The ROI of Care Management Solutions

In today’s ever-evolving healthcare landscape, payers are constantly searching for the right balance of providing exceptional care while keeping costs in check. Care management platforms have emerged as a solution to address both sides of this equation. However, measuring the return on investment (ROI) associated with care management solutions is not easy, given the complexity of healthcare operations and the multifaceted nature of care management.

Care management teams are given a tall order: Provide the highest-risk members with the most complete, whole-person care plans possible, all with the expectation that these members will adhere to their care plan and experience better health outcomes at a lower cost of care. Care managers are feeling pressure from every angle, struggling to balance the expectations of all stakeholders, including providers and care team staff, member families, government entities, and the health plan that employs them.

The reality is that care management is hard work. Care managers often work with the most complex and challenging members who are often hard to reach. These populations are multidimensional, meaning psycho-social factors and social determinants of health are almost always in play. In order to deliver whole-person care successfully, they have to build trusting relationships with these members, which is easier to do with access to the right data or the right technology solutions that can bridge communication gaps.

From an operational perspective, coordinating care across multiple, siloed care settings and community services is also difficult since most systems don’t talk to each other, and care managers have to log into multiple disparate systems to find the information they need. These outdated care management solutions hinder care manager productivity and efficiencies as caseloads continue to rise.

The Role of Modern Care Management Solutions

Modern care management solutions like GuidingCare can address these challenges and help health plans quickly see a return on their investment through extreme operational efficiencies and total cost of care savings. Here’s how it works:

1. Enhancing Care Manager Efficiencies:

GuidingCare streamlines care management processes by automating routine tasks, enabling care managers to focus on high-value activities and reach more at-risk members. With real-time data access and intelligent workflows, care managers are always equipped with the most up-to-date information to make informed decisions. The result? Improved care manager efficiency, reduced administrative overhead, and measurable time savings.

2. Cost Reduction and Expense Management:

GuidingCare’s predictive analytics and care coordination capabilities help payers proactively identify at-risk members, supporting early interventions and reducing expensive hospitalizations and emergency room visits. The care management solution provides transparent cost tracking, making it easier for payers to accurately quantify cost reductions and expense management achievements.

3. Optimal Allocation of Services:

GuidingCare’s data-driven approach ensures that services are allocated based on individual member needs. Payers can now measure the direct impact of their care management efforts on quality of care and member satisfaction.

Achieving Meaningful ROI with GuidingCare

In conclusion, GuidingCare represents more than just a care management solution; it is a strategic investment that empowers payers to successfully navigate the complexities of healthcare. By delivering measurable results, GuidingCare is the key to achieving better healthcare outcomes and effectively managing costs.

To learn more about how GuidingCare care management solutions can help your organization improve care quality while reducing costs, visit

6 Key Strategies for Change Management Success

A few decades ago, change management success boiled down to phrases like, “Just do it!” or “Tough it out!” This kind of energy may have worked for short-term motivation, but it lacks the ability to inspire ongoing effort and address employee concerns. People want to know what’s in it for them when it comes to new workflows and expectations.

Today, change management is about effective listening and communication with your team—a strategy popularized by GE’s Change Acceleration Process. In times of change, employees are likely worried about job security or status and may not see why the change is necessary. Helping your team move from the current state to the improved future state requires managerial and structural support.

There are two questions your organization needs to answer before enacting change management:

  1. Have we listened to employees and understood their pain points?
  2. How will we communicate what we need each team to do?

This process doesn’t happen automatically—it needs to be proactive and intentional. We’ve identified 6 strategies that are essential for change management success.

1. Engage senior leadership.

One key indicator of effective change management is engagement from senior leadership. This is especially true when implementing new workflow technology or replacing a core administrative system. But what does it mean for leadership to be engaged?

To start, company leaders should be talking about the coming changes. Employees need to know why the changes are strategically important. Sharing this information helps them understand why adapting is worth the effort and gives them a sense of purpose beyond simply being told to adapt.

An objective way to measure engagement is by using the “calendar test.” Are executives attending project steering committee or other informative meetings? If not, it’s important to make sure they start. They should be able to speak about the ongoing project and understand how the implementation is progressing. This is also beneficial so senior leaders can see and appreciate the hard work middle managers and other employees are doing to ensure change management success.

2. Outline why change is necessary.

A common misstep that health plans make is assuming that employees know why you’re making this change. Many people won’t understand the need for new technologies or workflows when the original way seemed to work just fine. Your company leaders should be able to articulate the impacts in a way that helps employees feel involved in the decision-making process.

In what areas do you anticipate the most benefit from new systems? That could be paying claims faster or more accurately, complying with state audits, or modernizing legacy systems. Sometimes, the existing technology just isn’t viable any longer and can’t be properly maintained over time. Your employees want to work toward solving an important problem—so give them the information and motivation they need to do so.

3. Communicate the company vision.

Now that your employees and executives understand why change is necessary for your health plan, what is the vision for your organization over the next few years? Paint your team a compelling picture of the future state and where the company is headed. Ideally, your vision contains wording that speaks to both your team’s minds (i.e. intellect) and their hearts (i.e. emotion).

Make sure your team knows that with new technologies comes a chance to improve individual skills and maximize what they’re able to accomplish. In the case of HealthRules Payer, for example, the platform automatically handles adjudication and reviews for errors. This vastly reduces the need for manual reviews, giving employees time to focus on more complex, impactful tasks only they can do.

4. Gain internal commitment.

Encouraging your employees to commit to the change process is about more than education and passive acceptance. Identifying early adopters and internal influencers can be vital for gaining widespread support. These individuals already support the new adoption, which makes it easier for them to be engaged early in the project . They can then become a resource for other employees who have questions or need support during the process.

It is also beneficial to identify who might be resistant to change within your organization. Generally, areas of resistance fall into three categories: technical, political, and cultural. You don’t necessarily need to convert them into supporters, but it’s important to know why they might be hesitant and address their concerns so they’re not constantly pumping the brakes.

To help convince resisters why the change is important, turn to the three D’s:

  1. Data: Use data, such as higher payment accuracy rates, to explain why the new system will be better.
  2. Demonstrate: Show the new solution and share how other groups best utilize the platform.
  3. Demand: Share regulatory requirements and customer expectations that convey why the new technologies are needed.

You do not need everyone at your health plan to be on board. In reality, when approximately one-third of your employees are supportive, the rest will follow and accept the coming change.

5. Adapt underlying systems and structures.

With new tools come new processes. So how can you encourage the change and not force the change?

First, have a plan for how processes will change with the new system and communicate it clearly to your employees. It is possible that the new tools will alter team structure and reporting, leaving some individuals without the support they’re used to. Knowing how they will be expected to work moving forward will help mitigate some of their apprehension.

Changing employee incentives can help with this process. Certain employees might have different goals because the organization can now sell to larger companies with bigger contracts. For others, it may be as simple as removing access to the legacy system and encouraging them to sign in to the modern user-friendly system. Once your team understands the structure of work, they can be more creative and accepting with how they get there.

6. Monitor progress with data.

What gets measured gets done, and what gets rewarded gets repeated. How is your organization measuring progress? What are the key milestones to reaching your goals? Your timeline will be unique based on your company goals, but it’s vital to add checkpoints along the way. Get comfortable with the idea of designing, building, and validating your processes before you go live—and then review and reiterate.

You will also need to know your leading and lagging indicators of project success, as well as how to break them down for iterative measurement. Once the project metrics are agreed on and in place, you can better align your employees to meet them.


Throughout this process, it’s important to remember: if you aren’t adapting and growing, you’re falling behind. Working with the right professional services team can support your organization in defining what change management success means for your organization. This includes steps like project planning to identify scope and milestones, meeting with senior executives to determine measures of success, establishing a steering committee, and enabling your team to continue building toward your objectives.

For more information about the HealthEdge Professional Services team and how it can impact your organization, click here.



4 things Medicaid members need from a health plan experience

More than 3 in 5 Medicaid members have felt overwhelmed by managing their health. The healthcare system can be confusing enough to navigate. For Medicaid members, it can be even more challenging in the face of financial, transportation, and social barriers. To better serve Medicaid members, health plans have to uncover and understand their key concerns.

Based on the results of Wellframe’s 2022 Member Engagement Survey, we compiled a list of 4 services Medicaid members need most from their health plans.

1. Assistance navigating the healthcare system

Any member new to health insurance might have trouble understanding how to access the benefits and services they need. Health plans have the opportunity to educate these members on important topics—like why they need a PCP, how to get reimbursed for health services, or understanding the healthcare system.

By helping members navigate the healthcare system, health plans and care teams can build member trust and maintain long-term relationships. Giving members a positive health experience can also help improve plan loyalty and retention—and make it easier for them to take control of their own health and wellness.

2. Support for managing chronic conditions

Nearly 3 in 4 Medicaid survey respondents are living with at least one chronic condition. The most common conditions included mood disorders (22%), arthritis (14%), asthma (13%), and diabetes (9%). Managing a long-term condition can be exhausting and expensive—and many members live with more than one. As state Medicaid programs increasingly include beneficiaries with complex needs in MCOs, health plans will have to develop comprehensive strategies to treat members’ whole health needs.

3. Access to health interventions wherever they are

For high-need and high-risk members, it can be difficult to get timely health support. Many health plans offer nurse hotlines to make it easier for members to get in touch with a provider when they need it. However, more than half of Medicaid members didn’t know they have access to a no-cost nurse hotline.

About 54% of Medicaid members are already using at least one app to manage their insurance benefits or communicate with healthcare providers. To make it easier for members to reach out to their providers, health plans can make nurse hotline information and text-based messaging available through a mobile app.

4. Clear communications from their health plan

Health plan documents and communications can be confusing—especially if they include a lot of healthcare-specific terms. Your plan can help avoid member confusion by removing healthcare jargon from your member communications whenever possible. When removing industry terms isn’t possible, you can include an explanation in the text. Using plain language in your member-facing information can help improve members’ health literacy and increase benefits utilization. In turn, this can help prevent care gaps and lower member care costs.

Avoid Common Payment Integrity Pitfalls with a Single Source

Ensuring accurate claims payments can be difficult and fixing errors can be costly. And health plans face challenges throughout the payment process. Multiple rounds of editing, pricing, and review leave payment integrity pitfalls for your organization to fall into. A billion-dollar market has been built around detecting payment inaccuracies—and it continues to grow.

59% of organizations listed “in-sourcing payment integrity functionality” as a . While outsourcing aspects of payment integrity can help organizations scale their operations, it can also lead to loss of data visibility, increased operating costs, and reliance on contingency vendors.

How can your organization promote greater payment accuracy while reducing costs?

Here are three ways a payment integrity solution like HealthEdge Source™ can impact your health plan.

1. Combine pricing and editing capabilities in one place.

75% of organizations said it would be “very valuable” to Consolidating solutions can help improve efficiency by bringing key information together, rather than taking extra time gathering fee schedules from multiple locations.

HealthEdge Source users, for example, can leverage native content including CMS, Medicaid, and AMA policies in one place—without the need for additional integrations. Having third-party best-of-breed content available within a single resource enables health plans to gain greater visibility into the payment process and organizational inefficiencies.

2. Improve visibility and analytics

Enable analytics by bringing pricing and editing information—for claims across all lines of business—into one place. See top providers, DRGs, CPT codes, and other insights that make it easier to understand how new policies could impact your claims.

It can be easy to fall into a pattern of relying on a vendor to detect certain issues and patterns without diving deeper into why these errors occur. Leveraging a single solution can reduce administrative burden and reduce the opportunity for mistakes, such as inputting incorrect fee schedules. Instead of trying to pull data from multiple cap systems and present it together, your organization could gain visibility into the root causes of inaccurate payments.

3. Reduce IT burden

Some organizations have reported spending up to a week updating fee schedules in 6 or more places. Each of these platforms has different upload requirements and requires IT support. If IT can’t deliver help in time and there’s an error, then you’d have to rely on a vendor solution to catch it later in the workflow.

This is where bringing pricing and policies together is important. If your team is managing fewer solutions, they’re able to work more efficiently and with a deeper knowledge of the platforms they’re using. There will also be less demand for IT and other internal stakeholders to keep software and other technology up to date.

This is not to say contingency vendors can be beneficial. However, eliminating more straightforward issues like reoccurring overpayments can open the door for vendors to focus on solutions for new and more complex issues. Once your health plan has a single solution in place, your teams can identify leakage in the workflow, understand why it’s happening, and move that information upstream to the primary editing space to ensure more accurate reimbursements.

Shifting from multiple solutions to a single platform doesn’t have to happen all at once. To learn more about the HealthEdge Source payment integrity solution, visit our guide, “Beyond the Basics: The Modern Approach to Payment Integrity Vendors With HealthEdge Source.”

Read the guide


Scaling a culture of continuous learning at HealthEdge

At HealthEdge, we’re proud to promote a culture of continuous learning as part of our dedication to ongoing improvement. It starts with support at the executive level, making sure employees feel heard and respected. And then we provide the tools, attitude, and environment to refine the way we work and achieve better results.

How do we maintain this culture? We interviewed Wendi Ellis, VP of Talent and Learning, to learn about three strategies HealthEdge uses to encourage continuous learning across the organization.

Setting examples through leadership

One way we help build our company culture is leading by example. We set the expectation with company leaders that we prioritize ongoing education. Steve Krupa, HealthEdge’s CEO, is an excellent example of a continuous learner.

“He’s super supportive of recommending books and any of the programs we want to roll out,” said Ellis. “Our entire leadership team is. And I think that, because they’re setting that example at the top, it trickles down across the organization.”

At a structural level, in addition to communicating our learning expectations, we’ve adjusted how we solicit feedback from our employees. We send two engagement surveys every year to help us better understand how employees are being impacted by our new initiatives—and we make sure to take action quickly. This is especially important when it comes to questions about manager behavior and effectiveness.

“It can take up to 12 weeks to change a behavior,” said Ellis. “Not waiting 12 months to see how someone’s improved is a long time. Someone who’s disengaged with their boss will find a job within 90 days in that kind of environment.”

Being able to measure performance and impact every 3-6 months gives employees a chance to hear feedback, change their approach, and then check their progress.

Supporting people managers

Approximately 70% of employee engagement is tied to a person’s manager. Managers impact their employees lives every single day—and now that so many of us are working in a remote environment, we’re impacting people’s home lives as well. As such, Wendi sees being a manager as a responsibility and a privilege.

At HealthEdge, we are passionate about developing managers. We’ve worked hard to create an environment of continuous feedback. This means that we give managers the tools and the framework they need to be able to deliver meaningful and accurate feedback. In 2021, we found that employee performance ratings were overinflated. Managers tended to shy away from giving constructive feedback to avoid the conversations feeling like a confrontation. This was influenced in part by “the great resignation” that happened across industries

To help support managers in these discussions, we started by focusing on education. We gave managers a baseline of how we expect them to deliver feedback, including frequency and different ways to approach the conversation.

Improved feedback and review cycles

In addition to giving managers the tools to hold meaningful discussions with their direct reports, we also adjusted our annual performance review cycle. Instead of holding mid-year performance reviews, we now have mid-year check-ins. This shift allows mid-year conversations to center around what is going well for individual employees and where they’d like to continue improving rather than focusing on a rating.

“That conversation is going to be less threatening, more productive, and more empowering for our employees,” said Ellis.

To prepare members and individual contributors for performance conversations, we held training sessions to make sure everyone understood the core competencies they we’re being measured against. As part of this, we updated our descriptions of the behaviors we expect when it comes to those competencies.

And we don’t limit feedback to performance reviews. Another action we take is holding focus groups after every new initiative we launch. We ask employees what went well, what didn’t go well, and what changes they would like to see in the next iteration.

“That continuous improvement mindset is something we’ve built into everything we do,” said Ellis. “I’ve never worked for an organization where we have that level of respect, and where our voices can be heard the way that they are here.”

HealthEdge Source™ and Machine-Readable Files for Transparency

Costs for healthcare services are often a mystery until after treatment or services have been implemented and a bill is issued. The Transparency in Coverage (TiC) regulations set by the U.S. Departments of Labor, Treasury, and Health and Human Services in October 2020 aims to make rates more readily available for cost comparison by healthcare consumers.

To stay up to date with TiC regulations, the HealthEdge Source™ team has developed a comprehensive solution that focuses on:

  • Adherence to CMS mandate
  • Recognition of customer nuances
  • Customization of requirements including schedule to match system capabilities with customer needs
  • Ability to generate MRFs that include rates specific to selected configurations
    • Rates are generated based on:
      • Medicare payment systems for Professional and Institutional Provider Types.
      • Commercial payment methodology, as configured in your Source environment.
      • Schedules and parameters that you configure within the Source application.

The TiC functionality within HealthEdge Source leverages existing configurations to adhere to the CMS mandate by automatically generating machine-readable files (MRFs) that are specific to those configurations. For example, if a customer is using a configuration that has 105% of Medicare professional rates, this would be reflected in that customer’s MRFs. Customers will be able to select the configuration, the state, the provider type, if necessary, and users can add subscribers to the message alerts when files are ready in a pre-determined location to be picked up by a SFTP process.

Below, I’ve addressed some common questions our customers have about working with MRFs in HealthEdge Source.

Q: What is an MRF?

A: An MRF is a digital representation of information. The TiC regulations require MRFs in an open-standard format that can be used for sharing with healthcare consumers, for example, on a portal or website. HealthEdge Source supports the JSON format, which complies with the CMS requirement.

Q: What is the basis for creating MRFs in Source?

A: MRFs can be created for contracts that have been set up as configurations in Source. The rates produced in MRFs will be based on configuration-specific provider type and payment methodology.

Q: Is HealthEdge Source able to produce rates more specific than configuration-based rates?

A: Yes. The system can produce rates based on services (billing codes) and modifiers included in CMS fee and data schedules.

Q: How frequently can MRFs be generated?

A: HealthEdge Source can generate files monthly per CMS mandate and per customer need. The generation of files may be scheduled in advance by product end-users to support timely delivery of rate updates.

Q: How will rates be accessed?

A: Rates that appear on an MRF will be accessed as JSON based files via SFTP. An email notification can be configured when files are ready to be picked up. Due to file size, the file itself will not be emailed; however, a link to where files are housed will be provided.

Q: What types of rates do MRFs contain?

A: TiC MRFs consist of rate schedules for healthcare items and services. These rate schedules are based on your HealthEdge Source configurations and include the in-network and negotiated rates per your provider contracts as well CMS rates and policy data for all localities and ZIP codes. Each rate schedule covers a type of billing code, including case-mix group (CMG), HCPCS, CPT®, HIPPS, MS-DRG, and revenue code (RC).

Q: Is this feature licensed?

A: The capability to generate MRFs is available for all HealthEdge Source clients; however, a license is needed to turn it on in your environment.