AI May Cure The Ills In Healthcare Tech

As our healthcare system struggles toward a model in which consumers are at the center of the equation, technology is playing a rapidly increasing role in smoothing their way through the ecosystem. Consumers are demanding a better healthcare experience, but there’s a massive collision coming between the exabytes of global health data and consumer health and insurance illiteracy.

“Interoperability” describes a set of American regulatory initiatives that are in play right now and will drive change in the industry for years to come. As president of a healthcare technology company, I believe them to be as significant as any changes to the system made in this century, including the introduction of HIPAA privacy regulations and the Affordable Care Act.

Among them are requirements that health plans must share information about a member’s past claims experience, such that a member’s history now travels from plan to plan with them. Other information-sharing regulations make enormous amounts of health and insurance data directly available to patients, most likely downloadable to their smartphones. Some health plan portals and apps are already providing volumes more data than they did just a year ago.

Poor Literacy Equals Worse Care

This creates a new set of hazards. Research results show that low health insurance literacy among consumers has negative impacts on health. For example, when consumers don’t understand that certain health screenings are free, they are more likely to skip them. High deductibles can discourage people from seeking care due to uncertainty about potential costs. A limited understanding of health concepts and terminology will hamper receiving appropriate care. The results of research from the Centers for Disease Control indicate that complex health information confuses nine out of 10 Americans. Although no consumer should be expected to have a scientist-level understanding of medical terminology, the level of basic health knowledge is dangerously lacking.

What’s likely to happen when people receive their first smartphone-full of medical terms in Latin abbreviations, industry insurance codes and administrative jargon? I expect that most will turn to their keyboards, as Google already receives more than 1 billion health queries every day. There’s an abundance of symptom-checkers online, many of which are worse than no information at all.

As it is, some providers already find themselves spending an inordinate amount of precious patient encounter time clarifying, explaining and overcoming information consumers have mustered through internet searches. Whether patients have self-diagnosed or are filled with anxiety-driven questions about their genetic profiles, they’re taxing the system in new ways. I’m all for consumers advocating for their health, but unfiltered data in the hands of the anxious or unschooled can burn up resources or lead to poor decisions.

Current Tools Are Still Primitive

In addition to encouraging consumers to become more educated, I believe we should put artificial intelligence (AI) to work in translating insurance and medical jargon into actionable data for patients. Machine-learning (ML) and natural language processing (NLP) models can decipher complex medical terminology into simple, consumer-friendly language. AI and NLP can serve as translators and clarifiers, sifting a vast universe of diagnostic and treatment data, as well as insurance coding and terminology. AI and NLP models can push structured and unstructured data, as well as noisy data, to apps in ways that make the information consumable. This will allow patients to manage their health, their worries and their finances.

Creative minds are already at work on this conundrum for patient portals, but the tools are still primitive. Smartphones are likely to require even more sophistication but hold the promise of greater interactivity and real-time responses.

The freedom of patients to have their own health data has been an objective for many years, but the wheels of legislation and regulatory implementation have turned slowly because the complexity and the stakes are high. Technology will be the essential tool making the “back end” of healthcare more streamlined and intelligent. New treatments, pharmaceuticals and surgical robots capture the headlines, but the work done behind the scenes is just as revolutionary.

Innovation at HealthEdge: Making Waves in Healthcare Payer Technology

The journey of transforming healthcare starts with innovation. We recently sat down with Sanjeev Sawai, Chief Innovation Officer at HealthEdge, to understand how innovation can be traced to the roots of HealthEdge and what innovation looks like going forward.

What is HealthEdge’s role in the digital transformation of the healthcare landscape?

To keep up with digital disruption in the healthcare industry, payers need intelligent, next-generation solutions. Payers who do not invest in next-generation technology will likely be left behind. HealthEdge offers modern, flexible, and inter-operable solutions that pave the way for payer strategies to meet tomorrow’s shifting market demands. HealthEdge accelerates digital transformation in healthcare through facilitating real-time transactions, integrating applications with IT systems, and making real-time data available.

How will HealthEdge provide health plans with data and technology to support the entire healthcare ecosystem?

At HealthEdge, we understand that the payer ecosystem is large and complex. That is why all HealthEdge products are built to seamlessly integrate with all vendors and technology needed for our customers to do business. Our focus is on supporting a composable architecture that includes partner relationships. HealthEdge will offer APIs for application integration, based on standards, that will allow plans to easily integrate with applications in their IT ecosystem. This will also enable HealthEdge to create an application partner program and offer a digital marketplace of valuable applications. Additionally, HealthEdge plans to offer a data and analytics platform for health plans to perform operational reporting, ad-hoc analytics, and AI/ML modeling to enhance specific business outcomes.

The HealthEdge data science team is developing analytics to identify process improvements within our products, as well as collaborating with select customers to develop ML models for specific use cases. HealthEdge is committed to supporting digital-first experiences for plans through seamless integration of applications and unified views of data.

What does innovation at HealthEdge look like going forward?

Currently, HealthEdge is focused on the following three areas of innovation:

  1. Efficiency in business processes, workflows, and automation through closer integrations among the HealthEdge product portfolio. While each solution is viable and extraordinary on its own, the unique value is how these applications work together in a meaningful way. The integrated solution suite makes possible a vision where claims processing is enhanced with software-driven payment integrity at the point of service, feeding data to an end-to-end care management solution. The result: Lower administrative and healthcare costs, improved patient outcomes, and regulatory compliance.
  2. Increased automation through analytics and machine learning. HealthEdge is investing in core teams and technologies to create new value and outcomes based on payer and related data. Advanced analytics on administrative and clinical data will yield operational insights into improvement areas such as auto[1]adjudication rates, member dis-enrollment, compliance reporting, member risk-scoring, care interventions and more. Embedding machine learning algorithms seamlessly into operational workflows will support efficient improvement of targeted business KPIs.
  3. Creating an application partner ecosystem through API access and data exchange with the HealthEdge application platforms will provide a variety of additional solutions that deliver value health plans. Applications will be available through a marketplace and will be certified to work with the HealthEdge product portfolio. Health plans can select and deploy the partner applications that enable them to achieve their business goals.

Learn more about HealthEdge and innovation here.

D-SNP Care Management: Ensuring Member Compliance & Satisfaction

DSNP care management | HealthEdge

Dual Eligible Special Needs Plans (D-SNP) are a special kind of Medicare Advantage Plan for people who qualify for both Medicare and Medicaid. This program takes members’ Medicare, Medicaid, and Part D needs and puts them all together into one package to provide an overall healthcare experience.  D-SNP plans are unique in that they provide extra benefits. In addition to Medicare, Medicaid, and Part D coverage, they also help with additional healthcare coverage, including transportation (to doctor visits), dental or vision coverage, and credits to purchase OTC products.

Support for Highest-Need Populations

D-SNP members represent some of the most vulnerable populations in the United States. Health plans serving D-SNP programs need a holistic platform for end-to-end care management and population health that enables their unique Model of Care and keeps them compliant with state and federal regulations.

Best-in-class D-SNP care management platforms hinge on two critical factors: compliance and member satisfaction.


  • Federal & state compliance
  • Compliance reporting
  • ODAG and CDAG Reporting
  • User-friendly documentation management
  • Complex Assessments
  • STARS ratings
  • HEDIS scores

Member Satisfaction

  • Coordination of care and collaboration
  • Coordination of activities of daily living (ADL) needs identified via responses to assessment questionnaire which will generate service plan needs that can automatically feed authorization of such required services.
  • Ongoing communication and engagement
  • Member care plans with intelligent automation and evidence-based goals and opportunities
  • Leverage social determinants of health (SDOH) connections to address nontraditional challenges for improved member outcomes

The right D-SNP managed care platform means better health outcomes and compliance with federal and state regulations.

HealthEdge’s GuidingCare: Next-gen care management platform for health plans with D-SNP

With strong expertise and experience in providing care management and population health services for government-funded payers and plans, HealthEdge is fluent in the needs of state-sponsored programs serving the most vulnerable and high-risk populations.

Nationally, 1 in 5 Medicaid members are managed on GuidingCare. GuidingCare is currently live in 35 states for Medicaid, 29 states for D-SNP, and 14 states for LTSS. Learn more about how GuidingCare supports D-SNP populations here.

Good digital experiences demand good data

As consumers of digital services in our daily lives, our expectations of personalized self-service experience have been set by the likes of Amazon, Netflix and others. We are very comfortable with transacting digitally for shopping, banking, and so many other activities. Interacting with businesses through apps or the web has become the norm.

The businesses who must provide this capability to their customers, typically have to go through a “digital transformation”. They must virtualize delivery of services and the key business processes that enable them. This is done through integrating their information systems and ensuring the right data is available at the right time.

In addition to having data available at the right time, it must be accurate, high quality and complete. High quality data is free from errors, not duplicated, contains all necessary fields and is up to date. Healthcare data is contained in several disparate systems, each used and maintained by separate teams. This leads to a challenge in matching data across systems with a unique identity. Names and addresses need particular attention to ensure that they are spelled and formatted correctly and are unique (consider combinations of initials, middle names and abbreviations).

A data quality program is essential to keep data accurate, by cleansing it of errors and merging from several sources. Errors in data can be prevented by employing a data governance program that prevents errors at data sources. An app user looking for a doctor should be able to see all the correct specialty, office location, hours and network information.

Digital transactions also need access to APIs and real-time data. Information such as eligibility, appointment schedules, payment status must be timely to be useful.

Incorrect or stale data makes for a poor digital experience, and reduces user confidence in the business. Customer experiences are key to retention. A foundation of trusted data as a basis for applications is the key. Good digital experiences demand good data.

The HealthEdge approach to enabling greater access to real-time data centers on three main principles:

– Accurate Data

– Organized Data

– Accessible Data

Learn more about how we are working to give our customers, our applications, and our partners’ unprecedented access to real-time data here.

What are the top features of optimal Medicaid payment technology?

Medicaid MCO claims management is complex and dynamic. The traditional approach to Medicaid payment policies and fee schedules is challenged by the increasing complexity of claims and dynamic state-by-state regulatory and payment environment.

Health plan leaders need to embrace technology solutions that enable accuracy while minimizing the lift for internal teams, especially with the variability in Medicaid. But what should you look for in your search for Medicaid Payment technology?

Top Features of Optimal Medicaid Payment Technology:

  1. Cloud-based service – Enables automated, frequent Medicaid and CMS regulatory updates to eliminate IT lift
  2. Depth of content – Includes reimbursement rates and payment policy for all care settings in each state, including facility and professional claims down to the provider level
  3. Claims payment process unification – Complete editing and pricing before adjudication
  4. Complete audit trail – Provides transparency that supports audits and improves provider relations

HealthEdge’s Source: Revolutionary Technology + Unique Depth of Content

With over 15 years of experience providing Medicaid and Duals support, our delivery of Medicaid pricing and fee schedules is unparalleled in the industry. As cloud-based platform, Source, is the only prospective payment integrity solution that natively brings together up-to-date regulatory data, claims pricing and editing, and real-time analytics tools into a single IT ecosystem. This transformational approach allows payers to make payments with total confidence and make business decisions with real intelligence.

The Value of a Great Vendor Partner

The ROI can be tremendous for health plans that find the right vendor partner. In one case a Source customer that processed 12+ million claims annually was able to reduce claim reworking by 40%, save approximately $6-12 per claim, and reduce IT overhead while gaining control of their workflow. The health plan improved CMS multi-state Medicaid program regulatory compliance, increased transparency on payment results, and spent less time preparing for audits, the latter of which increased staff satisfaction and retention.

Is a Traditional Approach to Medicaid Claims Payments Hurting your Health Plan?

Download our white paper Medicaid MCOs: It is time for a new claims management strategy to understand how our Payment Integrity solution, Source, is revolutionizing the way Medicaid claims are handled.

6 Ways Technology Can Lighten Your Medicaid MCO Team’s Workload

According to the Kaiser Family Foundation, there are over 280 Medicaid Managed Care Organizations (MCOs) that provide comprehensive managed care for over 55 million US adults, which is over 70% of all Medicaid enrollees. The diversity and economic status of the Medicaid population mean it can also be a more medically complex population than other payer sectors.

For health plan leaders that want to reduce these inefficiencies and drive down claims processing costs, they need to think differently and invest in solutions that lighten the load on internal teams while providing frequent and accurate data updates health plans need to succeed in managed care.

The typical release cycle for state Medicaid data varies from state to state, and updates can happen at any time. During natural disasters or events like the COVID pandemic, the number of updates to payment policies and fee schedules related to durable medical equipment and vaccine testing, for example, can increase dramatically. Unfortunately, since health plans typically only update Medicaid content at varying frequencies, improper payments are compounded during times of crisis, increasing the likelihood of rework.

In a typical large health plan, there may be 20-30 people managing the legacy process and increasing capacity means adding additional staff. Shifting from manually managing Medicaid MCO’s to cloud-based technology provides a myriad of benefits.

Six ways technology can lighten your team’s workload:

  1. Process claims correctly the first time. Avoid errors with up-to-date pricing and important edits in each state.
  2. Include all provider types and settings. Data that cover all providers in every care setting eliminate the need to piece together multiple data sources.
  3. Automate updates and data loads. Reduce the need to manually update data sets, which can result in delays and human error.
  4. Update more frequently. Quarterly updates can be too slow for an organization that wants to react quickly and remain agile.
  5. Keep an audit trail. Automate the audit trail so teams do not need to rely on incomplete archives that place the burden on the user to prove and support claims pricing results.
  6. Eliminate costly infrastructure. Moving to a cloud-based solution can reduce demands on internal IT and business teams as well as eliminate maintenance of costly legacy software.

By implementing a cloud-based claims processing solution that automatically updates the latest regulatory and pricing content, eliminates the need for infrastructure support, and maintains audit data, many of these talented individuals previously used to support the legacy system can be redeployed to more value-added responsibilities.

Download our white paper Medicaid MCOs: It is time for a new claims management strategy to understand how our Payment Integrity solution, Source, is revolutionizing the way Medicaid claims are handled.