How Safety Net Health Plans Can Advance Care Management

Safety Net Plans face unique challenges as they work to connect and engage with hard-to-reach populations to improve the health of the communities they serve. These challenges include:

  1. Working with groups of members requiring very complex care plans
  2. Inefficient and costly processes resulting from manual, fragmented workflows
  3. Siloed systems that make it difficult to access up-to-date, accurate member data
  4. Collaboration with social services groups and systems that don’t talk to each other across organizations
  5. Extensive tracking and reporting that creates more administrative burden

All of these challenges come amidst the backdrop of even broader health insurance industry challenges, such as workforce shortages that are driving up costs of labor and care. Regulatory changes are requiring payers to adapt processes and technology to meet new guidelines. Evolving business models are creating new opportunities while driving demand for greater business agility. And today’s healthcare consumer expectations are rising to match their everyday retail experiences.

These challenges were echoed by a recent survey of nearly 300 health plan leaders serving Medicaid, Medicare, Duals, and Marketplace members. The survey showed the top two challenges were managing costs & creating new operational efficiencies. The top goals for the year were increasing quality, enhancing regulatory compliance, and improving provider relationships. The primary steps to achieve these goals were to better align business and IT goals, make significant investments in innovation, and modernize technology.

These findings point to the fact that health plans are ready to start their digital transformation as they bring IT and business stakeholders together and invest in innovative solutions to move the business forward. Now is the time for payers to become digital payers.

What is a digital payer?

Digital payers are identified by five attributes that enable them to rise above the competition and lead the way to better outcomes across the entire healthcare delivery system. Digital payers focus on:

  1. Leveraging digital tools to improve end-user and member centricity
  2. Achieving higher levels of quality to deliver better outcomes for members and communities
  3. Increasing business transparency, breaking down siloes and improving exchange of information
  4. Advancing customer service by empowering teams to support inquiries with next-generation solutions
  5. Constantly reducing transaction costs through automation and connectivity

These are the payers that will emerge as leaders through this dynamic period of change and truly improve outcomes for every patient and stakeholder across the healthcare ecosystem.

Story of a Digital Transformation: VillageCare

VillageCare is a community-based, not-for-profit organization serving nearly 20,000 seniors, people with chronic care, continuing care, or rehabilitation needs in New York. VillageCare set out on a journey to transform business processes with a next-generation digital foundation that could:

  • Support clinical and business operations through integrated work processes
  • Support a data-driven organizational culture
  • Support VillageCare’s healthcare clinical partnerships through data integration
  • Expose data to members and clinical partners using data standards
  • Use best-in-class applications that integrate to create a seamless systems environment

VillageCare wanted to implement a digital foundation that would enable mission-critical clinical workflows in a value-based, patient-centric, and fully integrated ecosystem. Their ecosystem of connected SaaS solutions powers mission-critical areas of the business including:

  • Care Management
  • Utilization Management
  • Appeals & Grievances
  • Authorization Portal
  • Business Intelligence
  • Population Health
  • Member Services

Impactful Results with HealthEdge

By developing this digital foundation with HealthEdge, VillageCare experienced transformational experiences for stakeholders.

  • Members:

Prior to VillageCare’s digital transformation, health plan members struggled through disconnected touchpoints to navigate the process of finding a provider, determining eligibility & costs, utilizing available benefits, & communicating with their care team. As a digital payer, VillageCare streamlined processes by shifting these touchpoints to easy-to-use, self-service tools that consumers expect – delivering all in a single access point.

VillageCare uses digital solutions from GuidingCare® to simplify workflows and improve access to data and information. As a result, they can deliver a frictionless member experience and increase member engagement and satisfaction, while ultimately improving health outcomes.

  • Providers

Many of VillageCare’s providers were frustrated by time and manual effort required to gain insight into patient benefits, inefficiencies in the process of seeking authorizations, multiple systems required to get answers, inaccurate claims payments, and managing reimbursements.

VillageCare eliminated provider abrasion by delivering instant access to real-time patient benefit and claims data through GuidingCare. They provided connectivity and access to collaboration tools that enable steps to be completed and information accessed in a single solution.

  • Member Services

Prior to their transformation, VillageCare’s member service teams experienced inefficiencies that negatively impacted the member experience, including wasting hours searching for member & provider information, navigating multiple software systems, and uncovering inaccurate and out-of-date information.

VillageCare transformed member services engagement by providing self-service tools and access to accurate, real-time data for members.

  • Care Managers

Prior to the organization’s digital transformation, VillageCare care managers were challenged by disparate technology systems, disconnected workflows, and manual workarounds. They spent countless hours hunting for member & provider information, attempting to connect with at-risk members, tracking authorizations & compliance, and accessing and completing care plans & educational programs.

VillageCare empowered care managers by putting real-time important member data at their fingertips in one location, so they can focus on building trust with members and optimizing care outcomes. They now automate authorization and utilization management workflows. This improved the experience for the care managers and improved efficiencies. They also use unified care team communications and real-time care alerts to improve health outcomes.

  • IT Teams

At VillageCare, the pre-transformation experience for the IT team involved navigating communications across multiple vendors, managing updates across multiple systems on different schedules, dealing with disconnected workflows and broken integrations, addressing regulatory changes with outdated systems, and advancing business and IT alignment.

After transforming the organization with next-generation solutions from GuidingCare, the VillageCare IT team could operate more efficiently and deliver on business needs more effectively. Now, they have greater flexibility to collaborate with the business and use available tools to ensure technology investments are achieving business objectives. The modern solutions are designed with interoperability as a priority, leveraging HealthEdge’s robust API framework and industry standards, such as FHIR. As a result, the IT team can optimize how their workforce is deployed, improve access to data for end users, and quickly and easily adapt technology to address emerging business opportunities and regulatory changes.

Stuart Myer, Chief Information Officer at VillageCare shared, “Our digital transformation journey has truly changed the way our teams operate, improving the experience for members, providers, member services, care management, and IT. It has allowed us to become a data-driven organization that operates more efficiently and creates better outcomes for the community we serve.”

Learn more about HealthEdge’s care management software GuidingCare.

Tackling the D-SNP Complexities in 2023 with Modern, Interoperable Systems

Enrollment in dual-eligible special needs (D-SNPs) care management plans grew by 20% in 2022, increasing from 3.8 million in 2021 to 4.6 million beneficiaries in 2022. This population now represents just 20% of the Medicare beneficiaries, but they make up 34% of the Medicare spending. They also represent 15% of the Medicaid population and account for nearly 1/3 of the spending.

Dual-Eligible Special Needs Plans (D-SNP) are a special kind of Medicare Advantage Plan for dual-eligible individuals who qualify for both Medicare and Medicaid and Part D coverage.

With such growth in this population comes a growth in the number of health plans serving these complex beneficiaries, with hundreds of health plans now supporting one or more D-SNP populations.

However, the complexities of the dual-eligible experience, from a medical and social perspective, coupled with the highly fragmented nature of Medicare and Medicaid systems, often presents significant care coordination challenges that health plans must be prepared to address.

In addition to the high prevalence of issues such as high food insecurities, behavioral health issues, and cognitive impairment, most D-SNP members live in rural communities that can have limited access to proper healthcare professionals, as well as limited access to broadband services. Other challenges health plans must be prepared for include the ever-evolving regulatory environment that exists at both the federal and individual state levels.

With the modifications CMS made in its 2023 Final Rule, it’s now more important than ever for health plans to have a modern, flexible, and highly interoperable infrastructure, including:

  • Robust care management platform
  • Flexible and configurable CAPS
  • Modern member engagement solutions

Track Record of Success

HealthEdge has supported health plans that service government-covered lives for decades, including those who cover D-SNP. For example, Eldercare, the only 5-star Medicaid Advantage Plus (MAP) plan in New York State, uses HealthEdge’s care management platform, GuidingCare®.

According to Craig Azoff, Senior Vice President, Health Plan Information Services, “Elderplan specializes in intense, complex care management of our membership, and GuidingCare supports these care management goals as well as our compliance goals, as far as STARS ratings, HEDIS scores, and other initiatives.”

Here are a few additional samples of success stories health plans have experienced by turning to HealthEdge:

  • Customer Spotlight 1: The midwestern state was looking to reduce the number of Medicated Managed Care Organizations by one third, and the health plan had to prepare to recompete for its Medicaid business, which represented a significant portion of its members. Its outdated legacy care management system could not accommodate the ever-increasing complexities of state requirements.
    • The solution: GuidingCare + Mobile Clinician + HealthEdge’s years of experience with safety net plans.
    • The results: The plan won the bid with advanced care management capabilities and mobile clinician in addition to HealthEdge’s years of experience with safety net plans.
  • Customer Spotlight 2: This health plan needed to transform its operations to reduce operational inefficiencies and eliminate redundant manual tasks. The team was challenged with 30-40% of incoming claims being marked with a pricing inquiry or set up to require manual pricing.
    • The solution: Source payment integrity platform designed to manage both claims pricing and editing in one place using the latest regulatory data.
    • The results: Reduced repetitive building, reduced dollars spent on maintenance, generated six-figure range in annual savings, reduced the number of claims requiring rekeying by 40%, generated 25% savings over previous processes by eliminating hundreds of manual tasks.
    • “The biggest benefit we have seen from Source is the capability it has to do one-stop pricing and editing. When it comes to building and managing claims, I never want to go back to anything else.” – Director of Policy and Editing
  • Customer Spotlight 3: This independent, non-profit health plan serving more than 2 million customers, was seeking to deliver more human-centric experiences for members, providers and staff. Other goals for the team included: identify and act on operational inefficiencies; gain a more comprehensive view of member services; and bring new solutions to the market faster.
    • The solution: HealthRules ® Payer + GuidingCare® + Source
    • The Results: Average auto-adjudication rates increased from 50% to 80%, ease of configurability improved speed-to-market and ability to identify sustainable savings, integration between HealthEdge systems delivered new opportunities for automation of manual processes, and greater access to authorization data across systems is reducing gaps in care.
    • “HealthEdge understands the everyday challenges we face, like manual processes, workflow inefficiencies, and data disparity. They are bringing solutions to the table that address those challenges and facilitate greater integration across our claims, care management, and payment platforms because they are now all under one roof. HealthEdge is the source that is fueling our digital strategy.” Staff VP of the Advancement Office
  • Customer Spotlight 4: This Pittsburg-based managed care plan servicing more than 534,000 Medicaid and Medicare beneficiaries across Pennsylvania and Delaware was looking for a better way to effectively and affordably deliver government member services while maintaining high levels of quality care. The team knew they needed to become more agile to keep pace with complex and rapidly changing federal regulations and state issued mandates, reduce the overhead costs associated with financial reconciliation for provider payments, as well as correct issues related to managing maximum out-of-pocket, claims tied to duplicate providers, and mismatches between old and new contacts
    • The solution: HealthRules Payer + GuidingCare + Source
    • The results: Improved auto-adjudication rates 50%-93% through better authorization matching capabilities and more accurate pricing, increased the volume of electronic claims submissions, and improved business agility through the use of advanced benefit, and improved payment accuracy through the seamless integration of HealthRules Payer and GuidingCare
    • “As a user of multiple HealthEdge products, we see tremendous value in the tight integration between the platforms. Things like being able to match on authorizations can not only help streamline care management, but also improve payment accuracy to facilitate better relationships with our providers.” — Director of Strategy & Operations

Health plans serving D-SNP members need a comprehensive, highly interoperable platform for end-to-end care management and population health that is effective at simultaneously reducing overall costs and improving care, while ensuring the plan is compliant with state and federal regulations.

To learn more about how HealthEdge solutions can help your organization address the unique challenges of D-SNP, visit the Dual Eligibles page on the HealthEdge website.

How to Systematically Integrate Social Determinants of Health into Care Management Programs

Over the past several years, there has been an explosion of interest in social determinants of health (SDOH) data and strategies among healthcare payers, particularly among those who are pursuing value-based and at-risk payment models. However, the ability to systematically incorporate SDOH into an organization’s care management workflows has proven to be more challenging than many expected.

The variability of the data that is available plus the lack of integration between systems that can automate the capture and processing of SDOH data have been key barriers in payers’ ability to rapidly integrate SDOH into their care management programs.

But given the most recent push for health equity and SDOH by CMS and accrediting bodies like NQHA, now is the time for payers to implement practical plans that enable them to embrace SDOH data and strategies in a more systematic way. Going forward, their ability to do so will have a significant impact on their quality scores, member outcomes and satisfaction scores, as well as their financial reimbursements.

Here are five things payers can do today to leverage SDOH to optimize care management programs that optimize both member health and organizational financial outcomes.

  • Collect data on SDOH: Payers can start by collecting data on SDOH for their members. This can include information on factors such as income, education, housing, food security, transportation, and social support. By gathering this information, payers can identify which members are at higher risk for health disparities and target interventions accordingly.
  • Analyze data and identify gaps: Once the data is collected, payers can analyze it to identify gaps in care related to SDOH. For example, they can look at which members are more likely to have unmet needs related to transportation or housing and develop targeted interventions to address these issues.
  • Develop partnerships: Payers can partner with community organizations, social service agencies, and other stakeholders to address SDOH. These partnerships can help payers connect their members with resources that can address their social needs and improve health outcomes.
  • Integrate SDOH into care management: Payers can integrate SDOH into their care management programs to ensure that members receive the support they need to address their social care needs. This can involve connecting members with community resources, providing care coordination services, and developing care plans that address both medical and social needs.
  • Track outcomes: Payers should track the outcomes of their SDOH interventions to evaluate their effectiveness. This can include tracking changes in health outcomes, healthcare utilization, and member satisfaction.

The GuidingCare® solution suite helps HealthEdge® customers rapidly bring SDOH data and insights into their care management programs in several ways, including by capturing member’s data relating to age, gender identity, preferred language, sexual orientation, race/ethnicity, zip code etc. Through GuidingCare’s integration with Findhelp, a leading social services search-and-referral platform, care managers have instant access to localized listings and programs in every ZIP code in the United States, enabling a more efficient process for managing referrals for critical services for members.

Further, GuidingCare is integrated with Wellsky, which enables care managers on the GuidingCare platform to identify, refer, confirm delivery, and track outcomes for member social services needs.

To learn more about GuidingCare’s unique approach to empowering care management teams with the content and tools they need to optimize member care, visit the GuidingCare page.

Incorporating SDOH into care plans can help payers improve health outcomes, reduce healthcare costs, and promote health equity for their members.

9 Care Management Platform Must-Haves for Payers

Too many obstacles stand in the way of implementing a person-centered model of care. Complex workflows. A lack of coordination among medical, behavioral and community health organizations. Inadequate partner and patient engagement. No access to real-time, actionable data. An inability to identify gaps in care. And more.

If your organization strives to improve member health outcomes and better manage costs, these are the 9 care management platform must-haves:

  1. Deep Clinical Expertise

Robust understanding of clinical operations, regulatory compliance and technical aspects of the business, bridging the clinical and technical is critical.

  1. Leading Innovations

Market-leading capabilities enable the most complex clinical models today, with significant investment and growth toward composable digital health solutions.

  1. Ease of Integration

An out-of-the-box integration suite facilitates easy connectivity across your vendor ecosystem for lower costs and better member outcomes.

  1. Operational Efficiency

An advanced rules engine and user-friendly workflow capabilities automate business processes to streamline operations.

  1. Reimagined Implementation & Upgrades

Using the latest technology innovations makes it easy for payers to incorporate standard new functionality and innovations frequently and easily for a lower cost.

  1. Resiliency to Change

Highly configurable features and workflows enable payers to embrace change, stay competitive, and take advantage of opportunities created by a variety of market dynamics.

  1. Actionable Insights

Near real-time business intelligence arms your leaders to make informed key operational and clinical decisions.

  1. Regulatory Support

Managing the ever-evolving state and federal requirements so you can stay compliant while improving member engagement and satisfaction, STAR ratings, health outcomes, and more.

  1. Security & Compliance

HITRUST certification is a must to reinforce robust enterprise compliance and security safeguards.

HealthEdge’s GuidingCare

The GuidingCare suite of solutions enables health plans to support care management, utilization management, appeals and grievances, authorizations, and population health in a next-generation, fully integrated platform. The unique solution enables digital payers to transform care management by improving mission-critical workflows and delivering access to real-time data that drives superior financial and health outcomes. Learn more here.


SummaCare & Source: A Long-Term Partnership for Success

At SummaCare in Akron, Ohio, the customers’ voice can be heard loud and clear. In fact, listening to the needs and wants of the communities it serves is a fundamental principle that has guided this local health plan since it started more than 25 years ago. But the company’s secret sauce to success has been its ability to turn that customer input into action while also meeting ever-evolving regulatory requirements. Today, SummaCare covers more than 62,000 lives and offers a wide range of services, including Medicare Advantage, self-funded, fully insured, and the government Marketplace.

According to Melissa Rusk, VP of operations at SummaCare, “Listening to our customers, whether it is our members, brokers, or even our employees in our own self-funded plan, is the first and most important step to success. But what really sets us apart is our ability to use modern technology to help us put our ideas into action fast. Products like HealthEdge Source really give us that edge.”

The System Behind the Success

For more than 20 years, SummaCare has trusted Source, the industry’s leading payment integrity platform that is now a key component of the HealthEdge suite of solutions, for its claims editing and pricing. Originally implemented to support its employer group customers who had members traveling to and living in multiple states, Source helped SummaCare navigate the complexities of pricing in many different states. However, as the business grew, so did the need for other pricing tools that addressed the complexities of commercial payers.

“For years, we were dependent on multiple editing solutions for our different lines of business. But when we upgraded to the latest version of Source, we were able to move everything to the new platform. Now, we are running all of our claims, including Medicare and commercial, through Source. It’s now a one-stop shop. This not only reduces the IT burden of having to maintain and update multiple systems, but it also makes it easier for our team members to investigate claims issues. They only have one place to go.”

In addition to finding new efficiencies in the editing process, the team was able to move all pricing data out of its legacy claims system, freeing them to evaluate more modern core systems that can help them adapt even faster to customer input and competitive threats. They also brought the edits into their provider portal so members and providers can see the edits themselves and submit questions or appeals directly through the application. This has reduced the phone calls and emails coming into the provider engagement teams.

Rusk added, “No one holds a candle to the information you have at your fingertips with Source. For example, you can look at fee schedules that existed 10 years go if you need to. You can model future things, like new contracts and the reimbursement implications, so you can make better decisions. We’ve seen Source evolve over the years, and we’re pleased with how they actively engage their own customers’ voices, just like we do with our customers. It’s been a great partnership.”

The Future Looks Bright

As SummaCare looks to the future, the team plans to move to more modern systems that allow them to collaborate with their customers and respond to changing regulatory and competitive market dynamics on a whole new level. Functions such as contract modeling and exploring new payment models are definitely on the horizon, according to Rusk. “We look forward to being more innovative and forward-thinking when it comes to what our contracts should look like. And as new payment models, such as bundled payments, emerge, modern technology like what HealthEdge provides will give us even greater flexibility.

Learn more about Source here.

Introducing Personalized Service Solutions with EDGEcelerate™

Health plans today can face challenges managing their day-to-day operations because of staffing challenges, the regulatory environment, and the need to reduce administrative costs. With the Core Administrative Processing System (CAPS) system at the heart of this dynamic and challenging world, it needs to run smoothly to facilitate business operations.

Top 4 Health Plan Challenges 

  1. Staffing  

80% of health plans are having self-described staffing problems, including:

  • Overworked staff & high turnover
  • Extended replacement time
  • Over-reliance on senior staff
  • Employee burnout
  1. Regulatory Environment

Managing and adhering to regulatory requirements & changes is a constant challenge. Health plans are consistently faced with:

  • Reaction time to mandated changes
  • Knowing what comes next
  1. Administrative Costs 

In a 2022 survey of 300+ health plan leaders, when survey respondents were asked to report the top three challenges that their organizations face today, managing costs and driving operational efficiencies were top of the list – jumping dramatically from the prior year’s fourth and fifth positions.

  1. Consistent CAPS Quality of Service

Many factors can impact CAPS quality of service, including:

  • Manual processes
  • Issues/defects impacting operations
  • Maintaining high auto-adjudication rates
  • Reducing operational PMPM costs


Introducing EDGEcelerate: A Path to Minimize the Challenges 

Health plans need flexibility and personalized solutions as they grow and respond to market pressures. HealthEdge’s new tiered services solution, EDGEcelerate, can offer the targeted, personalized solutions health plans need to tackle these multi-dimensional challenges.

HealthEdge EDGEcelerate  provides customized, full life cycle support of the CAPS system HealthRules® Payer. With this, health plans can:

  • Create efficiencies through automation
  • Experience a reliable CAPS system tuned to your needs
  • Reduce manual work arounds
  • Improve KPIs
  • React & respond faster to regulatory mandates

Every health plan has challenges. Let’s solve them together. Learn more about HealthEdge’s personalized service solutions with EDGEcelerate.