By Ethan Zhu + Justin Wolkowicz

From Burden to Breakthrough: Tackling Document Chaos with AI

At HealthEdge, our AI-first approach isn’t about abstract promises. It’s about solving real, persistent pain points across the healthcare ecosystem. One of the most pressing? The manual, error-prone world of document processing. Despite the digital transformation sweeping through the industry, faxed and scanned forms still clog workflows and slow down care.

Our AI Team saw this challenge as an opportunity. What began as a targeted experiment in intelligent document recognition has evolved into a powerful, enterprise-grade Optical Character Recognition (OCR) platform that’s transforming how health plans handle prior authorizations and other document-heavy processes.

The Bottleneck: Why Prior Authorization Forms Are So Painful

In healthcare settings, large volumes of documents are still submitted via scanned or faxed pages in non-uniform formats. This creates a significant workload that necessitates manual, error-prone processes for data conversion into standardized formats. Traditional OCR methods can extract text and numbers from images, but they cannot intelligently understand the meaning of the surrounding context of the interesting data.

Prior authorization forms are a prime example. The volume is substantial: our customers process between 50,000 to 100,000 documents each quarter. Each form requires extracting approximately 50 fields from documents with variable layouts, field names, handwritten sections, and non-standardized formats.

The current manual process is inefficient and error-prone. Staff must open a faxed document and must first identify the correct patient. They manually search for member information, but handwritten names often don’t match system records exactly. When the initial search fails, staff must try alternative search methods like member IDs, requiring multiple passes through the fax document to locate the correct identifier.

Once the member is identified, staff manually build the digital prior authorization form, navigating across 10–12 different workflow screens, copying and pasting information, and transcribing handwriting from the fax into various fields. They must cross-reference member eligibility, verify benefit information, check authorization history, and ensure all data points align correctly. This process is time-intensive and introduces errors that can delay patient care or create compliance issues.

The impact extends beyond efficiency. Approximately 45% of processed fax documents are never entered into any digital system and thus will never be used for authorizing a downstream claim. For patient care, this becomes a significant bottleneck as many major care services must wait for authorization before they can be delivered.

Building a Platform for Real-World Complexity

To address this, the HealthEdge AI Team designed a configurable OCR solution that reduces manual workload while maintaining confidence and auditability of results. Our solution is not restricted to processing prior authorization forms. It can be expanded to process a variety of documents, including provider demographics documents, appeals processing, care management documents, and claims-related forms.

Our approach focused on three objectives:

• Eliminate manual data entry through intelligent document processing
• Ensure healthcare compliance with built-in security and audit trails
• Enable rapid deployment across different document types and use cases

The solution classifies documents into categories for targeted processing. For each category, we use specific strategies that deliver better performance and enable the extraction of different field types. This allows us to adapt the solution to new use cases and customer needs.

Our OCR engine is capable of converting fax information into structured JSON data, reducing manual data entry and improving productivity. The field names of the detected output can be easily matched to whatever data model our users need. It handles diverse document formats, including handwritten notes and multilingual content, which traditional OCR systems cannot process effectively.

Most methods are capable of providing confidence scores and bounding boxes for every field, giving users visibility into processing accuracy. The confidence score helps identify fields that may require human verification, and the bounding boxes let the human quickly verify the origin of the extracted information. All extracted data remains editable, ensuring human oversight for sensitive healthcare information. The system never takes automated actions without user approval.

Proven Results: Measurable Workflow Improvements

The transformation from manual to AI-assisted document processing delivers measurable operational improvements:

• The automated workflow eliminates most manual steps through intelligent member-matching algorithms that pre-populate patient information. Relevant data is extracted and highlighted with confidence scores, allowing staff to create authorizations with minimal manual input.
• What previously required extensive searching, copying, and cross-referencing across multiple screens now happens automatically in the background. Organizations can scale from processing 10 fax files per day to over 100 per person through asynchronous, background processing that can handle large volumes of data.
• Healthcare staff can now focus their expertise on authorization decisions and patient care coordination instead of repetitive data entry tasks. This shift improves both job satisfaction and care quality by allowing clinical staff to spend more time on clinical activities. Staff no longer have to struggle with handwritten text interpretation or member identification challenges that previously consumed significant time.
• Comprehensive audit trails can now be easily captured, tracking every user action and decision. This supports HIPAA compliance while providing transparency for healthcare quality assurance and regulatory requirements. Every processing step is documented and attributable to specific users, creating a complete compliance framework without adding administrative burden.

From Experiment to Essential: What Comes Next

This document processing platform is just one example of how HealthEdge’s AI teams are creating tools that not only work but also scale. Built for real-world complexity, with guardrails for compliance and transparency, it embodies our vision: use AI to augment teams, not replace them.

Looking ahead, our focus is on expanding adoption across customers and product lines, integrating across HealthEdge solutions, and continuing to evolve the platform to handle new document types and emerging use cases.

AI-enabled document processing is becoming a viable solution to long-standing inefficiencies, offering health plans a clearer path toward reducing manual effort and administrative error, while enhancing cost savings.

To learn more about our AI strategy, visit our AI blog series on our website.

At HealthEdge, our AI Team was created with a clear mission: to accelerate the innovation and adoption of AI technologies that deliver real value for both our customers and our internal teams. Like any transformative technology initiative, we faced a pivotal question early on: should AI capabilities be decentralized into product teams to maximize speed and innovation, or centralized to establish standards and eliminate redundancy?

The answer wasn’t one-size-fits-all. We chose a hybrid approach, balancing autonomy and alignment, by defining three distinct roles for our AI Team: Enablement, Platform Development, and End-to-End Solutioning. We also developed a simple decision-making framework to determine when and how our team engages in each role. This structure enables us to scale AI effectively, maintain quality, and quickly leverage cutting-edge AI tooling and methodologies across the organization.

• Enablement: In the Enablement role, the AI Team guides stakeholder teams in applying AI technologies. We might suggest no-code solutions such as Claude Desktop in combination with MCP (Model Context Protocol) tools to automate a simple but time-consuming operational process. For a more AI-ready stakeholder team, we might offer architectural guidance on how to set up a multi-agent system using LangGraph with the appropriate handoffs, evaluations, and guardrails.

At HealthEdge, the AI Team plays the Enablement role by providing chat support and regular “office hours” to users in our Claude Pilot Program. We share best practices and reusable templates for concepts such as prompt engineering and context management. We’ve also partnered with HealthEdge’s Learning & Development team to centralize learning resources and present about AI innovations to the entire organization.

• Platform Development: The AI Team’s core contribution is developing a scalable, robust platform of reusable AI components that provide value across the business. This includes core features of a generative AI system, such as multi-agent architectures, tools, and RAG (retrieval augmented generation), as well as supportive functions like logging, traceability, evaluations, and guardrails. It also includes building out common use cases such as information summarization or Q&A. Individual product teams then configure or combine these components to fit their own needs.

For example, the AI Team built the Claims Summarizer platform as a flexible tool that delivers consistent value across different products. Product teams define their own configurations to achieve uniform results despite varying applications. A claims review analyst can use the Claims Summarizer to quickly assess key claim details before adjudication in our flagship HealthRules Payer product. Similarly, a care manager can leverage the tool to understand a member’s medical history in GuidingCare before determining next steps for care.

• End-to-End Solutioning: Occasionally, it is necessary for the AI Team to build a complete end-to-end solution beyond just providing functional components to product teams. This can be mandated for high-priority, complex use cases where AI expertise is required for successful delivery of value. Complexity may entail highly networked multi-agent architectures leveraging a broad range of tools or sensitive outputs, necessitating robust evaluations and guardrails. End-to-end solutioning is also a good opportunity for the AI Team to showcase what is possible with AI technology while simultaneously building out the platform to allow other teams to follow the pattern.

At HealthEdge, the AI Team took ownership of an automated document extraction workflow for prior authorization. This involved using OCR to extract key data fields from various prior authorization forms and leveraging AI to map them to internal elements. The large variety of form templates and the lack of one-to-one mappings of data fields made this complex use case a good candidate for the AI Team to take on end-to-end. The project also had a high business impact, with the potential savings of automating the processing of hundreds of thousands of prior authorization forms annually. Given that errors could lead to increased operational costs and delays in care, the AI Team’s thoughtful architecture and thorough evaluations were critical to its success.

CARBS: AI Team’s Role Decision Framework

Given the high demand for the AI Team’s expertise across a large number of initiatives, it was necessary to develop a framework for determining which of the three roles the team would play for a given project, conveniently fitting the acronym “CARBS”:

• Complexity: how much AI expertise does the project require?
• AI Readiness: how much AI expertise does the stakeholder team have?
• Risk: how sensitive is the output (due to privacy, regulatory, or clinical concerns)?
• Business Impact: how much value does the project bring to the organization?
• Scalability: how reusable is the solution across the organization?

When the CARBS framework is combined with the AI Team’s various roles, we maintain quality and avoid repeated work while scaling our impact to the organization.

Why This Matters

The AI Team is designed to collaborate with, not replace, our domain experts. Domain teams continue to own their products, define user needs, and validate success criteria. The AI Team acts as a multiplier, providing them with tools and infrastructure that they might not otherwise have time or expertise to build themselves.

The AI Team’s approach ensures we can move fast without sacrificing quality, avoid redundant work, and scale innovation efficiently. Whether we’re enabling teams with the right tools, building reusable AI capabilities, or delivering complex solutions, our focus is always on turning AI’s potential into tangible results for HealthEdge and the people we serve. For more information about HealthEdge and our AI strategy, visit our blog series found here on our website.

For many health plans, it’s easy to get stuck in a costly cycle of claims rework: pay a claim, spot an error months later, hire a recovery vendor, then repeat. This reactive approach uses unnecessary resources, impacts provider relationships, and reduces efficiency.

Breaking this cycle requires advanced technology and an open-book approach to payment integrity—focusing on transparency, collaboration, and proactive problem-solving.

Examining the Costs of Fixing Errors After Payment

Let’s look at a common scenario faced by health plans. A patient suffers a ski injury and receives multiple diagnostic imaging procedures for their foot and leg. The provider submits a claim with each procedure listed separately. The health plan pays the full amount for each line item and quickly moves on.

Months later, during a routine post-payment review, the health plan discovers the system didn’t apply the Multiple Procedure Payment Reduction (MPPR) rule. As a result, there’s an overpayment of $295.75 on that single claim. This “small” mistake adds up when multiplied across thousands of claims.

Now, the health plan must hire a recovery vendor to chase down the overpayment. But these vendors typically recoup only 50-60% of lost funds, and charge a percentage fee based on the recovered amount. That means a significant portion of the overpaid amount is never returned to the health plan.

Claims recovery also contributes to increased administrative burden. Health plan teams must verify the vendor’s findings, notify the providers, negotiate repayment, and reprocess claims. Providers, in turn, must spend additional time adjusting claims and appealing disputed recoveries. These negative experiences can result in provider abrasion, potentially reducing provider willingness to work with your health plan and impacting member satisfaction.

On an individual basis, these cases may seem minor. But on a larger scale, repeated errors drain budgets and operational bandwidth. Taking an open-book approach promotes collaboration with providers, increases transparency in claims processing, and reduces the risk of disputes or overpayments.

Enhance Initial Claims Accuracy with HealthEdge Source™

The HealthEdge Source payment integrity solution transforms claims processing by helping stop inaccuracies at their source. Traditional technologies handle claims step-by-step, starting with pricing and then moving to editing. This handoff between steps is where errors often slip through. HealthEdge Source takes a more integrated approach using parallel processing. This means that all claim rules, policy edits, pricing checks, and reimbursement calculations happen in the same step for enhanced control and accuracy.

Let’s revisit the ski injury scenario. With parallel processing, HealthEdge Source reviews the claim, applies MPPR edits, recalculates payments, and adjusts for secondary procedures in real time. If there’s a discrepancy or a potential overpayment, it’s caught before the claim is finalized. Instead of waiting months to uncover mistakes, the plan and provider receive timely, accurate payment information.

The operational benefits are immediate:

• By stopping overpayments before they happen, health plans avoid losing money to errors and recovery vendor fees.
• Internal teams are freed from managing vendor contracts, auditing claims, and reprocessing payments.
• Enhanced accuracy cuts down on disputed claims while fostering provider trust.
• This approach easily adapts to growing claim volumes and regulatory changes, future-proofing payment operations.

Access Real-Time Claims Editing

Healthcare is getting more complex. Errors will only grow costlier if left unchecked. Stopping them before they start saves money, frees resources, and puts you ahead of regulatory changes.

An open-book strategy encourages cost and pricing transparency to help eliminate unnecessary spending. By adopting an open-book approach to payment integrity with advanced technology like HealthEdge Source, health plans can stop overpayments, improve transparency, and strengthen provider relationships. This allows teams to focus on member satisfaction and growth instead of backtracking. Break the pay-and-chase cycle and make integrity the standard for your team.

“If people change the way they think about payment integrity, it will start to inspire people to work on improving the system.” – Ryan Mooney, HealthEdge Chief Product Officer]

Discover how Platform Access from HealthEdge Source makes it possible for health plans to gain more control of the claim process and streamline edit configurations to save time and reduce hassle. Watch the webinar on-demand: Edit Smart Not Harder with HealthEdge Source™

Extensive legislative reform is shifting the healthcare landscape. The One Big Beautiful Bill Act (OBBBA) introduces significant changes to eligibility requirements across Medicaid, Medicare, and Affordable Care Act (ACA) plans. For health plans, this means navigating a new era of regulatory complexity, operational disruption, and member retention risk.

But with the right partner, health plans can not only adapt but stay ahead of the curve while better serving their members.

Medicaid Retention in the Spotlight

Among the most urgent challenges posed by OBBBA is the tightening of Medicaid eligibility. The legislation mandates:

• Six-month redetermination cycles replacing annual reviews
• Stricter definitions of citizenship and immigration status
• Mandatory community engagement or work requirements for certain populations

These changes are projected to result in 11.8 million people losing coverage by 2034, with Medicaid members being disproportionately affected. For health plans, this translates into increased membership churn, administrative burden, and the potential erosion of trust among vulnerable populations.

Health plans must now plan to retain members at risk of losing coverage. That means proactive outreach, real-time eligibility management, enhanced care coordination, and seamless integration with state systems.

HealthEdge®: A Partner Built for the Future of Healthcare

HealthEdge offers a connected ecosystem of solutions purpose-built to help health plans navigate OBBBA’s regulatory shifts and retain Medicaid members with:

Real-Time Eligibility Management

With HealthEdge HealthRules® Payer, plans can:

• Anticipate and adapt to eligibility changes before they impact operations
• Validate member data in real time
• Seamlessly integrate with state Medicaid systems to reduce delays and errors

Advanced Payment Integrity

HealthEdge Source™ allows:

• Nimble contract configuration to manage business rules
• Enterprise-wide custom claim edits to help address complex policy rules
• Integrated data across systems and applied AI across claims, enrollment, and care workflows

Scalable, Unified Source of Truth for Provider Data

HealthEdge Provider Data Management supports:

• Accurate, real-time provider information to streamline workflows
• Improved outcomes and reduced costs

Whole-Person Care Coordination

HealthEdge GuidingCare® enables:

• Streamlined workflows across institutional, community, and home-based services
• Advanced automation and real-time data to manage high-risk populations
• Support for whole-person care that helps improve outcomes and reduce costs

Digital Outreach and Engagement

HealthEdge Wellframe™  empowers plans to:

• Reach hard-to-engage Medicaid populations with mobile-first tools
• Deliver personalized, timely communication during redetermination cycles
• Build trust and help improve member satisfaction

Future Proofing Starts Now

OBBBA is not just a compliance challenge, it’s a call to transform how health plans operate. The pace and unpredictability of regulatory change demands agility, foresight, and the right technology partner.

HealthEdge’s suite of integrated solutions empowers health plans to stay compliant while retaining members, improving outcomes, and protecting revenue.

Learn more about what matters most to Medicaid and Dual-Eligible members, and how your health plan can meet them where they are. Watch the webinar on-demand: Understanding Your Medicaid and Dual-Eligible Members as Consumers – What Matters Most Today.

Ready to navigate regulatory change with confidence? Partner with HealthEdge and stay ahead of whatever comes next.

The One Big Beautiful Bill Act (OBBBA) is reshaping healthcare, especially for Medicaid and Medicare plans. With tighter budgets, closer oversight, and an emphasis on population health in rural communities, care management is entering a new era. For health plans, the message is clear: adapt quickly or risk falling behind.

The New Reality for Care Management

OBBBA is bringing big changes that demand smarter, more flexible strategies. Medicaid cuts mean plans must deliver more with fewer resources, making efficiency and measurable outcomes essential. Regulators are also raising the bar. The Centers for Medicare and Medicaid Services (CMS) and state audits are increasing, especially around risk adjustment and overpayments, so accurate documentation and strong data practices are more important than ever.

At the same time, $50 billion in new funding for rural health creates opportunities to expand digital care and engagement strategies that close long-standing gaps in access.

How Health Plans Can Prepare

To succeed under OBBBA, health plans will need to rethink how they connect with members, strengthen operations, and adapt to ongoing change. Health plans now must focus on reimagining member engagement, improving population health, leveraging AI, and remaining agile to comply with new regulations.

Reimagine Member Engagement Through Digital Tools

Members increasingly expect to connect digitally with their health plan. A recent HealthEdge survey found that 78% of all health plan members and 81% of Medicaid members are open to, or already using, their plan’s mobile app. User-friendly channels improve accessibility and health literacy, giving members the support they need anytime and anywhere.

When healthcare experiences are personalized and intuitive, members are more likely to feel satisfied, stay engaged, and remain loyal over time. For underserved groups in particular, digital-first outreach can be the difference between receiving the care they need and going without it. Digital-first solutions are more than convenient, they extend care team capacity, reduce administrative burden, and make it easier to engage and retain hard-to-reach populations, particularly in rural areas.

Focus on Population Health Outcomes

The focus on “health equity” may have shifted back to “population health” but the goal is the same: address nonmedical drivers of health while meeting regulatory expectations. Doing so not only helps members, but it also controls costs and improves quality scores.

Health plans should look to advanced risk assessment tools and care gap analytics to help identify rising-risk members earlier, so they can intervene before problems escalate. Flexibility is also key, as integrating both built-in and external tools allows plans to tailor strategies to their populations. Done well, these approaches support better outcomes across measures like Medical Loss Ratio, Star Ratings, HEDIS, and quality improvement programs.

Leverage AI Tools and Optimize IT Resources

AI-driven tools have become essential for modern care management. These AI tools streamline workflows, surface actionable insights, and help care teams make faster, better decisions. Beyond efficiency, AI provides intelligence that makes it easier for care managers to quickly understand a member’s history, coordinate care, and take timely action. This can result in lower costs and a more personalized, connected experience for members.

There is also an IT efficiency opportunity for health plans. Many health plans juggle disparate tools that do not work well together, creating internal data silos and inefficiencies. Consolidating these into an integrated digital ecosystem reduces complexity, improves data sharing, and makes scaling easier. When care teams have seamless systems, they spend less time troubleshooting and more time supporting members. This kind of IT optimization not only strengthens operations but also ensures digital transformation delivers real results.

Stay Agile with Regulatory Changes

OBBBA is set to adjust regulations on a rolling basis and differ by state, so health plans need to be nimble. Running “what-if” scenarios and adjusting benefits or eligibility structures on the fly is now table stakes.

Plans that can adapt quickly will avoid compliance headaches while staying ahead of the curve as regulations continue to evolve. Agility is a competitive advantage now more than ever.

Using the OBBA as a Catalyst for Change

The One Big Beautiful Bill is not just another piece of legislation—it is a catalyst for health plan transformation. Health plans that embrace digital-first engagement, focus on outcomes, harness AI, optimize IT ecosystems, and remain nimble with regulations will be best positioned to succeed. It goes beyond compliance to delivering better outcomes for members while controlling costs.

Solutions like HealthEdge GuidingCare®, HealthEdge Wellframe™, and the broader HealthEdge solution suite tackle these care management challenges head on to give health plans a competitive advantage. By consolidating technology, streamlining care management, and enabling smarter engagement, these platforms provide the foundation for meeting today’s challenges while preparing for what comes next.

Want to learn more about how HealthEdge solutions can help payers consolidate and enhance care management? Read the case study, “How a Regional Health Plan Unified Care Management with HealthEdge.”

Healthcare payers are under increasing pressure to integrate and unify digital solutions so they can streamline workflows and improve operational efficiency. With the passing of the Interoperability and Prior Authorization Final Rule (CMS-0057-F) from The Centers for Medicare and Medicaid Services (CMS) in 2024, modernizing prior authorization practices became an area of strategic focus for many health plans.

Enhancing prior authorization better enables payers to deliver timely, evidence-based care while reducing administrative burdens. Many health plans have already announced their efforts to “streamline, simplify and reduce prior authorization” in favor of accelerated decision-making, improved transparency, and expanded access to affordable care.

Why Modernizing Prior Authorization Matters to Health Plans

Modernizing prior authorization processes is essential to maintaining high-quality and effective care delivery without unexpected costs to payers, providers, or members. Traditional processes often lead to delays, inefficiencies, and frustration for both patients and providers.

Adopting an advanced and integrated prior authorization workflow can enable your health plan to:

• Deliver More Timely, Relevant Care: Patients need timely access to diagnostics, treatments, and non-clinical services. Streamlined prior authorization processes can reduce delays so members can get the care they need when they need it and avoid complications down the line.
• Reduce Administrative Burdens: Providers spend countless hours navigating manual prior authorization workflows, detracting from time spent on patient care. Automating routine authorizations can help significantly reduce this burden.
• Enhance Pricing Transparency: Modernized prior authorization processes can provide the clear, consistent information patients and providers need to make more informed decisions about care access and delivery.
• Improve Member Outcomes: Advanced digital solutions can analyze member information and flag high-risk members for intervention, helping improve clinical outcomes.

How HealthEdge GuidingCare® Supports Payers in Modernizing Prior Authorizations

At HealthEdge®, we’re proud to support health plans in transforming their prior authorization processes. HealthEdge GuidingCare® is a comprehensive care management workflow solution designed to give payers the insights they need to accelerate approvals and increase provider satisfaction.

By leveraging the Utilization Management module within the GuidingCare solution, health plans can achieve goals such as:

• Seamless Automation: GuidingCare automates prior authorization workflows, reducing manual data entry and streamlining approvals. This allows providers to focus on delivering care rather than navigating administrative hurdles.
• Real-Time Decision-Making: With advanced AI-driven and FHIR®-native APIs, GuidingCare enables real-time data sharing and faster decision-making, helping ensure patients receive necessary care without unnecessary delays.
• Regulatory Compliance: With robust data security measures and compliance with CMS and NCQA standards, GuidingCare helps health plans meet regulatory requirements with confidence.
• Enhanced Communication: The platform provides clear, actionable insights into prior authorization determinations, making the process more transparent and easier to navigate for payers and providers.
• Continuity of Care: GuidingCare facilitates seamless transitions for members by maintaining prior authorization records and supporting uninterrupted care.

GuidingCare®: Your Partner in Prior Authorization Transformation

At HealthEdge, we’re dedicated to helping health plans navigate the complexities of prior authorization and care management. GuidingCare is more than a platform—it’s a strategic partner that empowers health plans to achieve their goals and deliver better outcomes for their members.

“We now have the data that shows us by service how many prior authorizations are coming in, how many are we approving, how many are we denying, and what they cost,” said the Vice President of Care and Utilization Management at Priority Health. “We can make educated decisions on the value of asking for that prior authorization, and if there’s no value in it, then why are we asking physicians to jump through them?”

Read the full case study to discover how Priority Health worked with GuidingCare to achieve a preauthorization rate of 80%.