Alternatives to HealthRules Payer

HealthAxis provides integrated solutions to payers, providers, and health organizations. These integrated solutions include an advanced claims processing system, TPA services, and actionable analytics. We simplify operations and improve patient and client outcomes. Healthcare is becoming more technologically connected, but it is still hindered by legacy technology, coordination problems, and information management. We aim to bring innovation to those who are struggling with these issues. Our client philosophy is to be a complete business partner. HealthAxis believes that our success is not based on selling our solutions, but rather on our business partners' continued success and growth. We empower our partners to bring value to the communities that they serve. We thrive with them as they grow their membership and expand their scope. Each member of our team is aware of their responsibility to help our partners realize their potential.

Genius Avenue powers the insurance industry with innovative platform solutions and custom capabilities that connect products to customers and increase bottom line. Insurance Carriers With a team of insurance professionals, go beyond the software. Voluntary Benefits End-to-end customizable capabilities that simplify operations and drive sales. Brokers Get payroll benefits and streamline enrollment and administration. Captives Carriers Eliminate outdated systems and optimize enrollment. We assist our partners in expanding markets, simplifying enrollment and administration, optimizing business processes, and unlocking the full potential of customer-centric, digital platforms.

PLEXIS offers a comprehensive suite of top-tier applications designed to equip payers with the advanced capabilities required for contemporary core administrative systems. These applications encompass functionalities such as real-time benefit management, adjudication, automated EDI transmission, and self-service customer portals, ensuring that PLEXIS Business Apps meet all your needs. The Passport feature facilitates crucial connections between core administration and claims management systems, PLEXIS business applications, custom applications, and existing internal systems. Its adaptable API layer allows for real-time integration with various portals, automated workflow tools, and business applications, ensuring that connectivity knows no bounds. By employing this centralized, modern core administration and claims management platform, you can enhance workflows effectively. This approach enables the efficient processing of claims while simplifying the complexities associated with benefit administration, resulting in a swift return on investment and the ability to provide exceptional customer service. Ultimately, PLEXIS empowers organizations to thrive in an increasingly complex healthcare landscape.

PlanXpand™ is the specialized transaction processing engine developed by Acero, which serves as the backbone for all products aimed at health benefits administrators. With this innovative engine, clients have the flexibility to implement Acero’s offerings either all at once or gradually over time. Beyond simply selecting from our standard range of products, administrators have the option to harness PlanXpand™ to create tailored solutions that enhance their current system functionalities. Acero’s distinctive, integrated solutions utilize a Service-Oriented Architecture, enabling health benefits administrators and insurers to augment their existing adjudication platforms with new features and capabilities. Furthermore, our advanced design and engineering facilitate real-time adjudication for all claim types, directly interacting with the core claims system, which leads to improved processing accuracy, increased customer satisfaction, and a reduced necessity for claims adjustments. This adaptability and precision in processing claims ultimately positions Acero as a leader in the health benefits administration sector.

Claims adjudication services cover a range of areas including medical, dental, vision, and prescription claims, as well as short and long-term disability cases. These services can be accessed either on-site with a license or through a hosted application model (ASP). Utilizing Microsoft technology, the system is powered by an SQLServer database paired with a Windows front end. Our customer service is highly regarded, staffed by healthcare claims professionals who boast a minimum of 12 years of industry experience. All support inquiries are recorded, and their statuses can be monitored online. The system features a plan copy and modification tool that facilitates rapid plan implementation. Auto-adjudication is achieved through benefit codes that are constructed using business rules derived from over 25 variables connected to both the claims and the claimants, which are then processed by the adjudication engine. Claims can be submitted in various formats, including scanned images, EDI, or paper submissions. The system is compliant with HIPAA EDI 5010 transaction sets, ensuring secure and efficient processing. Additionally, re-pricing fees and UCR schedules can be pre-loaded into the system prior to their effective dates, while the date-driven logic ensures that re-pricing occurs based on the service date, optimizing the claims processing workflow. The comprehensive nature of this system allows for a more streamlined and efficient claims management experience.

A data-driven solution for managing claims and remittances specifically designed for healthcare providers looking to streamline their workflows, enhance resource efficiency, minimize denial rates, and expedite cash flow. Boost your initial claim acceptance rate significantly. Our all-inclusive edits package ensures you remain compliant with evolving payer guidelines and regulations. Increase your team's efficiency with user-friendly, exception-based workflows and automated procedures. Your personnel can conveniently utilize our adaptable, cloud-based platform from any device. Effectively manage your secondary claims volume through the automated creation of secondary claims and explanations of benefits (EOB) derived from the primary remittance advice. Leverage predictive artificial intelligence to identify and prioritize claims that require attention, allowing for quicker error resolution and minimizing denials before submission. Achieve a more efficient claims processing experience. Additionally, print and distribute primary paper claims, or compile and send collated claims along with EOBs for secondary submissions. This holistic approach not only enhances operational efficiency but also promotes better financial performance for healthcare providers.

The FINEOS Platform stands out as the sole comprehensive end-to-end SaaS core product suite for clients, featuring FINEOS AdminSuite for managing everything from quote to claim, alongside add-on products such as FINEOS Engage to enhance digital interaction, and FINEOS Insight for advanced analytics and reporting capabilities. It serves as a cornerstone for your digital insurance approach. By integrating FINEOS AdminSuite, FINEOS Engage, FINEOS Insight, and robust platform capabilities, the FINEOS Platform establishes itself as the most contemporary single core insurance solution tailored for Life, Accident, and Health sectors. In contrast to outdated legacy core systems that relied on a 'one size fits all' technology model, which is no longer suitable for dynamic businesses, modern consumers, employers, and brokers now benefit from sophisticated SaaS solutions and software that elevate expectations for an insurer's digital initiatives. The previous monolithic insurance software systems primarily concentrated on the intricacies of insurance contracts, overlooking the need for flexibility and adaptability in today's fast-paced market. Embracing the FINEOS Platform means adopting a future-ready approach that aligns with current consumer demands and technological advancements.

Enter gets Providers (doctors and practices & hospitals) paid faster that anyone in history. Enter processes insurance claims and pays within 24 hours. It also automatically communicates and collects patient responsibility using a white label collection engine that includes payment plans. Enter is 30x more efficient at getting claims paid, and 45x quicker at getting patients billed at the exact same cost as existing medical billers. In just one year, we processed over $150 million in claims. Providers have access to a $100mm credit facility. United Healthcare Nevada - Revenue Cycle Management Partner Enter supports a wide range of specialties, including ASC, Orthopedics and Neurology, Dermatology. Emergency Rooms, Behavioral Healthcare, Pain Management, and many more. - Enter works with all government and commercial health insurance carriers. - Enter integrates all EMR/practice management systems. No monthly fees No integration fees. Venture backed by Enter

USSI takes pride in showcasing its complete range of professional insurance software solutions, crafted as a comprehensive turnkey administration package. These all-inclusive software offerings are designed to guarantee that your insurance firm functions at peak performance in a rapidly evolving and competitive industry landscape. The InsurancePlus Individual Life and Health Administration software from USSI effectively oversees the management of business portfolios for both traditional and innovative Life and Health insurance providers. This solution accommodates various product lines such as Whole Life, Term Life, Interest Sensitive policies, Final Expense plans, Annuities, and Supplemental Health insurance. Additionally, USSI's InsurancePlus Group Life and Health Administration software efficiently manages portfolios for Group Health insurance companies, Self-Insured Funds, and Third-Party Administrators (TPAs), supporting a diverse range of plan options like Point of Service, Major Medical, Term Life, High Deductible, and Traditional Indemnity plans. With such a wide array of features, USSI ensures that its software solutions are versatile and adaptable to meet the unique needs of every client in the insurance sector.

QuickCap, developed by MedVision Solutions, is a comprehensive management tool designed to handle both administrative and clinical data processes, enabling users to prioritize their business operations instead of getting bogged down by paperwork. This solution offers scalable control over workflow and information, allowing for more efficient work practices. Users benefit from a customizable dashboard that enhances usability and automates processes for increased speed. Additionally, QuickCap simplifies claims handling, making the overall work experience smoother for users. Furthermore, it provides valuable analytics that assist users in easily assessing the profitability of individual providers. This combination of features ultimately empowers organizations to operate more effectively and make informed decisions.

Curacel's AI-powered platform allows insurers to track fraud and automatically process claims. You can easily collect your claims from your Providers and auto-vet them. Curacel Detection can help you identify and curb fraud, waste, and abuse in the Claims Process. Collect claims from providers to prevent fraud, waste, and abuse in the claims process. To understand where Insurers are losing the most value, we studied the Health Insurance industry. This was the Claims Process. The Claims Process is mostly manual and is prone to fraud, waste, and abuse. Our AI-driven solution helps reduce wastage and makes the Insurer more efficient, unlocking hidden value. Ravel insurance is unique in that it is built upon on-demand policies that only cover a short time. Both the policy holder and the insured want a fast and accurate claim settlement.

The process of filing claims is intricate and essential. Over 60% of individuals refrain from submitting complex claims due to the involved procedures and the time they require. Artivatic offers a specialized claims platform tailored to various insurance sectors, empowering companies to facilitate digital claims experiences, enable self-processing, automate evaluations, and implement risk and fraud intelligence alongside claims payouts. A SINGLE PLATFORM TO ADDRESS ALL YOUR CLAIMS REQUIREMENTS. Comprehensive Automation and Assessment for Claims. AUTO CLAIMS – HEALTH CLAIMS – TRAVEL CLAIMS – ACCIDENTAL CLAIMS – DEATH CLAIMS – FIRE CLAIMS – SME CLAIMS – BUSINESS CLAIMS – COMMERCIAL CLAIMS – EVERY CLAIM MATTERS.

Leveraging AI as a foundational strategy for payers, providers, and pharmacy benefit managers involves developing cloud-based products and platforms that enhance operational efficiency. A "healthcare digital platform" represents the amalgamation of various applications and cutting-edge technologies to deliver customized healthcare solutions that positively influence business results, marking a progressive and expedited shift away from traditional core administration processing systems (CAPS). To gain insights into how digital platforms and emerging technologies can help meet business goals, as well as their effects on healthcare payer key performance indicators (KPIs) and the overall appeal of these platforms, Infosys collaborated with HFS to survey 100 C-suite healthcare payer executives across the United States. This initiative aims to shed light on the evolving landscape of digital healthcare solutions and their potential for transforming industry practices.

CORE unites various sectors of the industry to speed up automation and enhance business processes that simplify healthcare for patients, providers, and health plans alike. By leveraging the most reliable source of provider and member information, CAQH empowers healthcare organizations to cut expenses, enhance payment accuracy, and revolutionize their business operations. In the rapidly changing healthcare environment, ongoing advancements in payment and claims processing are crucial. Healthcare providers and health plans nationwide rely on CAQH to gather and oversee professional data, verify primary sources, and keep track of sanctions. Consequently, this leads to more efficient administration, improved regulatory compliance, and superior management of provider information. Ultimately, the collaboration fosters innovation and ensures that all stakeholders benefit from a more effective healthcare system.

EbixEnterprise serves as an all-encompassing solution for insurance management, effectively optimizing policy oversight throughout its entire lifecycle. The platform comprises six key elements: Customer Relationship Management (CRM), health insurance exchange, policy administration, claims administration, data analytics, and a consumer web portal. These components are interconnected, facilitating the seamless transfer of data in response to various business requirements. SmartOffice CRM empowers organizations to efficiently handle agent and broker details, commission structures, sales pipelines, and state licensing information. Furthermore, the Online Quoting Portal, HealthConnect, stands out as a premier marketplace for both buyers and sellers of health insurance and employee benefits. In addition, EbixEnterprise Administration functions as a robust policy management system, equipping users with all necessary tools to oversee policies, define insurance plans, and maintain associated rate data. This comprehensive approach not only enhances operational efficiency but also drives improved decision-making across the organization.

Achieve a significant edge over competitors with AxisCore™, utilizing cutting-edge and modular technology that enables effortless automation of your health plan administration. Bid farewell to the challenges posed by outdated core administrative processing systems (CAPS) and welcome our comprehensive solution. Designed with precision to enhance benefits administration, streamline healthcare claims processing, and improve overall management of health plans, AxisCore™ equips your organization to excel in the ever-evolving healthcare environment. With its user-friendly interface and robust features, AxisCore™ ensures that your team can focus on delivering exceptional care and service.

HM Health Solutions offers a comprehensive end-to-end solution designed specifically for health plans. With the Enterprise Health Solution, you can obtain the necessary support and achieve the desired business outcomes from a singular, integrated health plan administration platform. This suite of applications and tools oversees a wide range of functions, spanning from sales and enrollment to billing and claims, along with provider and clinical management, as well as customer service. The Enterprise Health Solution (EHS) stands out as the sole verified end-to-end solution that ensures a smooth transition for members from the enrollment stage all the way to claims payment. While other providers may assert that they deliver a fully integrated solution, they often fail to clarify that this may require the sequential purchase of multiple modules to realize true integration. In contrast, the Enterprise Health Solution maintains a singular focus on health plan administration, ensuring that our expertise in the payer space is unmatched. Consequently, when you choose EHS, you are opting for a platform that prioritizes your health plan’s unique needs and operational efficiency.

Achieving significant advancements in both clinical and administrative outcomes, Evolent Care Partners, a healthcare system in the Midwest, has earned the distinction of being ranked third nationally for both total shared savings and the percentage of savings against benchmarks. By providing independent primary care physicians with essential capital and resources, Evolent Care Partners empowers them to engage in and thrive under two-sided payer contracts while mitigating their financial exposure. New Century Health enhances cost-effectiveness and quality of care in oncology and cardiology by leveraging clinical evidence to inform care decisions, a process that enjoys support from both payers and providers alike. Furthermore, Evolent Health Services streamlines health plan operations through a suite of comprehensive services backed by a modern, integrated platform and a genuine model of strategic partnership. Additionally, the organization encourages exploration of insights and news related to value-based care, population health, health plan administration, and various topics concerning the transformation of healthcare. Through these initiatives, Evolent aims to foster a more efficient and effective healthcare landscape.

Leading insurance firms leverage our SaaS solution to create a personalized shopping experience, streamline policy management, and enhance teamwork among clients, brokers, and health plan teams. Supercharge your operations with our top-tier platform, which delivers speed, adaptability, efficiency, and regulatory compliance throughout your organization. Ensure that you never overlook a chance to attract clients by showcasing your array of health plans and insurance offerings effectively. Increase operational efficiency, manage workflows seamlessly to maintain smooth business functions, and enhance client follow-ups. Save valuable time by allowing JET Insure to monitor events, enabling you to concentrate on essential business pursuits. Discover how we can refine your operations to meet both present and future healthcare demands, while also illustrating the ways our solution can accelerate your growth trajectory. By partnering with us, you can stay ahead in a competitive landscape and ensure sustained success.

Innovative new Health Reimbursement Arrangements (HRAs) streamline the health insurance provision process, offering you reassurance and simplicity. Wave goodbye to the complexities of traditional group plans. To initiate, simply respond to a few questions regarding your preferences for the HRA's functionality. You can rest easy knowing our platform will assist you every step of the way, empowering you to tailor your plan to your needs. After finalizing your HRA design, we will handle all legal obligations and ensure your employees are integrated into our system smoothly. Once everything is set up, our team will assist you in managing the claims process efficiently. Each day, we strive to foster a healthcare system that prioritizes your peace of mind, as we firmly believe that everyone deserves a more straightforward approach to health insurance. By prioritizing clarity and simplicity, we aim to enhance your overall experience with health benefits.

Jopari ProPay is an advanced cloud-based payment processing platform designed specifically for healthcare payers. It features a wide range of payment options, such as EFT/ERA, virtual cards, and traditional paper checks, along with a self-service portal for accessing Explanation of Benefits (EOB) and remittance advice (R) delivery, ensuring compliant 835 transactions for electronic billing. This solution enables healthcare payers to eliminate reliance on paper-based processes and lower their operational costs by optimizing payment and remittance workflows. By allowing payers to delegate their payment processing tasks, Jopari ProPay empowers organizations to redirect their focus towards essential business operations. For healthcare providers, the platform provides a versatile selection of payment delivery methods, enabling them to select the option that best suits their requirements. Additionally, providers can utilize the self-service portal to monitor their EOBs and payment statuses, enhancing their overall experience. Jopari ProPay stands out as a secure and compliant payment processing option, earning the trust of over 50,000 ERISA health plans and fully insured groups, which reflects its reliability in the industry. Moreover, its user-friendly interface and comprehensive support features contribute to its growing popularity among healthcare payers and providers alike.

Authorize, claim processing and payment are available at the point-of-care. Improve care coordination and improve outcomes for lower medical costs while streamlining administrative processes. Engage providers at point of care to share and capture data in real time, resulting in an unprecedented exchange of health information. We work with our clients to develop risk management strategies that produce better outcomes at lower costs. We aim to improve the user experience of everyone in the ecosystem. To optimize clients' resources, we deliver a minimum of a 3:1 ROI. Conexia has created a core technology platform (ONE), which can be customized to meet the different regulatory requirements and operational processes of each client in each geographic region. Our initial implementation is usually an overlay on the existing technology ecosystem of the payer to create real-time processes.

Introducing a comprehensive insurance quoting, enrollment, and lead management platform crafted specifically for modern insurance agents. Regardless of whether your operations are primarily conducted through in-person meetings, phone calls, online sales, or a combination of these methods, Quotit provides innovative solutions that enhance your clients' experiences through efficiency, tailored services, and automated processes. By investing in health insurance software, you can streamline operations and improve productivity, ensuring your clients enjoy seamless interactions at every touchpoint. Whether you seek a ready-to-use solution or require integrated data and capabilities, we have the right options for you. Our solutions, whether bundled or as standalone cloud-based APIs, ensure that you have centralized access to health plan information from a multitude of carriers nationwide, all in one convenient location, allowing you to focus on what truly matters—serving your clients effectively. Additionally, our platform is designed to adapt and grow with your needs, ensuring you remain competitive in a rapidly evolving industry.

HEALTHsuite provides a comprehensive benefit management system and claims processing software solution for health plans that administer Medicare Advantage and Medicaid benefits. HEALTHsuite, a rules-based auto adjudication solution, automates all aspects of enrollment / eligibility and benefit administration, provider contracting / reimburse, premium billing, care management, claim adjudication, customer support, reporting, and more.

VERMEG has developed SOLIFE, a robust policy administration system specifically designed for life and health insurance providers. This system streamlines the complete management of new business activities, policies, and claims, featuring capabilities such as cash and events management, seamless accounting integration, and oversight of distribution and fees. It also addresses reinsurance, tax and legal compliance, dedicated reporting, and efficient claims handling. With over two decades of industry experience informing its design, SOLIFE adopts a client-centric model and is regularly updated to align with evolving regulatory requirements, including MiFID and PRIIPs. The platform is built to facilitate digital processing via APIs and responsive design, ensuring a modern user experience. Its high degree of automation not only minimizes administrative expenses but also includes a versatile product-design workbench that enhances the speed of market delivery. Furthermore, the system accommodates various distribution models, making it adaptable to a wide range of business requirements, ensuring that it remains relevant in an ever-changing marketplace. This flexibility empowers insurance companies to optimize their operations and meet their unique challenges effectively.

Choose INSXCloud as your go-to platform for both on-exchange ACA health plans and off-exchange supplemental coverages, including options for dental, vision, accident, and short-term medical. Since the Federal Marketplace was launched in 2014, INSXCloud has been a valuable resource for agents, agencies, and issuers, facilitating the quoting and enrollment processes for individuals and families seeking Affordable Care Act coverage along with ancillary health options. Over the years, we have successfully helped agents and issuers enroll more than 2 million members in a variety of health, dental, vision, and supplemental plans. With our EDE version, e-Commerce is tailored to your needs, enabling both agent-led and direct-to-consumer enrollments. By partnering with us, you retain full control over your marketing strategies, ensuring that your messaging resonates with clients. Our platform also features convenient tools like an enhanced provider lookup to find doctors accepting specific plans and a 'Pay Now' feature available for numerous carriers, streamlining the payment setup for your clients. Additionally, this user-friendly interface makes it easier than ever for you to manage your clients’ healthcare needs efficiently.

I-CAPS stands for Intelligent Claims Administration System, designed to comprehensively cover all aspects of the health claims payment sector through a unified architecture that meets the diverse requirements of payers, including areas such as membership management, billing, enrollment, mailroom operations, claims processing, network oversight, contracting, pricing strategies, utilization reviews, and customer support. Our I-CAPS, along with our Advanced Value Scale (AVS) coding compliance software, facilitates informed decision-making to assist clients in managing expenses effectively. The Advanced Network Administrator (ANA) ensures the accuracy of provider information in an efficient manner, while our Resource-Based, Usual Customary, and RESPONSIBLE fee schedule (RB-UCR) is a pioneering solution in the market, built on RBRVS and NCCI frameworks. For a thorough assessment of your plan or provider’s performance, consider utilizing our Cost Containment Audit and Recovery Services (CCARS), which provide a meticulous and non-intrusive evaluation of claims efficiency. This holistic approach not only enhances operational effectiveness but also promotes greater transparency within the health claims ecosystem.

AUSIS – Comprehensive Behavioral Underwriting AUSIS empowers insurance companies to conduct thorough underwriting, scoring, and decision-making instantly. By utilizing AUSIS, businesses can experience significant decreases in costs, time, risk, and fraud while simultaneously boosting efficiency and decision-making capabilities through alternative scoring methods and additional features. Furthermore, AUSIS enhances the straight-through processing (STP) rate from non-straight-through processing (NSTP) and allows for non-invasive health data collection from various sources, including air quality index (AQI), geographical location, mortality statistics, social factors, images, videos, health monitoring devices, weather conditions, sanitation levels, and more. With AUSIS, insurance firms can achieve as much as a 40% reduction in the costs associated with issuing each policy. This innovative solution not only streamlines the underwriting process but also provides valuable insights that can lead to better risk assessment and management.

Our comprehensive platform provides fully integrated health plan solutions that add value and reduce the complexities of healthcare for employers, members, providers, and payers alike. Valenz combines member-focused services with insights derived from data, creating connections through personalized assistance that leads to high-quality care and enhanced outcomes. We prioritize early and frequent engagement through effective education, support, and services designed to prevent more severe and costly health issues down the line. By choosing Valenz, you can foster a healthier member population while consistently achieving cost savings for both plans and members year after year. To access the transparency and tools necessary for making quality-driven, cost-effective decisions, let’s discover your pathway to more efficient healthcare today. Additionally, the Valenz healthcare ecosystem optimization platform features a suite of fully customizable solutions that are all integrated within a single strategic framework, providing in-depth visualization of cost, quality, and utilization opportunities, ensuring you are equipped to navigate the healthcare landscape effectively.

Damco's InsureEdge Insurance Software is an all-in one software designed to help insurance companies gain maximum value from its extensive modules. This highly configurable and customizable software features the best insurance processing functions in the industry. InsureEdge is suitable for multiple insurance lines and can efficiently and effectively manage and streamline workflows to increase profitability, performance, and accuracy. It supports a variety daily operations via back office automation and other modules such as customer relationship management, policy administration and claims processing. InsureEdge, an insurance software that is flexible and scalable, is the key to future-proofing your business.

IMPACT serves as the cornerstone of our comprehensive suite of healthcare administration software, designed to facilitate all aspects of health care data transactions. Users of IMPACT rely on it to handle enrollment processes, manage provider contracts and re-pricing, oversee benefit plans, and navigate authorizations and referrals, in addition to claims payments and the complexities that arise from these tasks. Offering remarkable flexibility, IMPACT comes equipped with a diverse range of features tailored specifically for the healthcare industry. The satisfaction and appreciation expressed by our clients bring us immense joy, highlighting the importance of our collaborative interactions and the software we provide that enhances their professional experiences. We believe that technology should prioritize the needs of the customer, which is why MCSI is dedicated to developing solutions that seamlessly integrate into our clients' enterprises, allowing them to adapt and thrive in their respective markets. Our wealth of experience encompasses all dimensions of healthcare data management and solution implementation, and we take great pride in crafting software that emphasizes automation, precision, and dependability, ensuring our clients’ success in an ever-evolving landscape. In this way, our commitment to innovation and excellence drives us to continually improve our offerings, aligning them with the dynamic demands of the healthcare sector.

ResolvMD is a seasoned full-service medical billing firm that handles all types of health service claims, including AHCIP, for medical practitioners. Our mission is to empower physicians to feel as assured and skilled in their billing practices as they do in their medical expertise by providing data-driven insights and accessible knowledge. We offer the most advanced, affordable, and secure platform available for claims processing in the industry. Our primary audience consists of doctors, particularly specialists like emergency room physicians, urgent care providers, plastic surgeons, anesthesiologists, pediatricians, and general surgeons. These professionals seek a reliable billing partner to manage their health service claims, prioritizing attributes such as time efficiency, trustworthiness, cost-effectiveness, and expertise. Currently, we are focusing on physicians located in Alberta, specifically in cities such as Calgary, Edmonton, Red Deer, Medicine Hat, Lethbridge, Okotoks, and any other area with a population exceeding 25,000, ensuring that we meet the needs of a diverse and growing healthcare community.

Enhance your claims management process while reducing denials with superior edits and a top-tier clean claim rate. Healthcare organizations need advanced technology to ensure precise claim submissions and swift reimbursements. Claims Director, the claims management solution from SSI, simplifies billing procedures and offers transparency by assisting users throughout the entire electronic claim submission and reconciliation journey. As reimbursement criteria from payers undergo modifications, the system continuously tracks these changes and adapts accordingly. Furthermore, with an extensive array of edits across industry, payer, and provider levels, this solution empowers organizations to maximize their reimbursement efforts effectively. Ultimately, utilizing such a comprehensive tool can significantly improve financial outcomes for health systems.

WLT’s MediClaims system presents an economical, user-friendly, and highly effective solution for managing benefits and claims. Its rules-based framework combined with integrated EDI functionalities ensures that claims are handled swiftly, simply, and with precision. The system is designed to manage a diverse array of benefits and claims, including Medical, Dental, Vision, Prescription Drugs, Consumer-Driven Healthcare, Disability, and Capitation processing. With WLT's MediClaims, you can easily customize the configuration of your groups to accommodate either a single line of coverage or intricate benefit plans with multiple coverage lines. To achieve operational efficiency, a robust information system is essential, and WLT consistently utilizes cutting-edge technologies, delivering you the most advanced and adaptable systems available in the market. In an ever-evolving healthcare landscape, having such a dynamic claims processing system is crucial for maintaining competitive advantage and ensuring customer satisfaction.

At the heart of PBM Express lies the adjudication program, where claims undergo extensive edits to ensure precise processing outcomes, no matter how complex the plan design may be. The parameter drive program supports a highly adaptable framework that facilitates client-specific customization as required. Laker's cutting-edge software solution equips clients with exceptional performance and top-notch uptime that leads the industry. As a frontrunner in technology, Laker consistently upgrades and improves its systems to address the evolving demands of its clientele. Customers of Laker benefit from having access to the fastest, most versatile, and most resilient system in the market. Furthermore, Laker collaborates closely with its clients to conceive, test, and roll out new products, empowering them to enhance their competitive edge and secure new business opportunities. As client claim volumes increase, Laker evolves alongside them, underscoring the mutual benefit for both parties in implementing prompt and efficient software changes to support this growth. This commitment ensures that Laker remains a valuable partner in its customers' success.

Collective Health stands out as the pioneering integrated solution enabling self-funded employers to manage their plans, control expenses, and prioritize the well-being of their employees, all from a single platform. We invite you to discover how our tailored programs, seamless administration, and intelligent member experience enhance the benefits we provide. Serving a diverse clientele that includes scientists, truck drivers, and musicians, we take pride in having the most satisfied clients and members in the health insurance sector. Explore why many leading self-funded employers nationwide opt for Collective Health. If you are a broker or consultant aiming to advance your clients’ healthcare strategies, Collective Health offers a streamlined technology solution that optimizes employee healthcare for all stakeholders. With a membership nearing 250,000 and a portfolio of over 50 clients—including notable names like Driscoll’s, Pinterest, Red Bull, Restoration Hardware (RH), and Zendesk—Collective Health is revolutionizing the healthcare journey for innovative organizations. By focusing on integration and member satisfaction, we aim to reshape the future of health insurance.

Utilize the potential of data and technology to pave a way towards the future. Our efficient, secure, compliant, and scalable frameworks encompass comprehensive processes and services designed to enhance your institution's effectiveness and influence. By harnessing advanced digital technologies, you can revolutionize customer interaction and boost operational efficiencies. With state-of-the-art technology and extensive domain knowledge, we enable you to accelerate your market entry and realize value more quickly. Our solutions are designed to be lightweight and user-friendly, integrating smoothly into your existing processes, minimizing errors through automation, and enhancing overall performance. With an agile foundation, we possess the expertise and experience needed to elevate your digital transformation initiatives. Companies that place a premium on innovation and digital transformation in their business strategies often experience remarkable outcomes. Our specialized technology, business transformation frameworks, and profound insights in HealthTech, InsurTech, and FinTech position you for success. Embracing these advancements not only streamlines operations but also sets the stage for long-term growth.

Samedi is an innovative web-based software designed to enhance patient coordination while simultaneously reducing costs and improving services. This secure networking tool is applicable in various healthcare settings, including medical practices, clinics, and operating rooms. By utilizing effective resource planning, process management, online appointment scheduling, and task assignments, the system streamlines workflows. Additionally, the inclusion of video consultations and online forms allows for a more adaptable process, all while ensuring top-notch data security. Serving as an e-health software solution for physicians, clinics, and health insurers, Samedi connects the healthcare ecosystem and refines medical operations. With a focus on simplicity, efficiency, and security, our 12 years of experience in the e-health sector enables us to cater to your specific needs, providing customizable options for both straightforward and complex workflow demands. Our software integrates seamlessly with nearly all practice and clinic management systems, facilitating a hassle-free operational experience. This adaptability not only enhances productivity but also fosters better patient outcomes.

RiskAgility Financial Modeller (FM) serves as a dynamic and adaptable actuarial software tool tailored for life and health insurance providers as well as pension firms, facilitating the execution of precise financial models that accurately represent their offerings and organizational structures. Its design prioritizes seamless adaptation to both business workflows and compliance with regulatory reporting standards. Leveraging cutting-edge algorithms and modern software technology, RiskAgility FM significantly boosts user experience and operational efficiency, empowering companies to implement advanced analytical computations grounded in realistic economic frameworks, which in turn enhances their risk and capital management capabilities. The software is characterized by an open modeling environment that ensures precise calculations and effective reconciliations, even amidst shifts in product designs, corporate practices, and regulatory stipulations. Notable attributes include its ability to swiftly adjust to evolving business requirements, high performance and scalability for prompt outcomes, comprehensive integration with other systems to streamline reporting processes, and strong support for governance and automation, making it a versatile choice for organizations navigating a complex financial landscape. Additionally, its user-friendly interface further promotes accessibility for actuarial teams, enabling them to leverage its full potential without extensive training.

EvolveNXT’s platform is designed for health insurance carriers and any commission-based business, providing a customizable suite of solutions that enhance sales performance and simplify the management of intricate business processes. With over ten years of experience collaborating with top insurance carriers, we have crafted a solution tailored to meet the demanding requirements of competitive and regulated markets. Our compliance-focused approach allows organizations to boost the efficiency of their sales channels while promoting sustainable growth in enrollment. Notably, the intricate commission structures that apply to Medicare brokers are among the most challenging to navigate; EvolveNXT facilitates the management and automation of Medicare compensation while ensuring adherence to CMS regulations. By utilizing our commission management software, insurance carriers can not only streamline their operations but also empower their teams to achieve peak sales performance, paving the way for greater success in an ever-evolving industry.

Streamline revenue cycle management, care quality oversight, and workforce optimization through a unified, user-friendly portal featuring single sign-on capabilities. Over 47,000 provider locations depend on our cutting-edge tools to ease the complexities of the patient care experience. Transform the financial experience for patients while alleviating administrative and clinical challenges with the Inovalon Provider Cloud, eliminating the need for fragmented workflows. Our SaaS offerings are designed to enhance both financial and clinical results throughout the patient journey, facilitating improved revenue cycle processes for enhanced reimbursement and ensuring optimal staffing levels for high-quality care. This all-in-one portal enables your organization to elevate its performance, boosting revenue, staff satisfaction, and care standards. By enhancing operational efficiency, productivity, and overall effectiveness, you can unlock the full potential of your organization. Explore the transformative capabilities of the Provider Cloud today.

AgentSync builds modern insurance infrastructure to eliminate complexities and drive efficiencies in producer management and compliance workflows. Improving your broker onboarding, contracting, licensing, appointing, and compliance processes, AgentSync’s customer-centric design, seamless APIs, automation, and unparalleled service enable you to grow your business, create an exceptional producer experience, and prevent regulatory violations. Manage, AgentSync’s core product, reduces compliance costs and prevents regulatory violations before they happen. Manage automates the administrative paper chase necessary to verify that agents have the required appointments and state licenses to sell. By automating such tasks, the complexity of selling insurance is dramatically reduced.

PwC's SMART (Systematic Monitoring and Review Technology) enhances both the efficiency and effectiveness of evaluating the quality of inpatient and outpatient coding processes while establishing a framework for quality assurance and compliance reviews. In conjunction with the support from PwC Health Information Advisory, SMART reinforces your strategy for monitoring coding accuracy and overall data quality. The SMART Inpatient module features over 1,000 established business rules designed to uncover potential coding errors and opportunities for documentation enhancement, with the option to tailor business rules to meet your specific needs. Comprehensive reporting and data analysis capabilities allow for the assessment of staff performance and the identification of educational needs in areas such as Coding, Clinical Documentation Improvement (CDI), Quality, and Providers. Additionally, the SMART Outpatient module boosts claim accuracy and highlights issues related to charge capture and workflow optimization. By mitigating the risks associated with inaccurate coding, it also fosters better regulatory compliance, ultimately benefiting the entire healthcare organization. Furthermore, the integration of these tools significantly streamlines the coding review process, ensuring higher standards of care and operational efficiency.

The process of posting insurance payments exemplifies the 80/20 principle, where a mere 20% of payments, typically those derived from paper EOBs, can consume a staggering 80% or more of the overall workload. However, the introduction of POWEReob changes the game entirely. This service merges free software with a pay-per-transaction model to transform the paper EOBs you still receive from various payers into electronic remittance files that comply with ANSI 835 or NSF formats. These electronic files facilitate automated payment posting to your practice management system, streamline electronic secondary claims billing, and enhance denials management. Importantly, POWEReob is compatible with any practice management software that accepts remittance files from third-party sources, not just those linked to a specific clearinghouse. For practices without such compatibility, we can collaborate with your management system or clearinghouse to ensure you reap the benefits of fully electronic remittances, ultimately optimizing efficiency and reducing labor costs in the payment posting process. By leveraging this innovative solution, practices can significantly enhance their operational workflows and focus more on patient care rather than administrative tasks.

The flagship claims processing solution from Acrometis provides exceptional workflow management by utilizing a configurable rules engine to automatically route documents. This system is built around various elements such as claim assessment scoring, matching body parts to claim compensability, adhering to jurisdictional directives, and scoring relatedness, all aimed at minimizing both the duration and costs associated with claims. Notably, CLAIMExpert can autonomously process 65 percent of incoming medical bills and non-medical documents without requiring any user intervention. Documents that need adjuster review are efficiently flagged and organized to facilitate straightforward decision-making, ensuring that the process remains streamlined. With no need for adjuster involvement for the initial processing, clients often experience an improvement ranging from 11 to 23 points in medical loss within the first year. Furthermore, CLAIMExpert is equipped with rules addressing over 190 different document types, enabling it to swiftly manage whitemail and any other documentation that may arrive at an adjuster’s desk. This comprehensive approach not only enhances efficiency but also significantly impacts the overall claims handling process.