Future-Proof Your Claims-Payment Capabilities: Insights from Gartner® for Health Plans

In the ever-evolving landscape of health insurance, claims editors play a pivotal role as the first line of defense against inaccurate claim submissions. These editors are vital for the success of payment integrity programs as well as the pursuit of real-time claims processing environments of the future.

According to Gartner, “At a minimum, claims editors are meant to reduce appeals, decrease payment inaccuracies and ensure compliance. Additionally, changes within your lines of business and future needs can lead to more extensive requirements and expectations of claims editors. Situations that can point to growing complexity in claims editing include:

  • Increasingly complex value-based payment agreements.
  • Providers’ growing use of alternative coding methods for revenue cycle gain.
  • Self-funded employers’ demands for greater transparency.”

At HealthEdge® Source™, we help health plans navigate these claims editing and payment complexities with our modern Source Editing solution. Now is the time for health plan CIOs to re-evaluate existing claims editing technologies to ensure they are prepared to meet the future demands of real-time claims processing.

Evaluation Considerations for Future-Proof Claims Editing Solutions

In addition to the core capabilities of claims editing solutions, it is essential for claims editing solutions to support customized edits. Source not only delivers out-of-the-box edits, but the solution also supports the ability for users to customize edits that meet their unique contract and business requirements.

It is also essential for users to have clear visibility into the edits applied to different groups through user-friendly dashboards. Source delivers edit results via dashboards through its Audit Trail and Retroactive Change Manager capabilities. This transparency reduces dependencies on editing vendors, minimizes contingency fees, and empowers health plans to eliminate recurring errors.

In a future-proof claims editing solution, users should also be able to perform proactive reviews of edits before placing them into production. With Source, health plans can process claims in Monitor Mode to run what-if scenarios and better understand the impact of edits.

As more health plans transition from legacy core administrative processing systems (CAPS) to more modern, cloud-based platforms, claims editing solutions must be able to keep pace with the higher levels of interoperability these CAPS can facilitate. Source integrates with virtually every major CAPS on the market today. Plus, the new Payer-Source solution, which is the productized integration between HealthEdge’s CAPS (HealthRules Payer) and HealthEdge Source, delivers seamless integration, a more consolidated vendor stack, a single source for customer support, and a more unified long-term vision.

The Future of Real-Time Claims Processing

At Source, we are disrupting the mature space of claims editing by providing pricing and editing in a single call to deliver more comprehensive, accurate results. We are enabling payers to resolve issues further upstream for continuous improvements and significant savings on contingency fees from claims editing vendors.

By ensuring your claims editor aligns with your current and future needs, you can mitigate the risks of inaccurate claims processing, streamline operations, and provide better experiences for members and providers alike.

For further thought on the topic of future-proofing your claims editing solutions, download your complimentary copy of the 2023 Gartner How U.S. Healthcare Payer CIOs Can Future-Proof Claims Editing report today.


Gartner, How U.S. Healthcare Payer CIOs Can Future-Proof Claims Editing, Austynn Eubank, 20 April 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.

Interactive Discussion on Consumer Survey Research Reveals 55% of Consumers Want More from Their Health Plans

Health plans want to know – what can I do to improve member satisfaction? A recent AHIP webinar, co-hosted by HealthEdge, featured the results of an independent, nationwide study of more than 2,800 consumers to find out what matters most to today’s healthcare consumers.

During the webinar, more than 100 AHIP members joined to hear HealthEdge experts discuss key findings from the research, which included:

  • Only 45% of healthcare consumers, on average, are fully satisfied with their current health plan, leaving much room for improvement. When a care manager is involved, member satisfaction increases by more than 10%.
  • The top three things consumers want when shopping for health insurance include: benefits and coverage that meet their specific needs, the ability to keep their doctors, and the lowest costs available. However, generational differences are worthy of further review.
  • The top ways health plans can improve member satisfaction include more personalized engagement, better customer service, and more self-service tools that empower consumers to play a more active role in their healthcare journey.
  • 4 out of 5 consumers say that when health plans or care managers adhere to their communication preferences, it positively impacts overall member satisfaction, demonstrating the need for payers to adopt omni-channel communication capabilities.

But why is member satisfaction so important these days? On the webinar, HealthEdge executive Christine Davis described these times as the “perfect storm” for member satisfaction:

  • In our post-COVID world, healthcare consumers’ expectations have been shaped by their retail experiences, where interactions are often online, highly targeted, and personalized. Online reviews also play a larger role in the shopping experience these days.
  • Healthcare IT has historically lagged behind other industries, so as new market disruptors like CVS, Walmart, and Amazon enter the healthcare space, their tech-savvy platforms and loyal consumer following will require health plans to embrace modern technology to keep pace.
  • Competition within the traditional health plan space has also heated up, with the average Medicare Advantage beneficiary having 39 different plans from which they can choose1. Of the 16 million participants now on the ACA Exchange Marketplace, the average individual has three or more plan options from which they can choose2. And competition across all lines of business is expected to continue to increase.
  • Regulations continue to push toward member satisfaction and appear to support a sense of empowerment for consumers. For example, for the 2023 rating year, CMS is doubling the weight of member satisfaction in its Star rating system3. Interoperability mandates also play a role in health plans’ ability to adopt modern technology systems that can support transparency and data sharing across care settings and with members.
  • With the growing trend of high deductible health plans, more consumers are aware of the rising healthcare costs and are demanding greater transparency. These demands are supported by new legislation such as the No Surprises Act.


The webinar focused on highlighting the key findings, and the full research report is filled with useful insights, including generational differences, that can help health plan leaders better understand what matters most to today’s healthcare consumers and how to plan for future generations.

In addition, the report analyzes the market’s perception of health plans, with 70% of respondents saying that they trust their health plans the most to administer their benefits. However, an alarming 40% of respondents blame health insurance companies for the high cost of healthcare today.

Download the full research report to learn what more than 2,800 healthcare consumers had to say, and if you missed the webinar, watch the full recording here.



Care Management Platform Implementation: A Guide to Success

care management implementation | healthedge

Difficult care management implementations have led to the demise of many care management solution vendors. Sometimes success can be a vendor’s worst enemy. If they pick up too many customers and can’t implement them properly, word of that spreads quickly.

How We Help Our Customers Implement 

We’ve invested a lot in having a successful care management implementation team. We wanted to make sure that if we win new business, we implement the customers properly so they can stay focused on improving care for their members.

Every customer is assigned an executive sponsor for their implementation, someone on our senior leadership team responsible for the customer relationship and ensuring that we’re meeting their needs.

Each implementation also has a core team that includes a project manager, a business analyst, a clinical subject matter expert, and, most importantly, a solutions architect. The solutions architect looks at the health plan’s overall ecosystem and configures it in the best way for GuidingCare.

The role of the solutions architect is important because health plans today want to seamlessly connect their care management system to other entities in the ecosystem.

Take social determinants of health (SDOH), for example. Care managers need the ability to reach out to an SDOH vendor, such as Unite Us, Healthify or Aunt Bertha, make an appointment for the member on whatever it might be―housing, food, job― without leaving the care management system. Everything must be connected and documented so they can report against it. Or, during an appointment, a care manager may realize a member could benefit from receiving specific content related to their healthcare needs. Without leaving the system, the care manager should be able to reach out to a vendor like HealthWise through the care management platform, gather that information and send it to the member in their preferred format.

Our customers want more integrations, and we’re listening.

Today, we have a developer portal with hundreds of APIs and continue to make new ones every month.

Health plans want a care management platform that is brilliant at the basics and innovative for the future. From the beginning of the implementation, we want our customers to know we will always be there to run to any challenge, support their needs, and continually improve our product.

Driving Innovation and Customer-Centricity: Transforming HealthEdge Professional Services

In the fast-paced landscape of the healthcare industry, adaptation and innovation are key to success. At HealthEdge® Professional Services, this philosophy is not just a motto but a driving force behind the transformative efforts led by the Transformation Management Office. This office, spearheaded by professionals who have transitioned from service delivery teams, is dedicated to reshaping the way solutions and services are brought to market, driven by customer demands and operational challenges. Let’s delve into the journey of this evolution and the remarkable strides being made towards enhancing customer and employee experiences.

Empowering Change through Cross-Functional Synergy

For the HealthEdge Transformation Management Office, the primary objective is clear: to identify market needs, customer requests, and operational inefficiencies, and then design strategic solutions that drive growth and improvement. This involves the convergence of cross-functional teams, uniting departments that may have operated in silos in the past. An inspiring example of this approach is the Care-Payer initiative. This groundbreaking endeavor brings together claims processing and care management under the unified umbrella of One HealthEdge. It’s not just about technical integration; it’s about harmonizing product teams, consulting teams, and technical experts from different entities that were once separate.

The result? A more streamlined deployment process, enhanced training materials, and a simplified approach to understanding and mapping product hierarchies. This approach exemplifies how different components, once disjointed, can come together as a unified force to deliver a seamless experience. The key takeaway here is that while challenges exist, strategic collaboration can bridge gaps and pave the way for innovation.

Innovating for Customer-Centric Solutions

The commitment to innovation is not limited to internal processes. HealthEdge Professional Services is consistently expanding its range of offerings to cater to customer needs more comprehensively. An outstanding example of this is the EDGEcelerate™ solution that was launched earlier this year. Originally introduced to support health plans who use HealthRules® Payer, EDGEcelerate has since evolved to embrace GuidingCare® customers and more, exemplifying the adaptability and customer-centric mindset of the organization.

EDGEcelerate revolves around a master umbrella Statement of Work (MSOW) that provides a holistic view of services and features available to clients. This modular approach allows customers to choose and execute services as needed, providing flexibility and scalability. This approach is not about imposing predefined services; it’s about tailoring solutions to meet the unique needs and growth trajectories of each client. The underlying principle is clear: customers are not just clients; they are partners in growth and innovation.

Digital Transformation for Enhanced Visibility

Enhancing customer experience goes hand in hand with providing better tools for both customers and internal teams. HealthEdge Professional Services is harnessing the power of digital tools to elevate project management and visibility. The organization is piloting new tools that provide real-time insights into project progress, helping to identify deviations from the course and making timely adjustments. This is not just about keeping projects on track; it’s about facilitating transparent communication and informed decision-making.

From a governance perspective, the introduction of dashboards and stoplight indicators ensures that all stakeholders have a clear understanding of project health. This level of transparency extends to executive leadership teams, ensuring that they are well-informed and equipped to provide the necessary support. The goal is not just project success; it’s a collaborative effort to achieve excellence at every step.

A Powerful Partner in Digital Transformation

HealthEdge Professional Services’ journey is an inspiring tale of transformation fueled by collaboration, customer-centricity, and innovation. By embracing cross-functional cooperation, adapting offerings to customer needs, and leveraging digital tools, the organization is not only enhancing customer experiences but also fostering a culture of continuous improvement.

As the healthcare landscape continues to evolve, HealthEdge stands as a beacon of change, demonstrating that by aligning efforts and embracing change, remarkable accomplishments are achievable. The future promises more growth, more collaboration, and more innovation, as HealthEdge Professional Services continues to shape the healthcare landscape with a customer-centric mindset and a commitment to excellence.

To learn more about how HealthEdge Professional Services can lead your organization through a digital transformative change, visit www.healthedge.com.


Source Platform Access Delivers a Transformative Approach to Payment Integrity

In the fast-paced world of healthcare, the management of payment integrity initiatives has emerged as a critical challenge for payers. The increasing complexities of healthcare claims have led to a pressing need for a more efficient and effective approach to ensure accurate payment processes.

The traditional methods of handling payment integrity are proving inadequate in the face of evolving requirements, resulting in recurrent inaccuracies, inefficiencies, and wasted resources. It’s time for a paradigm shift, and Source Platform Access is leading the way.

The Challenge

Traditionally, payers have resorted to layering multiple editing solutions to address payment integrity concerns. However, this approach brings its own set of complications. Each editing solution operates on its own update schedule and data sets, leading to fragmented processes and siloed information.

Plus, the inherent incentive for primary and secondary editing vendors to safeguard their own intellectual property has led to a lack of collaboration and sharing among stakeholders. This not only hampers the overall accuracy of the payment process but also perpetuates a cycle of continuous charging for the same issues month after month, without any issue-resolution in sight.

The Solution

There is a better way, and it’s called HealthEdge® Source Platform Access. It challenges the status quo and creates a new path to payment integrity improvements by giving payers the power to identify the root causes of payment inaccuracy issues and correct the issues earlier in the process for greater efficiency gains and lower contingency fees.

Behind the innovative technology of Source Platform Access is a highly seasoned team of payment experts who work in partnership with Source clients. This collaborative approach ensures that the technology is not only implemented effectively, but it is also aligned with the long-term goals of the organization.

Today’s hectic healthcare environment requires an innovative approach to payment integrity, and Source Platform Access stands at the forefront of this evolution. With Source Platform Access, the path to transformative payment integrity is clear, and the possibilities are limitless.

Learn more about how Source Platform Access can help your organization challenge the status quo and dramatically improve the effectiveness of your payment integrity initiatives here.


Empowering Health Plans to Satisfy Members: Insights from the 2023 HealthEdge Consumer Survey

In the dynamic world of healthcare, consumer expectations are rapidly evolving. The rise of retail experiences has empowered healthcare consumers with higher expectations, prompting health plans to rethink their strategies to ensure member satisfaction.

In response, HealthEdge conducted an independent research study of more than 2,800 insured individuals in the United States to gain valuable insights into consumer preferences, perceptions, and expectations. The 2023 study reveals crucial findings that can help health plans adapt and thrive in today’s competitive landscape.

Snapshot of Key Findings

The study uncovered several significant findings that hold vital implications for health plans:

  1. Member Satisfaction: Only 45% of healthcare consumers report being fully satisfied with their health insurance provider. Interestingly, member satisfaction levels increase to 56% among those with assigned care managers. The answer to closing this satisfaction gap lies in delivering personalized member experiences – which is no easy feat.
  2. Social Determinants of Health (SDOH): While members who have a care manager report higher satisfaction levels, care managers still have significant opportunity to better leverage available SDOH data to deliver personalized, relevant services and address members’ individualized needs.
  3. Communication Preferences: An overwhelming 82% of consumers report higher satisfaction when payers communicate with them in their preferred ways. Adopting omni-channel communication strategies is crucial for enhancing access, convenience, and engagement.
  4. Improving Member Satisfaction: The survey identified two key actions for improving member satisfaction: enhancing customer service and increasing access to self-service tools. Equipping customer service representatives and care managers with data and tools for personalized care is essential, as is empowering members to take a more active role in their healthcare journeys.
  5. Trust in Health Plans: Despite increasing competition from non-traditional players, health plans remain the most trusted source among 70% of respondents for administering health insurance. However, generational differences affect trust levels, highlighting the importance of accommodating each generation’s needs.
  6. Transforming Perceptions: 40% of respondents blame health insurance companies for the high cost of healthcare. To change this perception, health plans must be perceived as partners in care rather than just payers of care.

Three Reasons Why Member Satisfaction Matters More Than Ever Before

  1. Choice: Historically, healthcare consumers had limited choices. Many simply accepted their employer provided benefits without question, as most employers covered 100% of medical expenses. Millions of Americans did not have health insurance. Medicare was the primary health plan for the majority of seniors. Most benefit plans left little financial burden on the consumer, and as a result, the average healthcare consumer didn’t think twice about the high cost of healthcare. Today, healthcare consumers have more choices than ever before. There are nearly 4,000 Medicare Advantage plans from which seniors can choose, with the average beneficiary having more than 39 different options in their coverage area.
  2. Competition: Market choice drives competition, and the competition among health plans has never been greater. Health plans that operate on outdated technology are unable to adapt to changing market conditions or deliver the innovative solutions today’s market requires. As more non-traditional players like Amazon, CVS, and Walmart enter the market and continue to raise the bar on consumer experience, health plans must match this new wave of tech-savvy competitors with modern care management and member engagement platforms.
  3. Criteria: New and expanding government regulations continue to put pressure on health plans to improve transparency and the member experience. In fact, the Centers for Medicare & Medicaid Services (CMS) doubled the weight of member satisfaction scores for the 2023 rating year. The increase means member satisfaction has a larger impact on performance metrics that affect health plan bottom lines.

Practical Guidance for Health Plans

To address growing consumer expectations and remain competitive, health plans should focus on innovation backed by modern technology. Implementing modern platforms, deploying digital member engagement tools, and empowering care management teams can significantly enhance member satisfaction and improve the overall healthcare experience.

The 2023 HealthEdge consumer satisfaction survey report highlights the urgency for health plans to prioritize member satisfaction in today’s competitive landscape. By leveraging modern technology and adopting innovative strategies, health plans can meet consumer expectations, remain competitive, and prepare for the generations of members to come. As healthcare continues to evolve, empowering the future of healthcare lies in delivering personalized, transparent, and convenient experiences to consumers. The time to act is now.

Visit the HealthEdge website to access the full research report or watch a recording of the recent AHIP webinar where HealthEdge clinical and business leaders discuss the survey findings.