to raise auto adjudication rates to as high as 99%, netting significant savings by eliminating the need for manual adjudication.

Embracing Disruption

The HealthEdge team views today’s disruptive healthcare market as an opportunity for innovation.

“The more confusion in the market, the more need for flexibility and the ability to change things quickly,” Desrochers says.

For example, with the growing use of electronic medical records (EMRs), employers, insurers and providers are seeking to marry EMR data with claims and financial data to get a complete clinical and financial picture of an episode of care or to identify patterns or trends in how care is provided and reimbursed. HealthEdge’s technology platform enables health plans to consummate that marriage.

“An EMR will tell you the doctor prescribed penicillin for an infection, but we know whether or not you even picked up the prescription,” Desrochers says as an example.

HealthEdge is embracing innovation by studying the problems inherent in healthcare and then developing solutions.

“Innovation is not necessarily creating a new market or a new idea,” he says. “Innovation is finding the simplest, most elegant solution to a problem that affects the largest amount of people.”

Innovator Insight: Innovation for the sake of innovation won’t work. You must be able to make the business case for your innovation in order for people to stand up, take notice and embrace your idea. And you need to make the business case for your innovation for both those who sell it and those who use it. They both need to know what’s in it for them financially.