The Pace of Industry Disruption Drives Need for Next-Generation Healthcare Payer Solutions

Recently, we met with health plan business and technology leaders to discuss trends in the healthcare industry, and the strategies they’re using to stay on top of consumer expectations and regulatory demands. Two key themes emerged: the pace of disruptive forces is rapidly increasing, which is, in turn, increasing the urgency for health plans to move to modern technology.

Some of the market forces shaping health plans’ priorities include:

  1. Retail experiences shape consumer buying behaviors. Consumers expect a digital experience like online shopping and prefer healthcare services that provide virtual scheduling, services, and information access. They’re also looking for access to comprehensive information about healthcare quality and prices.
  2. New entrants in healthcare bring innovation and enhanced services that elevate consumer expectations. New entrants in healthcare, including consumer-focused retailers, startups, and innovative care models, use digital technologies to improve the patient experience and fill gaps in the current medical infrastructure. They encourage innovation in care delivery and refine the consumer experience while bringing increased competition.
  3. Growing participation in Medicare Advantage and individual marketplaces. Medicare Advantage enrollment increased steadily over the past two years, with over half of the eligible Medicare population opting for coverage. In 2022, the average MA beneficiary had access to 39 plans. The individual marketplaces have also seen insurers expanding their service areas, with the Accountable Care Act marketplace reporting over $16M members and an average of five insurers per state.
  4. Regulation requirements evolve quickly, now with penalties. Healthcare regulations in the U.S. are constantly changing due to legislative mandates, administrative updates, and market trends. These changes make it challenging for health plans to keep up and result in increasing fines for non-compliance. While regulations aim to improve health coverage, consumer demands increase competition and require adaptation costs for health plans.
  5. Availability of data and maturing interoperability standards. The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) set specific API requirements that help improve access to health records for patients, providers, and payers. This enhances data sharing, improves care quality, and increases competition among health plans. However, achieving interoperability is complex due to differences in data standard implementation in legacy platforms, which slows down progress toward compliance.

HealthEdge Accelerates the Journey to Becoming a Digital Payer and Achieving Transformational Outcomes

Our conversations with healthcare leaders focused on solutions and opportunities amid mounting industry disruption. Many payers are already unlocking transformational outcomes through HealthEdge solutions, anchored by its modern Core Administrative Processing System (CAPS), HealthRules® Payer.

Recently, CAPS modernization has surged to the forefront of funding priorities. In 2023, 59% of payers prioritize allocating resources to CAPS, a significant leap from the 17% reported in 20221. This shift underscores the urgency and strategic importance of enhancing consumer experiences and streamlining operations. Here are a few examples of how health plan leaders benefit from HealthEdge solutions to support their digital payer journeys:

1. Remaining agile, adaptable, and accurate in an ever-evolving regulatory landscape. HealthRules Payer addresses the rapidly evolving regulatory landscape by enabling health plans to adjust claims processing rules or modify payment protocols quickly and easily to ensure timely compliance. When regulations are updated retroactively, HealthRules Payer facilitates revisiting claims, ensuring compliance, and making necessary adjustments.

HealthRules Payer helped our Medicaid group transition from a legacy platform where auto adjudication was significantly lower. Using the English-based configuration rules allows us to make significant changes relatively quickly and, as a result, improve auto adjudication and ultimately improve payment accuracy by eliminating the human factor in determining what needs to happen with a claim.”

Senior Vice President of Medicaid Operations at National Health Plan


2. Enabling automation and accuracy at the core of every process and workflow. The evolution of health insurance technology moved from initial integrated systems—which aimed for functionality consolidation but struggled with adaptability—to a best-of-breed approach that adopted specialized software, offering greater expertise and flexibility. However, this approach led to challenges integrating care management software and claims processing due to siloed functions, complex integration, and vendor fragmentation.

Today, health plans look to modern solutions that offer the efficiency of specialized applications and the seamless integration of a single vendor’s ecosystem, providing key advantages such as controlled integration. As the HealthEdge solution portfolio races toward integrated end-to-end solutions, barriers are coming down. This is 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—HealthRules Payer, HealthEdge Source™ payment integrity platform, GuidingCare® care management platform, and the Wellframe member experience platform—HealthEdge products themselves support an integrated end-to-end approach with numerous modules that are purpose-built.

“We outperformed our commercial platform within several months. Our Medicare business has been on a steady climb. When we launched it, we were expecting an auto adjudication rate of about 50%. But at the start, we actually hit 65% and very quickly got up to 82% or 83%, where we are right now. Our end users have grown, and we currently have over three million members on the platform.”

Executive Director, Product Management and Development, National Health Plan

3. Improving payer-provider collaboration on healthcare administrative spending and waste.  In 2020, health spending in the United States reached approximately 20% of the country’s gross domestic product. However, at least half of administrative spending is deemed wasteful. Collaborative efforts between payers and providers are essential to healthcare payment integrity and optimizing revenue cycles.

HealthEdge’s technology fosters collaboration and efficiency while addressing fraud and waste in healthcare. HealthRules Payer empowers health plans by streamlining administrative processes, enhancing efficiency, and ensuring accuracy. At the same time, Source revolutionizes claim payment through proactive business intelligence that prevents improper payments, saves time, and minimizes recovery efforts. With AI-enabled fraud detection, HealthEdge’s capabilities combat fraudulent claims, safeguard payer resources, and improve care outcomes.

“The health plan value proposition is losing, and the provider value proposition is being threatened by new entrants. Companies are either acquiring or incubating digitally focused healthcare start-ups or monetizing existing health plan platforms (analytics, claims processing, care management, sales, and marketing) by selling them as a service to other payers or into the emerging risk-bearing provider market. The demand for integrated end-to-end advanced automation across traditional payer and provider functions enables automation and accuracy at the core of every process and workflow.”

Leading Industry Analyst of Payer IT Strategies

4. Market expansion to beat the competition. The health insurance landscape in 2024 has significantly transformed, with new market expansion driving competition and growth. Providers have adapted to changing consumer preferences and the evolving competitive landscape. In this new consumer-focused era, health plans must appeal to diverse populations with unique needs, requiring flexibility and quick decision-making. With 62% of health plan leaders investing in digital transformation, modern systems such as HealthRules Payer are critical for supporting growth plans. To meet the demands of this new market paradigm, payers leverage modern technology in key areas like rapid benefit package creation, digital care management, and ASO arrangements.

“We use technology to solve the problems that you’ve had to solve for the past 30 years differently so you can go to market faster. So you can get to trends faster. So you can win new business faster.”

Alan Stein, Chief Product & Strategy Officer, HealthEdge

5. Managing and supporting Value-Based Care (VBC): The healthcare industry has shifted from a fee-for-service model to VBC, which aligns the interests of patients, providers, and payers by introducing financial incentives for healthcare providers to ensure patients stay healthy. As of 2023, 90% of CMS payments are linked to value, with 40% flowing through alternative payment models. However, fee-for-service arrangements persist. Many legacy systems cannot support this transformation, so the move to software solutions such as HealthRules Payer, which can support value-based care, is essential.

“Being a digital health plan for Highmark’s Medicaid segment means we are no longer in the era of calling our members between the hours of 9 and 5. They want to interact with us on their terms when they are available, whether through apps, portals, or web content. We have to meet the members where they want to be met. Highmark’s Medicaid members are looking for the Amazon experience. They want it simple.”

Senior Vice President of Medicaid Operations, National Health Plan

6. Exceeding member engagement expectations by providing a digital healthcare experience. Today’s healthcare consumers expect convenient and engaging experiences from their health plans. Therefore, payer leaders must adapt by offering self-service mobile tools and greater pricing transparency. Regulatory developments like the Transparency in Coverage Act and CMS’ Star Ratings changes emphasize the need for a strong focus on member experience.

In fact, two recent studies (the 2023 Consumer Satisfaction Survey of nearly 3,000 healthcare consumers and the 2024 HealthEdge Annual Market Report of 350+ health plan leaders) speak to this urgent need to focus on the member experience. Consumers expect health plans to leverage social determinants of health (SDOH) data to deliver more personalized services relative to their experiences. Customer service and self-service tools have emerged as top satisfaction enablers, along with a plan’s ability to adhere to members’ communication preferences.

“As a consumer, I focus on things that are important to me. When I am trying to order prescriptions or looking at lab results, what I would expect as a consumer is to have the right price, the right information about my quality of care, my claims, and my out-of-pocket expenses. Consumers feel the same way. It’s important that we give our members the same type of transformation to have access to a lot of good information, timely information, and quality information at their fingertips. We use HealthRules Payer, agile applications, and our network providers to make sure that the product is not only timely but also accurate.”

Vice President of Operations, Regional Health Plan

The Road to Becoming a Digital Payer

Digital transformation is a marathon, not a sprint. The critical steps in the change management and implementation process include:

  • Defining Success: Clearly outline your goals and objectives.
  • Plan and Prepare: Strategize and lay the groundwork.
  • Design for the Future State: Create solutions that align with your vision.
  • Build According to the Plan: Execute your strategy.
  • Monitor KPIs: Track how you’re measuring against key performance indicators.
  • Optimize and Customize: Continuously improve and adapt.

By automating business workflows and seamlessly exchanging data in real-time across the ecosystem, health plans deliver improved member experiences, increased quality, greater business transparency, ever-reducing transaction costs, and increased service levels. Through collaboration such as HealthEdge’s Leadership Forum, the company and health plan leaders are teaming up to ensure a path to success.

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


The Shift to Payment Accountability®: An Enterprise Approach to Healthcare Payment Integrity

Health plans are facing unprecedented challenges in accurately pricing claims due to a growing number of value-based payments and government regulatory requirements. As providers’ expectations for more efficient and accurate payments continue to rise, health plan leaders are turning to modern technology for help.  In the past, health plans used a traditional approach to solving these challenges. They relied on multiple business units and stacked third-party claims editing solutions—which resulted in a fractured approach that focused solely on measuring a percentage of recovered savings downstream. 

The future of payment integrity is shifting towards Payment Accountability®, an enterprise-wide approach that brings together different business units to increase focus on measuring cost avoidance instead of just recovery. Payment accountability emphasizes creating transparency to address root cause inaccuracies so that payers can pay claims accurately, quickly, and comprehensively the first time.  

Industry experts claim that this enterprise-wide approach can reduce medical expenses by 10% or more, with the potential for significant reductions in administrative expenses. An enterprise approach to claims adjudication can shift processes upstream, solve root-cause issues, increase accuracy, and reduce provider abrasion.  

The Source Approach to Payment Accountability 

HealthEdge Source™ (Source) was specifically designed and intentionally built to enable payers to allow health plans to insource more functionality, derive valuable analytics, and increase transparency and interoperability.  

The Source platform, to meet evolving market demands, is focused on the following core areas: 

  • Real-time integration expansion: Seamless integrations with third party solutions that expand payment integrity and reimbursement offerings and reduce the administrative burden on clients using multiple vendors. 
  • Continued content expansion: To deliver added automation, savings, and accuracy, including additional Medicaid, Medicare, Cost Containment, and other specialty edits and pricers. 
  • Improved accuracy: By including additional validating datasets such as prescriptions, medical records, and others. 
  • Adoption of AI/ML technologies: To automate and/or assist manual and tedious workflows. 
  • Efficient workflow and best-in-class user experience: Through self-service tools like policy creation, implementation, and management. 
  • Creating insights for data-driven decisions. 

But the team doesn’t stop there. Our product investment strategy includes a multi-year roadmap focused on enhancing the content, features, and technology to drive continuous improvement in the solutions we deliver. We’re currently piloting an AI-enabled chat bot that allows users to type questions in natural language regarding the Source edits, pricers, functionality, and other capabilities. This results in quick and accurate responses, freeing auditors or provider relations team members from scouring through multiple user guides, worksheets, and other materials. The chatbot can provide the necessary information in seconds.  

Additionally, Source is streamlining the process of managing configuration by utilizing APIs to create, manage, and publish edit changes to production. This process reduces the need for manual user intervention, allowing the payment integrity and configuration team members to focus on other critical business tasks. 

A Guiding Hand from the Payment Integrity Experts 

Source experts are available to participate in a Payment Integrity Health Check as part of the implementation process. This helps our team gain a better understanding of your current processes, data, and internal expertise so that we can work together efficiently and provide a solution that enhances your health plan’s strengths and aligns with the long-term payment integrity goals. Source experts will also work with our customers continually after go-live, to review data and identify areas that can add value to your payment integrity program. 

Post-implementation, Source maintains close partnerships with our clients. We gather feedback and input on our product roadmap in many ways, such as conducting 1:1 user research and design sessions with the product and engineering teams, monthly user groups, semi-annual customer advisory boards, regulatory steering committees, bi-annual virtual customer events, and annual client conferences.  

From Payment Integrity to Payment Accountability 

At Source, our solution aims to redefine payment integrity by shifting the industry from a black box to an open-book approach. Unlike traditional payment integrity solutions that often operate retrospectively and give limited intelligence to health plans, Source is designed to deliver transparency in editing solutions. Our goal is to empower payers with technology that enables them to gain control of their IT ecosystems, address root-cause issues, and reduce waste in the healthcare system.  

Source accomplishes this differentiation by providing the following unique features:  

  • The ability to configure contract reimbursement terms, edit and price claims, and run analytics in a single call to Source. 
  • Extensive editing and pricing content libraries that are out of the box and always up-to-date and accurate through our two-week update cycle. 
  • Configurable and customizable edits to make pre-payment claim decisions based on a health plan’s intellectual property. 
  • Real-time analytics to monitor utilization and financial impacts of edits prior to enabling their impact in the live adjudication workflow. 
  • Claims pricing based on negotiated fee schedules, including CMS and Medicaid methodologies, to ensure edits and reimbursement are accurate prior to adjudicating the claim. 
  • Continuous member claims history analysis by the Source team to recommend new edits that solve recurring post-payment issues.  
  • Integrated third-party content within the solution to improve accuracy, promote higher and faster automation, simplify workflows and vendor contracting, and keep all data in a single location. 

To learn more about how Source can help your organization successfully make the shift to payment accountability, visit the Source webpage 

Unlock Greater Efficiency & Value with HealthEdge® Provider Data Management

Amid a rapidly evolving healthcare industry, the integrity and efficiency of Provider Data Management (PDM) systems are key to achieving operational excellence. HealthEdge® is at the forefront of solution development, offering a comprehensive Provider Data Management solution that exceeds current market demands. We designed this PDM solution to optimize business operations by ensuring the integrity of healthcare provider data across your organization. 

4 Unique Features of the HealthEdge Provider Data Management Solution 

Many PDM tools available on the market are disjointed, characterized by using assorted point solutions and custom-built systems among health plans. The HealthEdge Provider Data Management solution offers unparalleled features that set us apart, such as: 

  • Provider Master Identifier: Allows health plans to uniquely identify providers and organizations, tailoring to specific business needs and requirements. 
  • Data Mastering with Prebuilt Match and Merge Rules: Match-merge survivorship rules adeptly manage and maintain data from diverse channels, addressing and resolving conflicts efficiently. 
  • Low or No Code Framework: Leveraging a generative AI-enabled framework, the PDM enables easy setup, source channel mapping, and configuration of downstream consumer systems with minimal coding effort. 
  • Observability Dashboard: Offers a transparent view of provider data with valuable insights into processing status, duration, and data quality. 

Access the Full Value of Provider Data Management 

The HealthEdge Provider Data Management solution ensures no data loss, offering 100% coverage for provider demographics, user-defined types (UDT), and benefit network data. It also supports real-time provider Application Programming Interface (API) services for addressing any discrepancies in provider information. Our team ensured the PDM solution is highly configurable, aligning with customers’ master data identification as defined in HealthRules® Payer (if applicable). This enables your organization to streamline processes to enhance automation while reducing overhead costs and inefficiencies. 

3 Features that Enhance Health Plan Capabilities 

HealthEdge’s PDM solution stands out not only for its differentiators, but for its comprehensive capabilities that optimize workflows, distributions, and integrations for health plans: 

  • Enrichment and Workflow Features: The solution provides data enrichment through validation checks and user-friendly workflows. It leverages a centralized framework with over 300 built-in quality checks and third-party validations, including National Plan and Provider Enumeration System (NPPES) and address standardization. 
  • Distribution and Integration Features: We offer configurable data distribution and native Core Administrative Processing System (CAPS) integration, including a self-service module for scheduling and delivering extracts, support for real-time API, event-based distribution, and seamless integration with HealthRules Payer. 
  • Platform Features: As a modern SaaS platform, the PDM boasts web-based workflows, high availability, unlimited scalability, seamless upgrades, role-based access, and a customer-extendable data model. 

As an organization, HealthEdge is not just joining in on the healthcare industry’s evolution—we want to actively help shape its future. The HealthEdge Provider Data Management solution exemplifies our commitment to innovation, efficiency, and reliability. By addressing the complexities of provider data management with progressive digital platforms, we’re empowering health plans to achieve operational excellence and deliver superior care. 

Do you want more information on how the HealthEdge Provider Data Management solution can help optimize business operations at your health plan? 
Read our data sheet

Achieving Transparency and Compliance with HealthRules® Machine Readable Files

Regulatory compliance and transparency are more than healthcare industry buzzwords: they’re key areas of focus for regulatory agencies and consumers. Staying compliant with shifting state and federal regulations can be a challenge, requiring efficient access to the most up-to-date information available. And pricing transparency has become an essential way for health plan members to make informed care decisions.

At HealthEdge®, we are committed to supporting our customers in achieving and maintaining compliance. Our mission is to empower your organization to become a digital payer, achieving key business goals—like improving the member experience and reducing costs—by leveraging innovative digital technology.

Introducing HealthRules® Machine Readable Files Suite

The HealthRules® Machine Readable Files Suite 3.x stands as a testament to our commitment to innovation, compliance, and transparency in the healthcare industry. Designed to address the requirements of the Transparency in Coverage final rule, our pioneering software solution offers a robust framework for generating machine readable files (MRFs) that detail negotiated rates for in-network providers and allowed amounts for out-of-network providers.

This initiative is not merely about complying with regulations; it’s about ushering in a new era of clarity and trust between health plans and their members.

3 Key benefits of using Machine Readable Files

Real-Time Reporting

Leveraging the power of cloud technology, our solution suite allows health plans to their own reports in real-time, ensuring your team has consistent access to the most up-to-date information.

Intuitive User Interface

The platform’s user interface was designed to make compliance as straightforward as possible and significantly reduce the complexity of generating machine readable files through the HealthRules solution.

Native Integration

As the only machine-readable file generation tool built natively into a Core Administration Platform Solution (CAPS), our MRF suite seamlessly integrates into your existing systems—minimizing disruptions and enhancing operational efficiency.

Key goals of offering an integrated MRF suite within the HealthRules solution are to clarify compliance needs, enhance transparency, and improve the member experience for our health plan customers. This innovative feature is just one representation of our dedication to not just meeting the needs of payers today but shaping the future of healthcare. Partnering with HealthRules can help your team work more efficiently to transform industry challenges and demands into opportunities.

Are you looking for more information on our advanced Core Administrative Processing System (CAPS) and how it can integrate with your health plan’s existing platforms? Visit the HealthRules® Solution Suite.




3 Functional Areas That are Ripe for Immediate Operational Efficiency Gains

“Operating margin improvement is a top three critical outcome for digital investments in 2024 for 67% of U.S. healthcare payers.”
— Gartner®, Three Operational Excellence Best Practices to Optimize Costs for U.S. Healthcare Payers, 1 November 2023, Mandi Bishop 1 

Healthcare payers’ operating margins are being squeezed like never before. As many payers turn to technology and automation for answers, it is important to identify areas in the business where manual resources are being used to do work that modern technology can easily accommodate.  

According to the same Gartner report, “You and your IT team must rationalize applications, hyperautomate manual-intensive processes (such as provider data management) and improve business collaboration today. This will deliver meaningful positive effects on business outcomes, operating metrics and enterprise-wide effectiveness over the next 18 months.”  

Barriers to Margin Optimization 

The problem is that many payers are still dependent on legacy, outdated core administrative processing systems (CAPS), siloed claims pricing and editing solutions, and disjointed care management systems. These systems are not able to accommodate today’s: 

  • Highly complex payment models, including value-based care 
  • Ever-increasing demands from providers to get paid faster and more accurately with more customized contracts 
  • Rising healthcare consumer expectations that are being shaped by their retail experiences. 

Again, referencing the Gartner report, “The prevalence of legacy IT systems and number of custom practices mean payers have significant human-involved processes.”  

As a leader in integrated digital payer solutions, HealthEdge has identified three main functional areas of the business where operational efficiencies can be gained to impact payer operating margins directly and positively.  

1. Claims Processing

Many payers are wasting valuable resources and time by manually reworking claims and reconciling inaccurate payments. In fact, according to a recent HealthEdge survey on the current state of payment integrity, the waste is pervasive:  

    • 90% of payers depend on two or more payment integrity vendors, which means multiple datasets, update schedules, and instances across lines of business. The IT burden and workflow complexities associated with this approach have become overwhelming for many health plans.  
    • 55% of payers report that more than 20% of their claims require rework due to inaccurate first-pass adjudication. Claims rework not only requires additional time and effort from the payment integrity team, but it also downstream work for other teams, such as provider relations. 
    • 70% of payers have more than 10 full-time employees (FTEs) dedicated to payment integrity, and 45% have more than 25 FTEs. When asked what the future looks like when it comes to dedicated resources, 56% say they expect that number to increase over the next one to two years, further compressing operating margins.

2. Contract Configuration

As healthcare providers attempt to manage many diverse contract types, the complexities continue to grow. This often requires hundreds of different configurations to be created, which results in additional manual oversight and administrative burdens to avoid compliance issues and payment inaccuracies. In the end, many payers find themselves wondering if these complex configurations are really worth the impact they have on operational efficiencies. 

3. Care Management

With rising healthcare consumer expectations for more personalized engagement and greater transparency, payers are struggling to assemble the right mix of digital solutions that support positive member experiences and compliance with new price transparency rules. According to the HealthEdge Annual Consumer Survey, only 55% of healthcare consumers are fully satisfied with their health insurance provider, leaving much room for improvement. And as CMS doubles the weight of the member experience when it comes to Star ratings for Medicare Advantage plans in the new year, it is more important than ever for payers to address the rising expectations. 

Striving for Operational Excellence 

There are modern, tightly integrated digital payer solutions on the market today that can help payers find new operational efficiencies in these three areas. As the only provider of integrated digital payer solutions, HealthEdge® offers payers the opportunity to identify these efficiencies through hyperautomation of manual process across multiple functions and lines of business.  

Here is a brief summary of those HealthEdge solutions and how they work together to help relieve some of the pressures on today’s health plan margins.  

  • HealthEdge Source (Source), is HealthEdge’s prospective payment integrity solution. With Source, payers get one source of truth for payment accuracy and accountability across all lines of business. And because it is a cloud-based solution, fee schedules and policy changes are updated automatically every two weeks. Designed specifically to integrate through a single API to any core administrative processing system (CAPS) for improved speed and performance, Source helps minimize the IT burden of implementing, connecting, and maintaining multiple editing and pricing tools. Plus, with Source Platform Access, payers are finally able to identify the root cause of inaccurate payments and resolve issues upstream so the errors do not repeat month after month.  

“By investing in a prospective payment integrity solution that highlights inaccuracies before the payment is made, you can stop the costly retroactive repayment process that negatively impacts your providers and members through administrative costs.” 2 

  • HealthRules® Payer is HealthEdge’s next-generation core administrative processing system (CAPS) that enables transformational outcomes and business agility for all types and sizes of health plans. Recognized as a Best in KLAS CAPS for the third year in a row, the platform helps payers unlock new efficiencies through a combination of modern technology and highly flexible solutions that support real-time automation of business processes, such as claims adjudication, enrollment, and billing. In addition, HealthRules Payer automates many of the workflows associated with rapidly emerging regulatory requirements and seamlessly integrates with other HealthEdge solutions through productized integrations like Payer-Source and Care-Payer, for improved transparency and interoperability. When it comes to contract modeling, the system allows health plans to easily configure and manage a wide range of contract types, including value-based care arrangements, bundled payments, and traditional fee-for-service contacts – for all lines of business in one system. 
  • GuidingCare® offers comprehensive solution that bridges the gap between payer capabilities and member expectations by facilitating more personalized member engagement. The platform achieves this through a set of integrated solutions, including Population Health, Utilization Management, Appeals & Grievances, Authorization Portal, and Business Analytics. In addition, GuidingCare provides a robust set of tools that support the unique requirements and complexities of many different state Medicaid programs. GuidingCare also integrates seamlessly with HealthEdge’s HealthRules Payer (Care-Payer) to give utilization management staff and care managers seamless access to real-time benefits information.  
  • Wellframe™ digital care management solutions offer care team members the ability to seamlessly connect with members through multiple channels to reduce inpatient admissions by an average of 17% and increase preventative medicine utilization by an average of 29%. Integrated with GuidingCare (Care-Wellframe) or used as a standalone application, the system delivers a framework for engaging members of target populations to help them get access to the support they need outside of traditional care delivery settings. Wellframe also supports self-service digital resources that empower members to proactively reach their health and wellness goals. With Care-Wellframe, care managers can work seamlessly within both systems to gain greater visibility into member benefit plans and utilization while also offering a closed-loop referral process for social care services. With greater member engagement, member satisfaction rates and outcomes increase while operating costs decrease.  

Looking Ahead 

When a series of integrated digital payer solutions, like those offered by HealthEdge, are in place, payers are able to achieve new levels of operational efficiencies and minimize administrative burdens of working with many different software vendors. These efficiencies relieve some of the pressure on payers so they can focus more on providing high-quality care and services to their members and develop collaborative relationships with their provider networks.  

Sources: 1 Gartner®, Three Operational Excellence Best Practices to Optimize Costs for U.S. Healthcare Payers, 1 November 2023, Mandi Bishop, 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. 

To learn more ideas on how to navigate the growing pressures on payer operating margins, download this complementary Gartner Report or visit HealthEdge at 

HealthRules Promote Empowers Health Plan Leaders for Agile Growth

Being agile enough to adapt and grow in a competitive market is essential for health plan leaders. This includes enhancing member care through continuous innovation—be it updating validation policies, modifying fee schedules, restructuring benefit plans, or launching new lines of business. But constraints and back-and-forth with IT departments to translate your visionary business concepts into actionable products or services can drain valuable time and energy, hindering your mission.

To address this challenge, HealthEdge developed HealthRules Promote, a revolutionary tool designed to restore power directly into the hands of health plan leaders like you. This platform is a testament to our dedication to disruption, offering a solution that is not only innovative but also empathetic to the hurdles your organization faces. With HealthRules Promote, we’re eliminating the technical barriers, enabling anyone within your organization to create configurations effortlessly.

Transforming Challenges into Opportunities with HealthRules Promote

HealthRules Promote isn’t just about easing the configuration process; it’s a catalyst for significant cost savings and improving efficiency. Medium-sized health plans can save up to $750K per year. Moreover, a health plan managing over 1 million lives was able to configure 81 plans in just 10 days with a four-person team. These figures showcase the profound impact HealthRules Promote can have on your operations and bottom line.

Real-Time Response to Market Needs

In today’s fast-paced healthcare industry, the ability to respond in real-time to new opportunities and market demands is invaluable. HealthRules Promote empowers you to quickly take on new business regardless of complexity, ensuring you’re always a step ahead. This agility is critical—not only for growth, but for sustaining relevance in a competitive landscape.

Streamlining Operations

Automating and streamlining existing lines of business—including Individual & Family, Commercial Group, and Medicare—are at the core of HealthRules Promote. By eliminating costly manual processing, we’re  improving operational efficiency while also enhancing accuracy and reliability. This shift towards automation frees up your resources, allowing you to focus on strategic initiatives that drive member satisfaction and growth.

Elevating Customer Service

At the heart of HealthRules Promote is a commitment to superior customer service. The platform enables your representatives to answer customer queries correctly the first time, fostering trust and loyalty. This level of service excellence is not just beneficial for member satisfaction—it’s a competitive advantage that sets you apart in the healthcare industry.

In a sector where change is the only constant, we understand the challenges health plan leaders face and offer a solution that makes it easier to respond to industry changes. Our vision is clear: to equip you with the tools necessary for agile growth, enabling you to care for your members effectively and efficiently. Let us embark on this transformative journey together, shaping a healthcare ecosystem that thrives on agility, innovation, and uncompromised care.