HealthEdge Horizons: The Changing Face of Healthcare Engagement in 2024

A pivotal moment has arrived in the ever-evolving landscape of the healthcare insurance industry. Healthcare consumers are no longer content with traditional engagement methods and seek more personalized experiences from their health plan providers. It has never been more important for health plan leaders to be aware of the key issues surrounding members’ rising expectations. The challenge is two-fold:

  1. Consumer buying experiences in other industries: Consumers now expect a level of engagement and convenience from their health plan providers that mirrors their experiences in other sectors, such as retail and banking. The days of primarily relying on phone calls for problem-solving are giving way to more digital and automated solutions. They want omnichannel communications that adhere to their lifestyles and interests.According to a recent HealthEdge survey of more than 2,800 healthcare consumers, the number one way health plans can improve member satisfaction is by adhering to members’ communication preferences. This shift underscores the need for insurance companies to adapt and equip their teams with modern, omnichannel engagement solutions.


  1. Increased access to healthcare information: With more health and wellness information available on the internet, members have unprecedented access to healthcare information. They are more educated about their conditions, treatment options, and even the costs associated with healthcare services. They can more easily find doctors on the internet who meet their specific needs. When they do engage with their healthcare provider, they typically leverage digital tools, such as appointment reminders, portals, and even text messaging.

This newfound knowledge and availability of more modern tools empower consumers to play a more active role in managing their care. As a result, they also expect greater access from payers regarding benefit information, authorizations, costs, and even clinical guidance that can help them make better decisions about their health.

A New Generation of Members Requires New Engagement Strategies

Health plan leaders must be cognizant of the changing preferences of consumers in a post-COVID world.  According to the same HealthEdge consumer study, today’s members seek self-service mobile tools and prefer to engage with their healthcare plans and providers on their own terms. Furthermore, when assigned a care manager, members want care managers to:

  1. Communicate with me in the ways I prefer
  2. Enable me to actively participate in my care plan
  3. Refer me to social services and resources
  4. Help me get and manage my medications
  5. Have my health information on hand when we communicate

Healthcare consumers are not the only ones pushing for greater transparency and better experiences. One significant regulatory development driving change in the industry is the Transparency in Coverage Act, which requires health plans and providers to provide members with greater visibility into the cost of services before they receive them. This transparency places additional pressure on healthcare payers to offer solutions that enable their members to access pricing information easily and make informed decisions about their care.

Additionally, CMS announced that it is doubling the weight of member experience when calculating payers’ 2023 Star Ratings.

Never before has there been a more important time for health plan leaders to address their members’  evolving demands when it comes to digital engagement strategies.

The HealthEdge Approach

HealthEdge recognizes these challenges and offers health plans a comprehensive strategy to address them. By providing both data and software solutions, the company aims to support healthcare payers in meeting the demands of the evolving healthcare market. From clinical engagement tools to benefit and health risk predictions, HealthEdge’s solutions are designed to enhance member experiences and improve overall wellness.

Here are some practical examples of how the HealthEdge portfolio of solutions helps payers create more personalized and meaningful member experiences:

HealthRules® Payer

    • Enabling health plans to provide superior customer service with first-call resolution
    • Real-time data allows members and providers to make decisions at the point of care
    • Enable self-sufficiency for members seeking cost transparency
    • Faster and more accurate claims payments lead to higher member satisfaction

HealthEdge Source™ payment integrity platform

    • Delivering accurate and transparent claims payments reduces the clerical burden on clinicians, which leads to burnout
    • Minimizing clerical burden on providers by removing rework, review, and waste
    • Ensuring that member eligibility and benefits information is accurate and available
    • “Every minute they spend on administrative tasks reduces the time they spend practicing medicine”

GuidingCare® care management platform

    • Drives secure member communication with their designated care team
    • Mobile clinician application enables offline access for care management staff in the field, enabling connection to members anytime, anywhere
    • Designed to meet NCQA health plan guidelines for Member Self-Management
    • View care plan goals and actions, access personal health records, track health and wellness data, complete health assessments, and more.

Wellframe member experience platform

    • Enables highest needs members to get access and support outside of traditional care delivery settings
    • Omni-channel communication seamlessly connects members
      to designated care teams, with an average of 34 digital touchpoints/member/month
    • Self-service digital resources empower members to reach their health
      and wellness goals proactively
    • Modern user experience increases both member satisfaction and engagement

Visit to learn more about how HealthEdge can help your organization engage with your members more personally and meaningfully, proactively reduce costs, and address ever-evolving regulatory requirements.


HealthEdge Horizons: Value-Based Care in 2024

From rapidly changing regulatory requirements and new competitive forces to changing payment models and rising consumer expectations, 2024 is shaping up to be another challenging year for health plans. In this 5-part blog series entitled HealthEdge Horizons, we dive deeper into the trends that are shaping our industry and explore how HealthEdge solutions are helping payers address their biggest challenges head-on. Be sure to check out the entire series:

The Origins of Value-Based Care

Since the Institute for Healthcare Improvement (IHI) first articulated the Triple Aim in 2008, the healthcare industry has undergone a massive transformation over the past 15+ years, shifting from paying for services (fee-for-service or FFS) toward paying for quality (value-based care or VBC).

Initially, the Triple Aim provided a framework for “optimizing health for individuals and populations by simultaneously improving the patient experience of care (including quality and satisfaction), improving the health of the population, and reducing per capita cost of care for the benefit of communities,” according to the IHI. Several years later, it evolved to include a focus on the well-being of the healthcare workforce and advancing health equity, with some now referring to it as the Quintuple Aim.

With the passing of the Affordable Care Act of 2011, the concepts of healthcare providers and payers working together to embrace quality finally began to take hold. However, when the existing FFS payment structure was put to the test in the Medicare Acute Care Episode (ACE) Demonstration Project in 2018, the feasibility of value-based care became apparent. It ushered in a new era of bundled payment initiatives, including what we now know as value-based care.

The Financial and Care Incentives

Value-based care introduces financial incentives for healthcare providers to ensure patients stay healthy. Under this model, providers are financially rewarded for maintaining their patients’ well-being. The key lies in value-based contract arrangements that distribute funds to providers at a broader level, such as a “bucket” or global level.

When patients remain healthy, cost savings are shared with the provider, creating a win-win situation. Patients benefit from improved health, lower expenses, and better care coordination. Providers are incentivized to focus on preventive care and wellness, as it directly impacts their financial compensation. In this way, value-based care aligns the interests of patients, providers, and payers.

Value-Based Care Today

So, where do VBC payment models stand after all of these years? According to a May 2023 Healthcare Payer Intelligence report, CMS recently reported successfully linking 90% of payments to value, and 40% of all payments flow through alternative payment models (APMs). While the rest of the healthcare industry is transitioning toward value-based care contracts, fee-for-service arrangements still represent a significant portion of the market. However, administering these contracts and transitioning from traditional models to value-based care has proven challenging. This is where modern technology, like HealthEdge solutions, comes into play.

The Role of Modern Technology

Transitioning from fee-for-service to value-based care requires a fundamental shift in managing and reimbursing healthcare. Traditional systems designed for fee-for-service models must adapt, but unfortunately, many legacy and outdated systems cannot support this transformation.

It’s one thing to say you are going to move from fee-for-service to value-based care, but it is another to administer the many different forms of value-based care, such as shared-risks, capitated arrangements, and many different forms of bundled payments.

How do payers take a traditional system that was designed for the model of “patient gets sick, patient goes to the doctor or hospital, a hospital gets paid, repeat the cycle” and convert it to supporting new models that tie reimbursements to patient outcomes and experiences with the doctor/hospital?

The answer: They can’t. Modern, flexible systems are a must-have in value-based care.

A Brighter Future with Value for All Stakeholders

HealthEdge recognizes the need for an integrated approach that combines contracting, claims administration, and care coordination in a single entity. This holistic approach ensures that the financial and care components of value-based care align seamlessly. With HealthEdge’s ecosystem of these three essential components, payers can efficiently manage value-based care programs and control costs effectively.

With HealthEdge, digital health plans have a unique opportunity to make this transition highly successful for all stakeholders: payers, providers, and patients. They can do so by leveraging the advanced automation capabilities and real-time data insights readily available in modern core administrative processing systems (CAPS) like HealthRules® Payer. With the right CAPS in place, the value of value-based contracts becomes crystal clear:

  • Cost Control: Value-based care models can help health plans control costs over the long term by focusing on preventive care and early intervention
  • Improved Member Health: By promoting healthier lifestyles and proactive healthcare management, value-based care can lead to improved health outcomes among members. This enhances members satisfaction and reduces the financial burden on payers.
  • Competitive Advantage: Payers that embrace value-based care early gain a competitive edge. They can attract providers and members who appreciate the benefits of this approach.

Here are a few practical examples of how all HealthEdge solutions are helping health plans navigate this transformation successfully, improving patient outcomes and reducing healthcare costs in the process:

  • HealthRules® Payer
    • Agile & flexible HealthRules Language
    • Quickly configure new benefit plans and contract arrangements
    • Share actionable data
      with stakeholders
    • Make value-based reimbursement & improved customer satisfaction a reality
    • Up to 96% billing accuracy, including with complex value-based agreements
    • Learn more about our core administrative processing system.
  • HealthEdge Source™ payment integrity platform
    • Accurately price claims based on complex contractual arrangements
    • Run in parallel with fee-for-service contract terms
    • Handle both prospective and retrospective bundles
    • Enable predictive modeling and impact reconciliation reports
    • Learn more about our payment integrity platform.
  • GuidingCare® care management platform
    • Facilitates complex workflows to manage care plans in value-based arrangements
    • Intuitive gaps-in-care analytics identify high-risk patients and potential health improvement opportunities
    • Evaluate performance across configurable measure sets such as HEDIS and Star ratings, plus state and custom measure sets
    • Learn more about our care management platform.
  • Wellframe member experience platform
    • Assigned programs focus on whole-person health and improved care outcomes
    • Proven ROI in utilization management outcomes, with a 17% reduction in inpatient admissions** and a 23% increase in preventive medicine utilization**
    • Builds framework for assessing target population and managing clinical needs
    • Learn more about our member experience platform.

Health plans that want to remain competitive and win new business need to support value-based arrangements at every touchpoint in their ecosystem and have access to relevant data outputs for internal and external tracking and analysis.

To learn more about how HealthEdge solutions can help your organization successfully implement value-based care, visit

HealthEdge Horizons: New Market Expansion in 2024

The landscape of health insurance has experienced a significant transformation in the past decade, with new market expansion becoming a key driver of competition and growth. Health insurance providers, both large and small, have had to adapt to changing consumer preferences and the evolving competitive landscape.

Payers need to recognize the critical role modern technology solutions can play in supporting their growth plans, whether it be through membership growth, mergers, and acquisitions, or even the rollout of new products or geographies.

As the market becomes more complex and the competition heats up, industry leaders reported technology to be both their biggest challenge and their greatest ally in the coming year in the recent 2024 HealthEdge Annual Payer Market Survey [link to report when ready]. Among the 350+ health plan leaders surveyed, 62% said “investing in modern technology for digital transformation” was the number one way they intend to achieve their organization’s goals. However, their most significant challenge was reported to be “alignment between IT and the business.”

The Shift in Health Insurance Markets

Historically, health insurance primarily operated within group-oriented markets, catering to large employers and their employees. Players in this space often stayed within their established markets, with national plans dominating the scene. Smaller regional players, on the other hand, often focused on specialized networks to differentiate themselves. Medicaid and Medicare programs operated at the regional level, with large group-oriented plans utilizing Administrative Services Only (ASO) arrangements to manage their offerings.

However, a significant shift occurred roughly a decade ago, moving the focus from employers to consumers. The rise of public and private exchanges marked the beginning of a new era, where consumers started to take a more active role in choosing and purchasing their health insurance plans. This shift introduced a fundamental change in how health insurance providers needed to operate and compete.

Competing in a Changing Landscape

In this new landscape, health insurance plans, whether large national entities, smaller regional players, or government programs, found themselves competing differently. They needed to appeal to various populations with unique needs and preferences while facing a broader range of competitors. In this changing environment, flexibility and speed became critical factors for success.

  • Flexibility: Health insurance providers had to adapt to the diverse needs of their target populations. What works for one group may not work for another, necessitating flexibility in plan offerings and services.
  • Speed to Market: In a world where consumers are now shoppers and buyers, quickly bringing new offerings to market is a competitive advantage. Health insurance plans needed systems to respond rapidly to changing demands and opportunities.

The Role of Modern Technology

To meet the demands of this new, expanding market paradigm, payers must leverage modern technology that can support their efforts in several key areas:

  • Rapid Benefit Package Creation: In the past, it might have been acceptable to take 3-4 months to create a new benefit package. However, insurers need systems that can swiftly design and build benefit packages to meet evolving consumer needs in today’s fast-paced market.
  • Digital Care Management: Offering new care management programs and digital care management platforms is crucial for addressing members’ health needs. The speed at which insurers can deploy these programs can be a decisive factor in their success.
  • ASO Arrangements: Health insurers often need to sign new ASO agreements with various entities that value health insurance offerings. The ability to do this quickly and efficiently is essential for expanding into new markets.

HealthEdge’s Approach to Supporting Payer Growth

At HealthEdge, we understand the importance of modern technology in supporting health insurance payers’ expansion efforts. We recognize that success hinges on what a system can do and how fast and flexibly it can do it.

  • Empowering Customers: We enable our customers to build and administer their functionality. Once customers are trained on the value of our solutions, they can control their destiny.
  • APIs and Testing: Everything we do focuses on the speed and efficiency of our technology’s tasks. Our emphasis on Application Programming Interfaces (APIs) and rigorous testing ensures that our systems can handle tasks quickly and reliably.
  • User Experience: We prioritize the user experience, ensuring that our technology is powerful and user-friendly. A seamless and intuitive interface allows insurers to operate efficiently and respond swiftly to market demands.

Here are a few practical examples of how HealthEdge solutions support payers’ ability to expand their businesses and grow into new markets successfully:

HealthRules® Payer

    • Create virtually any benefit plan or provider contract in hours and days versus weeks and months. Average set-up time for a new contract can be as little as 10-12 minutes
    • Mirror a plan’s actual world and setup
    • Ability to scale and keep up with the pace of membership growth. Up to 97% enrollment accuracy

HealthEdge Source™ payment integrity platform

    • Single API to support all claims systems and provider types
    • Easily create and customize contract configurations with synchronization of rules management across all LOBs
    • Designed to scale for your organization’s future growth, agility, and transformation

GuidingCare® care management platform

    • End-to-end solution with flexibility and scalability
    • Highly configurable for specific health plan needs and wants
    • Consolidated member information in a single, comprehensive care record
    • Built to scale to millions of member records, millions of transactions per week and 10K+ concurrent users​

Wellframe member experience platform

    • On-demand member content and benefits resources, plus digital customer service advocacy solutions
    • Enables health plans ownership of the member relationship, mitigating competition
    • Proven 6x increase in member interactions and double the staff capacity for active caseload size

HealthEdge: Your Competitive Edge for Growth in 2024

The evolution of health insurance markets from group-oriented to consumer-focused has brought about a need for health plans to adapt quickly and efficiently. In this dynamic landscape, speed to market and flexibility are the keys to success. Modern technology plays a pivotal role in supporting health insurance providers as they expand into new markets.

HealthEdge’s commitment to delivering systems that empower customers, emphasize APIs and testing, and prioritize user experience positions for health insurance payers for success in a highly competitive environment. With the right technology partner, health insurance providers can navigate the changing landscape with agility, meet consumer demands promptly, and achieve their expansion goals in a fast-paced and consumer-driven industry.

To learn more about how HealthEdge solutions can support your organization’s growth strategies, visit


The Evolution of Health Insurance Technology: Embracing End-to-End Integration

From rapidly changing regulatory requirements and new competitive forces to changing payment models and rising consumer expectations, 2024 is shaping up to be another challenging year for health plans. In this 5-part blog series entitled HealthEdge Horizons, we dive deeper into the trends that are shaping our industry and explore how HealthEdge solutions are helping payers address their biggest challenges head-on. Be sure to check out the entire series:

The Early Days: Integrated Systems

The landscape of health insurance has transformed dramatically over the last three decades, driven by advances in healthcare IT and back-office administration. From claims processing to digital care management, technology has reshaped the way health insurance payers operate. Now is the time for payers to explore emerging concepts and opportunities associated with end-to-end system integration to better support their 2024 clinical and operational goals.

In the early days of healthcare IT, the prevailing wisdom was to consolidate as much functionality as possible within a single system. The goal was to have everything in one place, minimizing the need for complex integrations. This approach had its merits:

  • GOOD: Centralization was seen as a way to simplify operations, reduce administrative overhead, and gain better control over various processes.
  • BAD: A single system could only do so much, limiting its ability to adapt to the rapidly changing healthcare landscape. As the industry evolved, it became clear that a single system could only address some of the specialized needs of health insurance payers.

The Shift Toward Best-of-Breed

Over the last several decades, the health insurance industry gradually shifted away from the all-in-one integrated systems to embrace a best-of-breed approach. Instead of trying to fit all functionalities into a single system, payers began adopting specialized software and systems tailored to their specific needs. This shift had several advantages:

  • Expertise: Specialized systems allowed payers to leverage the expertise of vendors who focused exclusively on claims processing, care management, or other critical aspects of their operations.
  • Efficiency: Specialized systems were often more efficient and effective in their respective domains, leading to improved performance in key areas.
  • Flexibility: Health insurance companies could choose the best tools for each aspect of their operations, allowing for greater flexibility and adaptability.

The Challenge of Separation: Care Management and Claims

While the best-of-breed approach offered clear benefits, it also introduced new challenges, particularly in integrating care management and claims processing. Unlike integrated systems, where these functions naturally worked together, the best-of-breed approach separated them into silos and created several new challenges:

  • Expertise: Claims processing and care management requires different skill sets and expertise. This separation led to administrative and technical challenges in bridging the gap.
  • Complex Integration: Integrating separate systems, with their own data structures and communication protocols, proved to be a complex and costly endeavor. Companies faced difficulties in ensuring that these systems worked seamlessly together.
  • Vendor Fragmentation: Another complication arose as health insurance companies started purchasing various products from different vendors to meet their needs. Each vendor had its own requirements for integration, further fragmenting the technology landscape. While technology improved over time, integration challenges persisted due to the diversity of systems and vendors.

The Path Forward: Integrated End-to-End Solutions

Today, health insurers are revisiting the concept of integration, but in a different way. Integrated end-to-end solutions are gaining traction, offering the best of both worlds – the efficiency of specialized, best-of-breed applications and the seamless integration of a single vendor’s ecosystem. This new approach delivers several key advantages:

  • Controlled Integration: When a single vendor provides claims processing, digital care management, and other functionalities, they can control the level of integration between these applications. For example, automating claims and payment editing becomes more straightforward when one vendor owns both components.
  • Real-Time Automation: Integrated end-to-end solutions enable real-time automation, improving the accuracy and efficiency of processes. This is particularly important to ensure claims are paid correctly the first time.
  • Future-Proofing: The market seems to be returning full circle to the best-of-breed concept, but this time with the added benefit of integrated end-to-end automation. Health insurance operations can be more adaptable and better equipped to meet evolving needs and technology trends.
  • Improved Member Engagement: Integrated end-to-end automation breaks down silos and fosters a smoother flow of data and processes. This results in better member engagement, creating a more satisfying experience for insurers and consumers.

The HealthEdge Advantage: Breaking Down Silos

Currently, many health insurance organizations operate in silos, relying on custom-built bridges between different components of their operations. The move towards integrated end-to-end solutions aims to break down these barriers, allowing health plans to take full advantage of a best-of-breed approach while benefiting from a cohesive ecosystem.

HealthEdge solutions were designed with integration in mind. As the HealthEdge solution portfolio moves toward integrated end-to-end solutions, they are breaking down barriers and allowing health plans to take full advantage of a best-of-breed approach while benefiting from a cohesive ecosystem.

In addition to productized integrations between HealthEdge solutions, including Care-Payer, Payer-Source, and the newly available Care-Wellframe, HealthEdge products themselves support an integrated end-to-end approach:

  • HealthRules® Payer

    • Auto-adjudication rates over 90%, with at least 99% claims accuracy
    • Highly automated features greatly increase productivity and transparency
    • Auto reprocessing capabilities
    • Hyper-automation supports remote operations
  • HealthEdge Source™ payment integrity platform

    • Cloud-hosted solution with continuous content updates that are delivered automatically
    • Parallel processing of payment policies and pricing to enable real-time claims transactions
    • Source SMEs research, develop, and maintain content and IT infrastructure
    • Built to enable seamless technology, open APIs, and true interoperability
  • GuidingCare® care management platform

    • API integration suite with 75+ unique vendors for all use cases
    • Automation tools proactively build and sustain robust member care plans
    • Best-in-class rules engine automates business processes and workflows
    • Streamline and consolidate the full appeals management process across all levels and reviewers
  • Wellframe member experience platform

    • Mobile delivery of 70+ pre-developed, automated care programs
    • Web-based staff dashboard with member prioritization, templated messaging, and 1-to-many workflows
    • Auto-generated SDOH and clinical risk survey questions and assessments routinely surfaced to members
    • Direct member access to self-service risk assessments

Moving Forward

The evolution of healthcare IT and back-office administration in health insurance has been a journey of trial and error. From integrated systems to best-of-breed approaches and now integrated end-to-end solutions, the industry has finally found the right balance between specialization and integration.

By combining the efficiency of best-of-breed applications with seamless integration, HealthEdge is enabling health plan operations to be efficient and adaptable to the ever-changing needs of the industry.

To learn more about how HealthEdge solutions can support an integrated end-to-end approach to your enterprise, visit


Artificial Intelligence for Digital Health Plans

With a surge in innovation around artificial intelligence (AI), health plan leaders, industry solution providers, and researchers are focused on the potential impact of AI in healthcare. In particular, emerging generative AI capabilities have captured the attention of the broad market and healthcare leaders searching for next-generation efficiencies and differentiating features.

The healthcare industry lags well behind other industries in adoption, which means there is tremendous upside if health plans can get this right. However, given the regulatory, privacy, compliance, and member service expectations, a measured approach is needed to ensure accuracy, ethical use, and privacy.

This blog explores the intersection of artificial intelligence (AI) and healthcare and then delves into how HealthEdge® helps health plans tackle the various opportunities and challenges that emerge in this domain.

The Promise of AI in Healthcare

Recent research from Harvard and McKinsey healthcare experts published in the National Bureau of Economic Research predicts wider adoption of AI could lead to a 5 to 10 percent decrease in healthcare spending in the US—about $200 billion to $360 billion every year. Researchers point out that the areas of greatest impact for administrative costs that are central to healthcare payers and providers are:

  • Claims Management
  • Member Services
  • Corporate Functions

One of the more mature and impactful use cases is in claims management. Payers use AI-enabled core administration processing systems (CAPS) to improve auto adjudication rates, prior authorization outcomes, and fraud, waste, and abuse prevention.

Behind the frontline of provider-patient interaction, core processing and claims adjudication are inherently complex, forcing many health plans to rely on manual processes. As AI technology enters the health insurance space, payers can harness AI’s power to automate processes, improve accuracy, and enable data-driven decisions.

Examples of AI Applications in HealthRules® Payer

Today, AI offers significant gains in efficiency, given it is effectively and responsibly leveraged within the healthcare technology stack. Within HealthRules Payer, HealthEdge’s CAPS, AI-driven claims automation, analytics, and reporting efficiencies are already available. Not surprisingly, Harvard/McKinsey research predicts there is the most opportunity for AI to do more work than humans in these areas.

Let’s look at some use cases, both benefiting health plans today and others on the horizon.

AI-Powered Analytics in Claims Automation

Within claims automation, AI algorithms within HealthRules Payer review and synthesize structured and unstructured data, including encounter details, medical records, and reimbursement policies. AI identifies patterns and anomalies, helping detect fraud or unusual claim behavior and surfacing opportunities to streamline the entire claims processing workflow. By supporting human reviewers and making auto-adjudication more intelligent, AI improves the accuracy and efficiency of complex claims reviews.

HealthRules Payer processes millions of claims. Health plans are under tremendous pressure to automate as much as possible to pay claims within 30 days or face steep penalties. Within HealthRules Payer, AI looks at all the claims requiring human intervention and understands the decisions being made. For example, the health plan can learn which combination of doctor, service, and dollar amount needs to be reviewed by a person. The AI models ensure maximum intelligent automation so that health plan staff can focus on the exceptions.

Therefore, auto-adjudication rates are optimized. Many health plans historically have averaged about 75+% auto-adjudication rates, but improving that by 5% would be optimal as they implement new technologies. HealthEdge found that a 1% increase in auto-adjudication is close to $400K in savings for health plans using HealthRules Payer. Traditional AI, or machine learning, in HealthRules Payer helps these organizations raise their auto-adjudication rates by identifying patterns and focusing on which to automate.

HealthEdge’s Payment Integrity platform Source is also implementing traditional AI algorithms to ensure that claims are paid accurately. According to estimates by the Centers for Medicare and Medicaid Services (CMS) approximately 9.5% of claims are paid inaccurately, which contributes to nearly $36 billion in overpayments. Reprocessing such claims and recovering payments increase the administrative burden on plans and also lead to abrasion in plan-provider relationships. AI algorithms are employed to find inaccuracies before a payment is made in order to improve accuracy.

Natural Language Reporting Queries

HealthRules Payer complements core reporting and analytics capabilities by allowing users to ask natural language questions about specific aspects. Each day, users have questions about vital operational metrics and want to dig deeper into these metrics better to understand information not readily available in existing reports. They may have specific inquiries that lead to curiosity to look deeper into things like daily claim volume, claims assigned to humans, auto adjudication rates, instances of overpayment, etc.

HealthEdge has put a spin on traditional reporting, which does a good job of answering the questions most health plan leaders want, but it doesn’t necessarily support human curiosity. If a report triggers a question such as “Why is that hospital billing the highest?” HealthRules Payer with AI allows the user to ask that question and instantly receive an answer. Similarly, if a user wants to know “Which services are the most expensive for this hospital in this time frame?” the application generates the answers.

Before AI, a business analyst or even a data scientist would get a long list of questions to explore, and those questions pile up, leading to delays in decision-making and insightful action. Now, HealthRules Payer eliminates those delays and instantly provides more insightful action. How many questions about data does a user have in a single day? Now, multiply that by all the leaders and users in a health plan. You start to see how powerful AI can be, making everyone more informed and streamlining decision-making.

Human-Friendly User Support and Training

Another powerful use case is for HealthEdge users who need to query our extensive product documentation, which spans approximately 8,000 pages. Traditionally, users would search through this documentation to understand product details. Getting to the answer can be cumbersome, involving trial and error to find what information is needed. Health plans often contact customer support or product managers to seek guidance on specific tasks, adding more time to solving the problem.

To address this challenge, HealthEdge developed an application in HealthRules Payer that leverages generative AI. This technology allows users to ask questions about the product using natural language, and the system provides accurate answers. Unlike manual searches, this approach is like interacting with a chatbot, streamlining the process and eliminating the need for time-consuming and exhaustive searches.

What is generative AI?

Generative artificial intelligence (generative AI) is a type of AI that can create new content and ideas, including conversations, stories, images, videos, and music. AI technologies attempt to mimic human intelligence in nontraditional computing tasks like image recognition, natural language processing (NLP), and translation. Generative AI is the next step in artificial intelligence.

Work in Progress: Generative AI for Member Services

A future application currently being explored demonstrates the potential efficiencies generative AI can deliver when it comes to care management with the HealthEdge GuidingCare® member engagement solution.

When members contact a service representative, they often inquire about their health insurance benefits. For instance:

  • The member asks how many physical therapy sessions they can be reimbursed for in a year or the cost of visiting a chiropractor.
  • The service representative manually navigates through the system to retrieve this information, which takes time for both parties on the call and depends on a person to interpret.
  • The member may be frustrated and feel that insurance coverage is a “black box” and a time-consuming burden to decipher.

Leveraging natural language processing in a chat-based interface will allow representatives to quickly access and provide accurate benefit details to members during live calls. Ensuring 100% accuracy is crucial, which HealthEdge is working toward now. Although the project is still in progress, HealthEdge believes this will streamline benefit inquiries, improve service, and enhance customer satisfaction.

A Bright Future: Streamlining Staff Workflowswith Summarization

Finally, there are future use cases that illustrate how generative AI can be used in healthcare. For example, when a patient requires a knee replacement, the health plan must approve the procedure through prior authorization. GuidingCare handles the case review during this, which involves a physician thoroughly examining a patient’s documentation. Often, these documents are hundreds of pages.

AI could be used to summarize the critical aspects of the documentation. By condensing the essential information, a physician can make a quicker decision, which leads to faster approval and more timely care. This efficiency is crucial because physician reviews are resource-intensive and critically important. Optimizing this process helps all stakeholders and can significantly impact the operational bottom line.

Similarly, the Wellframe team is planning to embed Generative AI summarizers into staff workflows such that case managers can rapidly and quickly catch up on the latest member activity across the Wellframe platform, including recent chats/inquiries, app activity, care program / assessment results without disrupting existing workflows​.


However, much work remains to ensure accuracy and address ethical considerations associated with summarization. Balancing efficiency with accuracy and ensuring transparency is a priority for HealthEdge.

The Challenges of AI in Healthcare

Despite AI’s current benefits and promise for health plans, HealthEdge is deeply mindful that a cautious approach, ethical considerations, and continuous monitoring are vital to reap AI’s benefits while minimizing risks. It’s imperative to:

  • Mitigate ethical and legal risks with privacy
  • Establish best practices in data and systems governance, and
  • Monitor the potential for “bias” in AI algorithms

These practices are critical for reliable AI applications. Above all, patient safety and cybersecurity must be prioritized, and risks must be mitigated. Within HealthEdge, all AI/ML use cases are vetted from ideation to deployment by an AI Governance Panel, which has legal, information security, compliance, business, and engineering leaders within the organization.

Relative to the use cases above, there are key considerations for the use of AI:

Probability and margins for error

With the incorporation of AI into intelligence that drives auto-adjudication systems, for example, probability and margins for error must be considered. Of course, even human reviews have inherent inaccuracies, but health plans want to improve that performance baseline while maximizing efficiency.

With HealthRules Payer, health plans can select their desired accuracy level, such as 95% or 100%. For instance, if a customer is comfortable with a 95% confidence level for a certain process, there is a 5% chance of misclassification. This aligns with the reality that human reviews are also subject to errors due to imperfect data. HealthEdge communicates this to health plans, allowing them to adjust the risk-reward ratio according to their needs. Relative to emerging generative AI, this process is relatively straightforward with machine learning.

Mitigating generative AI risks

The situation changes when it comes to generative AI, which relies on large language models. These models can generate content beyond the input data (often referred to as “hallucinations”) because they are designed to create new material. While this is advantageous for tasks like video generation or fun consumer applications, it becomes problematic when dealing with critical healthcare information.

Consider member benefits. Here, there is no room for error. If a member is told they have six visits for physical therapy, but the actual data indicates only four visits, the consequences could be significant. Generative AI excels at recommendations and answering questions. Yet, accuracy becomes paramount when dealing with essential details like insurance benefits or product documentation, so HealthEdge has implemented extensive pre- and post-deployment validation procedures. While health plans are excited about the potential benefits sooner rather than later, they can have confidence that HealthEdge’s oversight of these innovative possibilities will ensure the application is ready to go when brought to market.


AI holds immense promise for health plans. As HealthEdge invests in innovating with AI, it prioritizes a close partnership with health plans to maximize the benefits and mitigate the risks. The bottom line is that AI is adding powerful capabilities today in HealthRules Payer, and HealthEdge is focused on diligence when adding generative AI into solutions. The result will be that healthcare works better for everyone.

To learn more about how HealthEdge’s solution can help your organization leverage AI to improve efficiencies, reduce costs, and stay on the leading edge of healthcare innovation, visit


HealthEdge Horizons: Simplifying the Complexities of Healthcare Industry Regulations

Healthcare in the United States is one of the most highly regulated industries, where healthcare providers and payers must stay on top of a myriad of ever-changing rules and regulations that can have a massive impact on their financial future. The constant evolution of these regulations demands adaptability and efficiency in administrative processes and technology systems.

The Complex World of Health Insurance Regulations

For decades, health plans of all types and sizes have struggled to keep pace with ever-changing government regulations that occur at both the federal and state levels. While it may seem that federal changes would be easier to manage, the truth is that any regulatory shift is inherently difficult to administer mainly because these changes encompass a wide range of aspects, from timelines to benefit levels, and even provider contracts. Some regulatory changes are actually retroactive, forcing insurers to go back through claims and payments to make sure they remain compliant with government mandates.

Adding to the complexity, regulatory requirements can change over time as they are implemented. Payers are often given a three-year window to adapt to new programs, only to see mid-course alterations, sometimes for the better, but still demanding for payers to constantly respond and adjust course.

This constant state of flux has created a challenging environment that shows no signs of slowing down. In fact, it is expected to become even more frequent and command higher fines for non-compliance in the coming years. The pace at which CMS issues regulatory changes can be influenced by various factors:

  • Annual Changes: CMS typically releases an annual cycle of regulatory changes, which often coincide with the calendar year or fiscal year. These changes can encompass updates to payment rates, coding systems, quality measures, and program requirements. Health insurance payers can anticipate these annual updates and plan accordingly.
  • Legislative Mandates: Significant regulatory changes may be prompted by new healthcare-related legislation. When Congress passes laws related to healthcare, CMS is tasked with implementing and regulating these new requirements. The pace of change in this regard can vary depending on when new legislation is enacted.
  • Administrative Updates: CMS may issue administrative updates and clarifications as needed to address immediate concerns or ambiguities in existing regulations. These updates can occur throughout the year and may be issued more frequently when there are rapid shifts in healthcare policy.
  • Response to Public Input: CMS often seeks public input through the notice-and-comment rulemaking process. This involves publishing proposed regulations and allowing stakeholders to provide feedback. The time it takes to finalize regulations can vary depending on the complexity of the issues and the volume of public comments received.
  • Market and Healthcare Trends: Regulatory changes can also be influenced by emerging trends in healthcare, such as changes in technology, care delivery models, and public health priorities. CMS may adjust regulations to accommodate these evolving trends.
  • Political and Administrative Changes: The pace of regulatory changes can be affected by changes in presidential administrations and leadership at CMS. Different administrations may have different healthcare policy priorities, leading to shifts in the regulatory landscape.
  • Emergency Regulations: In response to public health emergencies or crises, CMS may issue emergency regulations to address immediate needs. These changes can be rapid and may not follow the typical rulemaking process.

In a recent Modern Healthcare article that summarizes the 2024 state legislative changes across 20 different states, “Health providers and insurers will have to navigate a bevy of state laws that took effect with the new year, covering key issues such as reproductive care, patient documentation, wages and reimbursement.”

For example, in Oregon, individual and fully insured group health insurance plans must cover three primary care visits per covered individual per year. Insurers also must cap the copay, waive the deductible for the visits and assign a primary care provider to the individual within 90 days of enrollment, if a member has not selected one within that period. In Pennsylvania, insurers are required to have an electronic communications network that allows prior authorization requests to be submitted and returned electronically. In Texas, payers are required to create and maintain a website where providers can verify if patients are covered by the issuer and see a patient’s potential deductible, copayment or coinsurance. Many of these state regulations mirror or complement federal regulations, such as the CMS Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule.

The Role of Modern, Flexible Systems

To help navigate this ever-evolving regulatory landscape, health insurance payers need flexible technology systems that can handle both federal and state-specific requirements with ease. While most systems can support compliance with federal requirements at a broad level, it is equally important for payers who participate in state-specific programs to have the ability to support the wide range of state-specific changes as well.

Very few systems can support a large portion of the state changes and care programs, leaving the rest of the rules to be implemented by already-scarce IT resources or vendor engagement. This is where flexibility in system configuration becomes critical.

Whether it’s adapting to changes in benefits, claim systems, fee schedules, or state-specific care programs, the ability to administer these changes in an automated fashion is key. The systems must be capable of adapting and accommodating these shifts without manual intervention. This applies to healthcare organizations of all sizes, from large health plans to smaller providers.

The Law of Large Numbers Gain

The regulatory burden is a “law of large numbers” gain, meaning that having more health plans on a single solution can everyone help tackle the problem more efficiently. Even if two health plans come together through a common platform, they can collectively handle the workload more effectively than two separate entities. Therefore, collaboration and synergy across the industry are essential to addressing regulatory challenges.

How HealthEdge is Making a Difference

At HealthEdge, we understand the importance of payers having access to highly flexible, configurable technology systems that can support an organization’s ability react to regulatory changes and CMS mandates to avoid sanctions, potential fines, and remain competitive. That’s one of the many reasons more than 130 health plans rely on our solutions today and why HealthEdge solutions consistently rank Best in KLAS for multiple years in a row.

Our technology solutions automate access to real-time data, ensuring regulatory compliance so health plans can save time, resources and streamline internal processes. HealthEdge solutions not only help payers meet regulatory changes, but also provide them with a competitive advantage in an increasingly complex industry. Here are a few practical examples of how HealthEdge solutions help payers address regulatory challenges.

HealthRules® Payer

    • Monitor federal and state level rules to identify rulemaking that impacts Payer Business Processes supported by HealthEdge
    • Develop business centric compliance requirements and use gap identification methods to develop a support strategy
    • Vet support strategy with the Steering Committee and collaborate with customers via monthly meetings
    • Communicate strategy and other compliance artifacts via a cloud-based repository, tracking over a year roadmap of compliance initiatives

HealthEdge Source™ payment integrity platform

    • Research, Policy, and Data experts actively monitor government and industry resources to develop, deliver and maintain the most up-to-date content
    • Full-service delivery of payment policies & edits every two weeks ensures tightly linked payment processes
    • Third-party ecosystem readily extends payment integrity capabilities

GuidingCare® care management platform

    • Tracked changes and updates to state/federal program, reporting, and auditing requirements
    • OOB CMS-compliant Audit and Part C/D reports plus self-service custom reporting
    • Support for Regulatory audits/surveys, NCQA & URAC (utilization) review accreditation
    • NCQA Certified for HEDIS measures and Pre-Validated for Population Health Management since 2018

Wellframe member experience platform

    • Secure, HIPAA-compliant messaging between care managers and members
    • Configurable, customizable programs and assessments aligned with state requirements
    • Direct member access to NCQA-aligned health and risk assessments
    • Real-time insights and alerts help care teams effectively identify gaps in care and improve HEDIS performance

We encourage you to consider HealthEdge’s full suite of solutions can help your organization stay compliant with federal and state regulations while also growing margins. Visit