Three Things Every CIO Should Consider When Evaluating Care Management Software Solutions

The pace of change in healthcare has accelerated at record speeds in recent years. Many health plan CIOs are struggling to help their businesses adapt quickly due to their dependencies on legacy care management systems that were built on outdated technology platforms.

As a result, there is a growing level of frustration among business, clinical and technical leaders alike, and therefore a growing number of payers looking to upgrade their care management capabilities. To help CIOs better understand and prioritize evaluation criteria, Gartner recently issued a report entitled, “Market Guide for U.S. Healthcare Payer Care Management Workflow Applications.”

The report stresses the urgency by which health plan CIOs should consider new, more modern care management software solutions. In fact, the Market Guide states, “The care management function is one of the few remaining levers available to a payer organization to impact its most important KPIs (namely top-line revenue, medical costs, quality measure improvement and operational efficiency).”

But with so many options and considerations to make, how should CIOs go about evaluating care management software solutions? Below are three of the most important criteria every CIO should consider.

Interoperability with Other Systems 

As the role of the traditional care management function continues to expand, care managers are being asked to support a wide variety of business and care delivery models that depend on coordination with a non-traditional service providers, such as home-based care, community services, and behavioral health specialists.

To support this evolving role, technical leaders are being asked to implement a wide variety of systems, which has led to complex infrastructures, massive data silos, and frustrated care managers.

The importance of having a highly interoperable care management platform that works seamlessly with virtually any third-party system cannot be understated. Interoperable systems with advanced APIs that require minimal IT overhead is no longer a nice-to-have – it is a must have. No single care management system can address all of the unique needs and care management goals of each payer so CIOs must place interoperability and the seamless exchange of data, whether it be structured or unstructured, as a top criterion.

Regulatory Compliance

For health plans, keeping up with the rapidly changing regulatory environment is one challenge, but making sure an organization’s care management platform and workflows can also be adapted to keep up is a whole different ballgame. Traditional systems often require significant IT involvement and complex rewiring of workflows to prepare for and implement regulatory changes. Some changes can take months and mountains of manual resources to implement in a traditional care management system. And with the pace of change ever-increasing, it’s often too late for system changes and payers end up building manual-intensive workarounds that cost time and money.

This is especially true for health plans serving government populations, where each state can have its own set of rules. And with the rapid growth in Medicare Advantage plans, Managed Medicaid programs, and self-funded employer plans, health plan CIOs must have a modern, agile care management software solutions that facilitates rapid change to meet regulatory requirements such as Medicare Advantage plan proposed changes or Medicaid state plan amendments.

In addition to a highly flexible platform, CIOs should look for care management vendors who have proven expertise in the government space. With seasoned experts on hand to translate business and technical decisions into clinical workflows that enable upholding compliance, payers can be confident in their ability to meet regulatory guidelines and even turn regulatory efforts into competitive advantages.

Health Equity & Social Determinants of Health (SDOH)

As the popularity of value-based pricing and risk-sharing arrangements reaches new heights this year, care managers are being forced to take a more holistic view of their members’ health, which includes social factors and community services that can have a profound impact on a member’s ability to access care and adhere to treatment plans.

Things like lack of transportation, limited access to healthy foods, and financial insecurities must be considered when building successful care plans. Community services and local groups must be incorporated into the care team, and as a result, care management solutions must accommodate for these non-traditional service providers and the SDOH data they can provide.

Connecting members with resources available in their community plays a critical role in improving member outcomes and satisfaction levels while also reducing care delivery costs – especially if the care management system can accommodate the data and resources.

Making the Move to Modern Care Management Software Solutions

In the 2023 Gartner Market Guide, HealthEdge was recognized as a Representative Vendor for GuidingCare in the care management solutions market.

Known for its robust API network, expansive ecosystem of pre-built integrations, custom configurations, and advanced analytic capabilities, GuidingCare and its team of regulatory and clinical experts check all of the main boxes industry analysts recommend to payers looking to meet the demand for more comprehensive, whole-person member care management of the future.

Learn more about GuidingCare on the HealthEdge website or email us at [email protected].


Gartner, Market Guide for U.S. Healthcare Payer Care Management Workflow Applications, Jeff Cribbs, Amanda Dall’Occhio, 3 January 2023.

GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved.

Gartner does not endorse any vendor, product or service depicted in its research publications, and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

Next Generation Payer Care Management: Why Now, and What Next?

Payer care management isn’t new. For decades, care managers have been providing information, support, and guidance to members facing chronic and acute healthcare challenges and complex transitions of care. Care management not only improves healthcare outcomes, but can also help health plans avoid unnecessary healthcare costs.

So why the recent attention on payer care management?

The answer is based on two ubiquitous drivers of change in the post-pandemic era. First is the increasing prevalence of physical, behavioral, and comorbid chronic health challenges caused or exacerbated by COVID-19. [1],[2] These challenges include the ongoing physical and mental symptoms associated with the virus in its acute and long form, as well as the secondary impacts including loneliness, depression, and anxiety. Second is digital transformation. This long-existing trend was significantly accelerated by the pandemic and our need for social distancing and remote solutions. In tandem, these two factors have increased the magnitude of opportunity for innovative and effective care management. They have also magnified the risk for missed-opportunity costs for payers who are not making the most of available solutions and existing digital investments, particularly in the world of care management.

McKinsey & Company has put forth an expended definition of care management which includes “…any payer-driven efforts to engage with targeted members and their care ecosystems to encourage and enable high-value decisions around their care and improve self-management…including traditional telephonic or in-person interaction as well as digital and asynchronous “coaching” and tech-enabled “nudges” [3]. Further, McKinsey estimated a 2:1 ROI for payers who can implement a care management model with the right processes, data, technology, and timing.

Key model components include:

  • Identifying and targeting high potential sources of value by member archetype
  • Engaging members using consumerist tactics
  • Calibrating service intensity to key moments in a care journey
  • Running care management as a data-based operation

While the ROI potential is clear, and the model imminently useful, this may not be something many payers are able to run with quickly. These key components require operational, procedural, technological, and possibly even marketing resources, oversight, and collaboration. This sets the stage for competing priorities that can leave many leaders unsure of where to even start.

This is where the company one keeps may really come into play. Today, most payers are using a care management platform or technology. But are they using it well? Is the technology optimized – and/or   are processes optimized for the technology? Could relatively small staff skills enhancements create big opportunities?

Payers with the right digital partners won’t have to answer these questions on their own. Instead, care management leaders have expertise to lean on, not just for technical support, but for clinical and transformational consultation as well. An external partner like HealthEdge with a solution such as GuidingCare will have insight gained working with a variety of health plans at varied stages of care management transformation, will be aware of common missteps and know the payer industry. With the advantage of distance and prior experience, trusted consultants can share invaluable advice on where to start based on current state and immediate priorities.

Don’t want to go on the journey of seeking next generation care management alone? Learn more here about how HealthEdge can help.


[1] The Healthcare System Is Facing Higher Acuity And More Sick Patients (


[3] The untapped potential of payer care management | McKinsey

KLAS Emerging Solution Spotlight on Source

The KLAS Emerging Solutions Spotlight on Source separates fact from fiction by conducting in-depth interviews with Source customers to understand their use of the platform, expectations and outcomes.

“Respondents are satisfied with the Source product, with all customers highlighting the biweekly updates around pricing guidelines and the first-time and real-time claims processing. HealthEdge is seen as responsive, and respondents say the vendor listens to customer needs and is willing to adapt.” – KLAS Emerging Spotlight Report, 2023

Key Performance Indicators

Source achieved top marks in all Key Performance Indicators including:

√ Supports integration goals

√ Product has need functionality

√ Executive involvement

√ Likely to recommend

Source emerging

Expected Outcomes

The report shows Source delivers on customers’ expected outcomes, including:

√ Automated workflows

√ More savings because of increased edits

√ Real-time processing

√ Reduction in agreement volume

√ Single source of truth for editing

Customer Comments

“I think that HealthEdge’s system is a viable longterm solution due to the cooperation that we have with the vendor in regard to new things that we may need. I see the system as a definite solution for us.” – Director

“What sets HealthEdge apart from other vendors is the capability to look up the Medicare rates in the system. I love that capability. If we have, for example, a provider that says that we didn’t price a claim correctly, we love the way that the audit tool can go in and look at the claim.” – Director

“The vendor is very good at listening to what we need, and their view of things has always been that if we need something, their other clients probably need it also. . . . HealthEdge is usually pretty good about trying to get our needs on the road map.” – Director

“The vendor does biweekly system updates. Before we had the HealthEdge tool, we only made updates to pricing once a year. HealthEdge does updates on major changes. But our claims are going through real-time processing.” – Manager

Source’s biggest differentiator?

As an interoperable, cloud-based platform built from the ground up, Source is designed to deliver rich pricing and editing content libraries while enabling our clients to address root-cause issues. With true transparency and control over their payment integrity operations, healthcare payers can finally unlock the ability to pay claims accurately, quickly, and comprehensively the first time. Unique capabilities like Retroactive Change Manager and Monitor Mode equip network management, claims operation, and cost containment teams with real-time data, thus helping to remove internal silos and enable enterprise payment integrity transformation. Learn more here.

Customer Success: 5 Key Steps to Successful B2B Partnerships

The business of the modern Health Plan is highly complex and to be successful, plans often require the assistance and contribution of outside providers for a range of goods and services.  Those outside vendors become an integral part of the organization’s path to success – and they are truly partnered for mutual success.

When businesses come to agreement on a Business to Business (B2B) product relationship, it is commonly asserted with great optimism that the entities will be entering into a “Partnership” that will maximize the value of the new offering. The idea of a working Partnership has such positive overtones that there is very little disagreement or energy around the launch of the engagement. The realization of this objective is typically the responsibility of an Account Executive, a Customer Success Executive or similarly situated role in the entity providing the service.

However, partnerships don’t just happen when a contract gets signed. It takes work, patience, commitment and a well-defined process to integrate the organizations. To accomplish the goal, there are several key factors that must be in place:

  • A shared, commonly agreed upon plan to level set expectations
  • Clear and consistent communications of the key aspects of the plan
  • Accurate assessment of required resources – and deployment of same to execute the plan
  • Well-defined metrics to track both the successful completion and risk of missing key milestones

PACER: The Key to Strong Partnerships

Large and complex organizations require a disciplined, formal approach to cultivating a healthy, functional partnership. One method that can help focus an organization’s energy is a program with a handy acronym: “P.A.C.E.R.”

PACER creates a roadmap to drive positive interaction with clients to ensure consistency and a disciplined approach to client interactions:

1.  PLAN – Articulate the recommendations of the supplying entity for improved efficiency and efficacy

2.  ALIGN – The supplier goals and objectives with those of the customers

3. COMMUNICATE – Shared commitments and deadlines clearly and concisely throughout both organizations

4. EXECUTE – Work the plan in accordance with agreed upon timelines and accountabilities

5. REPORT – Both positive progress and challenges

1. PLAN:

The first step in planning is an introspective look by the supplier at where you are compared to where you would like to be. Not just in terms of new product opportunities, but also as it relates to client success – i.e. is your product operating at an optimal level for your customer?

One way to think about this plan is as an internal “Wish List” – i.e. “I wish the client would_______”

      • Start doing X
      • Stop doing Y
      • Continue doing Z
      • Add ______ ancillary product(s)

This plan should be created in cooperation with as large a group of your colleagues as possible.  Solicit input actively and aggressively to encourage an honest appraisal of what is needed.  You may find that your colleagues are resistant to communicate a deficiency at the client under the adage that “the customer is always right.”  While client deference is always important, it is equally important to have an accurate assessment of what is needed to ensure client success – even if the needed changes involve challenging the client point of view.


Using the Plan created in Step 1 as a guidepost, the next step is to Align those ideas with a Strategic Plan that you develop with the customer.  The unique aspect of this process is that by going into the session equipped with a clear understanding of what your team feels will help maximize the, you will emerge with a collaborative document that maximizes the potential for Customer Success…which is the goal of this entire enterprise.

The aligned plan needs to be captured in a detailed, jointly prepared written document that includes an unambiguous list of shared objectives and an Action Plan with deliverable dates and accountabilities.  The plan is co-authored by the highest-ranking individuals who are engaged in the partnership – and who share authority and responsibility for its success.


The Plan needs to be distributed and promoted with great fan fair and appropriate resource commitments from the leaders.  To maximize the impact of the Plan, there can be no ambiguity regarding the goals and objectives, responsible players and the leadership support.  There is built in accountability in the Action Plan – but the impact of that accountability will be limited if there is not a sense of commitment and shared understanding of the Plan.


We live in a digital world, but one technique that can help create a breakout communication strategy is the creation of a hard copy notebook of the plan – with the authors identified on the cover – and delivered to key team members via an overnight package.  Email distributions are often ignored or minimized – nothing gets attention these days like an overnight package that arrives at the desk (or front door if virtual) of a team member.  Furthermore, if you create a professional binder with a recognizable title and visuals, it will live on a desk and serve as a regular reminder.

And as George Bernard Shaw famously said, “The difficult thing about communication is the illusion that it has been completed.”  Continual reinforcement of the importance and timeliness of the Plan will help maximize the potential for success.


All the work that is completed in the first three steps is simply a prelude to the ACTUAL work of PACER – which is to Execute the Plan.

If the Action Plan has been adequately prepared, every team member should have a clear view of what they need to do and when to do it. And if the team is clear on what the other members are doing, it is a self-monitoring process.  If I know that what I am doing impacts what you are doing – and vice-versa – there is a shared accountability.  And what is unique in this particular construct is that a jointly developed plan between supplier and receiver of the service means the successful execution is a team sport – played to the benefit of both organizations!


Keeping everyone clear on the progress throughout the course of the engagement helps to ensure that expectations are met – minimizing surprises.  Reporting can take many forms – from casual informal discussions in daily “Stand Up” meetings to deep dive reviews of the Action Plan deliverables as milestones come up.

Most importantly, regular accurate and meaningful reporting will ensure that future PACER reviews will build on the successes of the current undertaking and learn from any shortfalls experienced.

For Customers to Succeed with your product, both parties need to commit to an ongoing, active and iterative partnership model in which there is a feedback mechanism for continuous improvement, and honest internal appraisal of progress.  The PACER provides a framework within which organizations can collaborate and keep the Partnership fresh and successful.

Customer Success at HealthEdge

HealthEdge is very proud of the 100+ organizations that we service with our suite of state-of-the-art technologies that enable the digital future of our health plan customers.  We have a team of professionals in our Customer Success group that are committed to the Planning and Execution of a well-organized Plan – and to forming truly workable partnerships. Learn more here.

Understanding Genetic Testing Complexities in Healthcare

concert-genetics | HealthEdge

Genetic testing was once only available to individuals with a family history of certain genetic conditions or those who were experiencing symptoms. In recent years however, advances in technology have made it easier and more affordable to analyze DNA, making genetic testing more accessible to the general public. And as health plans are constantly looking for novel ways to identify individuals that may benefit from early intervention programs, genetic testing is becoming a powerful tool in this effort to provide more personalized medicine.

As a result of these trends, the volume and complexity of the medical policy, coding, and utilization review surrounding genetic testing has skyrocketed:

  • 150,000+ genetic tests are on the market, compared to 10,000 only 10 years ago
  • 9 codes are billed to represent a single genetic test
  • 1,000+ pages of medical policy for providers and payers to try to interpret

For many payers, processing genetic testing claims is a tedious, manual, and time-consuming process. There are several reasons for this:

  • Complexity of genetic testing: Genetic testing can be complex, and the interpretation of test results may require specialized knowledge and expertise. In some cases, payers may need to consult with genetic counselors or other experts to ensure that claims are processed accurately.
  • Lack of standardization: There is currently no standardized process for genetic testing, which can make it difficult for insurance companies to determine which tests are appropriate and what constitutes a medically necessary test. This can result in delays or denials of claims.
  • Billing codes: The process of billing for genetic testing can also be complicated. Each test may have its own unique billing code, and the correct code must be used to ensure that the claim is processed accurately.

Health plans that rely on outdated approaches are experiencing a growing volume of prior authorizations, denials, reviews, and appeals – all made more complex by multi-gene panel tests with multiple billing codes. The result is waste, variable quality, and frustrated members, providers, and medical directors.

Understanding Genetic Testing in Healthcare: A Better Way Forward

To navigate these challenges and help payers reduce the manual labor and time associated with processing genetic testing claims more accurately, Source has partnered with Concert Genetics, an industry leader in genetic test payment accuracy.

Concert Genetics has developed proprietary content and technology that streamlines clinical policy maintenance, prior authorization, coverage determination and claims processing for genetic testing. Here’s how it works:

  • Payment policies that clarify and enforce test identification and standard, predictable coding.
  • Clinical Edits flag tests that typically aren’t covered by health plans, such as experimental tests; tests not supported by patient age or gender; and tests not supported by specific diagnosis codes.
  • Coding Edits, such as invalid procedure codes, are based on the current procedure codes and the AMA’s coding guidelines.

The scope of claims addressed by the base package of edits includes:

  • Molecular Pathology
  • Genomic Sequencing Procedures and Other Molecular Multianalyte Assays
  • Multianalyte Assays with Algorithmic Analyses
  • Proprietary Laboratory Analyses (PLA) Codes

As a transformative payment integrity solution for payers, Source has developed partnerships with many different best-of-breed vendors, including Concert Genetics. As part of the Source ecosystem, Concert Genetics is able to leverage advanced APIs from Source to deliver pre-built integrations between the two systems.

This not only eliminates the IT burden for payers who want to use both solutions, but it also creates a more seamless user experience by giving users the ability to access the Concert Genetics rules and edits directly from within the Source interface.

To learn more about how Source + Concert Genetics and the entire Source ecosystem of third-party partners can help your organization increase accuracy and reduce waste when it comes to genetic testing claims, visit the Source third-party integrations page here.

Thriving in a Changing World: Why Versatility is the Key to Leadership Success

It’s no secret that change is the only constant in today’s business world. As organizations pivot to navigate the ever-evolving needs of their employees, customers, and markets, leaders must be able to keep up with the pace and thrive amidst it. The most successful people managers understand that exhibiting versatility isn’t just a nice trait; it’s essential for sustained organizational success and maximum impact among their teams. In this blog post, we’ll explore why being versatile as a leader is so important and provide great leadership examples.


Versatile leaders are adaptable and can adjust their leadership styles to fit different situations. They are open-minded and can embrace change, new ideas, and challenges without compromising their vision and values. A great example of this is Indra Nooyi, former CEO of PepsiCo. Nooyi was known for her adaptive leadership style, which allowed her to navigate various challenges and lead PepsiCo through a period of significant growth and transformation. She encouraged her team to think creatively and take risks, and she fostered a culture of openness and transparency. She recognized the importance of teamwork and collaboration and worked closely with her senior leadership team to develop and implement the company’s strategy.

Cultural Awareness

Versatile leaders are culturally competent and can work effectively with diverse teams. They understand the nuances of different cultures, respect different beliefs and values, and create an inclusive environment that values diversity. One example of a culturally aware leader is Satya Nadella, CEO of Microsoft. Nadella was born and raised in India, and he brings a global perspective to his leadership role. He has made a concerted effort to promote diversity and inclusion at Microsoft, recognizing the importance of cultural awareness and sensitivity in a global company. Under Nadella’s leadership, Microsoft has implemented several initiatives to promote diversity and inclusion. For example, the company has established employee resource groups to support underrepresented groups, such as women, people of color, and the LGBTQ+ community.

Communication Skills

Versatile leaders have excellent communication skills and can effectively connect with different audiences. They can tailor their messages to different stakeholders and use different communication channels, such as face-to-face, virtual, or written communication, to convey their ideas. One example of a leader who can communicate effectively with different audiences is Barack Obama, former President of the United States. In his speech at the 50th anniversary of the Selma-to-Montgomery civil rights march, he was able to connect with both black and white Americans, while also addressing the historical significance of the march and the ongoing struggle for civil rights. He spoke about the need for continued activism and engagement in the political process, while also recognizing the progress that had been made.

Emotional Intelligence

Versatile leaders have high emotional intelligence and can understand and manage their own emotions and those of others. They can empathize with their team members, build strong relationships, and resolve conflicts effectively. Mary Barra, CEO of General Motors is a great example of a leader with a high EQ. She is known for her approachability and her willingness to listen to employees at all levels of the organization. She has implemented several initiatives to promote employee engagement and development, recognizing that a motivated and engaged workforce is essential to the success of the company. She has done this while also driving innovation and change.

Strategic Thinking

Versatile leaders are strategic thinkers who can see the big picture while paying attention to details. They can analyze complex problems, identify opportunities, and develop creative solutions that align with their vision and goals. Jeff Bezos, former CEO at Amazon is an example of a leader who demonstrates strategic thinking. He recognizes the potential of new technologies and business models and was willing to take risks and invest in long-term growth. At the same time, he was able to manage complexity and scale, recognizing the importance of building strong organizational systems and processes to support a rapidly growing and evolving company.

As a leader, you can embrace versatility to create a positive and productive work environment where everyone is valued and respected. With an increased emphasis on flexibility, communication, and collaboration, versatile leaders can foster an open-minded atmosphere and collaborate effectively with teams of diverse backgrounds. Through these strategies, versatile leaders have the potential to maximize team effectiveness while creating a long-term culture of mutual trust and respect in the workplace. Ultimately, success as a leader depends on the ability to recognize problems and adjust strategies accordingly; developing versatility is essential for any leader looking to remain successful in the ever-changing business world.

Which leadership trait are you going to work on today?