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At a recent roundtable, the HealthEdge® Chief Medical Officer led executives from three leading health plans in a discussion centered around optimizing care delivery and efficacy while improving cost control and payer performance.

Panelists included:

• Chief Medical Officer at a member-owned health insurance company based in Illinois
• President at a Washington D.C.-based health plan focused on children and young adults receiving Supplemental Security Income (SSI)
• Department Vice President and Medical Director of Population Health at a not-for-profit health plan based in Kansas

1. Putting Members at the Center of Care Delivery

Department Vice President and Medical Director of Population Health: We see a unique opportunity to reposition ourselves and rearticulate the value of enabling and coordinating care to serve members well. First, we concentrate on clinical improvements. Second, we prioritize the member experience.

The healthcare ecosystem is inherently complex, and our role is to guide members through their journeys. We dedicate significant resources to high-cost claimants, as 1-2% of members can account for 30-50% of a plan’s total spend. We lead high-cost claimant rounds to review claims experiences, where a simple question like “How is the member doing?” shifts the focus from data points back to the individual.

This proactive outreach often provides the first indication of an upcoming issue that claims data would not show for another six months. It allows for more effective care coordination and fosters an empathy-driven mindset, ensuring we never lose sight of the people we serve.

In terms of outcomes, our care management programs achieve satisfaction scores in the mid-to-high 90s. As an organization, we prioritize the ease of doing business with our health plan, and we are outperforming market benchmarks. Most importantly, we translate these insights into actionable opportunities for our provider partners through value-based agreements and other relevant structures.

2. Driving Value-Based Reimbursement

Health Plan President: The journey to value-based reimbursement is unique in the pediatric space. Pediatric providers typically don’t take Medicare, so they have been mostly insulated from payment innovations. Our first obstacle was incentivizing them to even discuss alternative payment models.

We learned that value-based reimbursement starts with an engaged workforce within our health plan. Our first step was to define what we wanted to accomplish as an organization and how we would partner with providers to achieve it.

We used three strategies to achieve our goal:

1. Breaking Down Internal Data Silos: We used the HealthEdge GuidingCare® platform to bring Utilization Management, Care Management, and Appeals and Grievances into one integrated system. This provides our care managers with a 360-degree view of their members, including complaints, legal settlements, and care gaps. We then expanded access to our marketing, outreach, and customer service teams.
2. Embedding Care Managers: As our care management staff gained a complete view of the member, we embedded them in provider offices. This creates an interdependent relationship where providers and care managers can align their goals.
3. Leveraging Shared Data: We established a shared population health platform with our largest national provider. We don’t need to question each other’s data because we all see the same information. This allows us to focus on our mutual goals, which are set jointly through a shared governance model and reviewed monthly to ensure they remain accurate.

3. Strengthening Payer and Provider Collaboration

Chief Medical Officer: We also leverage GuidingCare as a unified platform for medical management and population health. One key function is allowing providers with a treating relationship to view a member’s care plan. This facilitates co-management and presents a coordinated care approach to the member.

Our collaborative efforts focus on two areas: Data transparency and value-based contracting.

• Data Transparency is essential for building strong and effective collaboration. We use Admission, Discharge, Transfer (ADT) feeds, health data exchanges, and other platforms to ensure transparent data flow between the payer and provider.
• Value-based contracting is a tool to align cost and quality metrics between providers and payers. We incentivize providers to support work that ultimately serves the person, whether we call them a member or a patient. Through Joint Operating Committees, we review leading indicators monthly to identify and address unfavorable trends early on.

We’ve learned two crucial lessons:

1. We must agree on what success looks like through a conversation with the provider, ensuring measures are relevant, reliable, and impactable.
2. We must structure contracts based on provider type, setting, population served, and their comfort level with accepting risk. Not everyone is ready for a full-risk contract. We guide them along the alternative payment model spectrum, from foundational steps to shared savings and losses, and eventually to full-risk contracts.

By applying these lessons and interventions, we’ve seen increased interest in higher-risk models, with providers more willing to take on these contracts because they feel equipped with the right tools and resources to succeed.

4. Utilizing Digital Tools for Care Management

Department Vice President and Medical Director of Population Health: Our historical data showed that telephonic care management engagement rates were dwindling, so we invested in HealthEdge Wellframe™ and GuidingCare as our digital care management front door. It turns out that many members would rather text than talk.

In 2025, 32% of our meaningfully engaged members have engaged digitally. That represents a significant missed opportunity had we not adopted a digital tool. When comparing engagement in care management programs this year to the same period last year, we are up 23%. This shows that if we are truly member-centric, we must meet members where they are and offer multiple engagement preferences.

To achieve this, we are reimagining member engagement by integrating digital tools with our community health worker program. This approach takes care directly to the community, enabling us to drive better population health outcomes.

5. Personalizing Care Plans for High-Risk Members

Health Plan President: Delivering personalized care hinges on strong care management relationships, which can be challenging with healthcare workforce turnover between 20-25%. To address this, we created care management pods, assigning a team (with nurses, social workers, and community support workers) to each enrollee’s medical home, ensuring continuity despite staff changes.

This relationship also impacts technology adoption. When we first implemented Wellframe, member adoption was low. This stemmed from care managers not embracing the tool due to productivity concerns. For complex populations, a primary care physician isn’t always the medical home—much of their care comes from specialty practices. Our model focuses on collaboration between the specialty medical home and the primary care medical home, with the care manager acting as the “glue” that directs traffic and brings everyone together.

True integrated care means ensuring smooth care transitions for members across different settings.

6. Closing Gaps in Care with Real-Time Data & Analytics

Department Vice President and Medical Director of Population Health: We have a lot of data, but the key is filtering through it to find actionable opportunities. One project we worked on was a multi-modality gap-in-care program using Healthcare Effectiveness Data and Information Set (HEDIS) methodology. We would trigger communications to members when they had an open care gap.

One leader at our organization went a step further and weighed the different gaps, so if a member had multiple gaps, we knew which one to prioritize in our communication. We pushed these notifications out through multiple channels: our mobile app, our care management app, and our customer service reps, who had scripts ready.

We also discovered that while members don’t open a lot of their mail, they almost always open their Explanation of Benefits (EOB). We started putting care gap notifications directly on the EOB, along with a QR code for our Wellframe app, and it’s been amazing to see how many people have used it to take a more active role in their care.

Over the past year, this pilot closed thousands of care gaps, with a success rate of over 50% for directly engaged members. Most importantly, these insights are helping drive population health outcomes collaboratively with providers.

Innovative Solutions for the Future of Care Delivery

Addressing challenges like care coordination, cost control, and provider collaboration requires innovative solutions that prioritize transparency and seamless workflows.

By focusing on enhanced member engagement and proactive care delivery, payers can help create a system that delivers better outcomes for members, reduces costs, and improves satisfaction.

Want to learn more about how health plans are leveraging digital solutions to improve data accuracy, transparency, and efficiency? Access insights from a payer executive roundtable in our recent article, “Unlocking the Future of Healthcare Technology: Interoperability, Transparency, and AI.”

Payment integrity has always played a critical role in payer operations, but in 2026, it has become a strategic imperative.

According to the HealthEdge® 2026 Annual Payer Survey, health plan leaders are navigating unprecedented pressure to control costs, manage regulatory complexity, modernize legacy systems, and improve collaboration with providers—all at the same time. Managing costs remains the number-one challenge for payers, while investments in automation, AI, and real-time data continue to accelerate.

Against this backdrop, payment integrity is evolving. No longer confined to post-pay recovery, it is becoming an enterprise-wide discipline focused on prevention, transparency, and measurable outcomes across the payment lifecycle.

Here are seven payment integrity trends shaping how health plans are preparing for 2026 and beyond.

1. Forecasting Capabilities Accelerate Confident Action

Speed matters, but confidence matters just as much.

Health plans increasingly want the ability to test changes before enforcing them. The Modeling feature within HealthEdge Source™ allows teams to model the financial and operational impact of new edits, policy updates, or regulatory changes before those changes go live.

This capability supports faster decision-making, reduces unintended consequences, and empowers payment integrity teams to respond quickly as business needs evolve.

HealthEdge Source in Action:

In a recent HealthEdge Source case study, a regional health plan used Modeling to preemptively gauge the impact of new payment edits before enforcement—allowing the organization to move quickly while avoiding downstream disruption to providers and operations.

2. Transparency Becomes the Foundation of Effective Payment Integrity

Health plans are moving away from opaque, single-direction approaches to payment integrity. Instead, they are prioritizing transparency, both internally and externally, as a way to reduce friction, improve accuracy, and build trust.

Modern payment integrity programs increasingly rely on:

• Software that explains how informational edits impact a claim
• Early alerts that surface potential issues before payment
• Provider-facing education tools that reduce disputes and rework

When payment decisions are clear and explainable, health plans can enforce accuracy while maintaining productive provider relationships—turning payment integrity into a collaborative process rather than a reactive one.

HealthEdge Source in Action:

In a HealthEdge Source case study, SummaCare used informational edits and early alerts to proactively communicate payment policy changes to providers. The result was a measurable reduction in provider inquiries and disputes, demonstrating how transparency can improve payment accuracy and provider relationships.

3. Cost Avoidance Takes Priority Over Post-Pay Recovery

In 2026, prevention is the new performance benchmark.

Health plans are shifting away from “pay-and-chase” models toward prospective payment accuracy, where errors are identified and addressed before dollars leave the door. This approach improves financial outcomes, reduces administrative burden, and accelerates claims throughput.

By embedding payment integrity earlier in the claims lifecycle, plans can:

• Minimize downstream rework
• Enhance transparency
• Improve overall administrative loss ratio (ALR)

HealthEdge Source in Action:

A large Southeast health plan featured in a Source case study shifted its payment integrity strategy upstream by enforcing prospective edits before claims were paid. By reducing reliance on post-pay recovery, the plan lowered administrative overhead and improved overall cost avoidance, supporting better ALR performance while accelerating claims processing.

4. Real-Time Data Enables Faster, Smarter Enforcement

Payment integrity is only as effective as the data behind it.

Health plans continue to struggle with fragmented systems and delayed insights, which limit their ability to act quickly. This is especially relevant for payers facing an increase in claims rework. AI-powered tools within payment integrity platforms can help payers meet the real-time claims volume and prevent their teams from being overburdened.

Modern payment integrity platforms must operate within a connected ecosystem, bringing together claims, contracts, eligibility, and provider data to enable faster enforcement and better outcomes at scale.

5. AI Moves from Detection to Decision Support

Artificial intelligence has been used in the background of payment integrity processes for years—and now it’s taking the spotlight as a foundational tool.

The HealthEdge report, “Elevating Payment Integrity: The Role of AI in Enhancing Payment Accuracy,” outlines how AI is transforming payment integrity from manual, rules-heavy processes into adaptive, intelligence-driven workflows. AI is now being used to:

• Identify complex patterns that traditional rules miss
• Prioritize high-risk claims and edits
• Continuously learn from outcomes to improve accuracy over time

Rather than replacing human expertise, AI augments it, helping payment integrity teams focus on the highest-impact decisions while improving consistency, speed, and precision.

HealthEdge Source in Action:

HealthEdge Source case studies show how combining machine learning with configurable edits helps health plans prioritize high-risk claims, reduce manual reviews, and continuously improve payment accuracy as business conditions change.

6. BPaaS Emerges as a Scalable Operating Model

As cost pressures intensify, health plans are rethinking not just what they do in payment integrity, but how the work gets done.

Business Process as a Service (BPaaS) is gaining traction as a way to combine technology, automation, and expertise into a single, outcomes-focused model. In payment integrity, this approach helps plans scale programs, respond faster to regulatory and policy changes, and reduce administrative burden without adding headcount.

What’s different in 2026 is the level of integration. Health plans have the opportunity to embed BPaaS directly into core claims and payment workflows. Deeper integration between claims administration and payment integrity platforms allows for plans to decrease overlapping work between claims and payment integrity teams. This type of integration enables unified configuration, streamlined claims review, and faster enforcement that helps reduce duplication, training complexity, and total cost of ownership.

HealthEdge Source in Action:

Through deep integration with solutions like HealthRules® Payer and HealthEdge Source, BPaaS can help ensure payment integrity workflows are increasingly unified, from configuration through claims review, allowing teams to act faster, reduce manual effort, and scale payment integrity operations without disrupting core claims processes.

7. Payment Integrity Becomes an Enterprise Trust Builder

Ultimately, payment integrity is no longer just about dollars. It’s about trust.

Accurate, transparent, and timely payments reduce friction with providers, support regulatory compliance, and reinforce confidence across the organization. When payment integrity programs are aligned with enterprise goals, they become a driver of operational excellence rather than a source of disruption.

In 2026, leading health plans are plans are focused now, more than ever, on network adequacy and building strong provider relationships—and payment integrity can help.

Looking Ahead: Turning Payment Integrity into Competitive Advantage

As health plans navigate rising costs and increasing complexity, payment integrity is central to the solution. The most successful organizations will be those that move beyond siloed tools and embrace a connected, intelligence-driven approach, prioritizing transparency, prevention, and measurable outcomes.

HealthEdge Source is designed to support this evolution, helping health plans improve payment accuracy, reduce administrative burden, and act with confidence as conditions change.

Want to learn more about the opportunities for AI within payment integrity? Download our whitepaper: Elevating Payment Integrity – The Role of AI in Enhancing Payment Accuracy.

 

At HealthEdge®, we strive to understand the key challenges health plans face so we can help anticipate and address new market opportunities. Recently, HealthEdge Chief Strategy Officer, Raj Sundar, and Chief Product Officer, Ryan Mooney, led a panel of healthcare leaders to discuss a critical issue: managing mounting cost pressures.  

Panelists included: 

• Vice President of Operations at a Minnesota-based health plan 

• Senior Vice President of Operations at a regional Pennsylvania-based nonprofit healthcare company 

• Chief Performance Officer at an Arizona-based health plan 

Hear directly from health plan leaders as they share strategies for addressing cost pressures and driving operational efficiency by focusing on provider collaboration, artificial intelligence (AI), and integrating digital solutions. 

How is your health plan reducing administrative costs without compromising quality? 

Vice President of Operations: One effective strategy is to implement upfront code editing in collaboration with providers. By introducing edits at the point of claim submission, invalid diagnosis codes and similar errors are addressed before entering the system.  

This approach minimizes unnecessary claim processing, reduces resubmissions, and allows for more timely corrections. Although some providers may require time to adapt to electronic data interchange (EDI) rejections, this method has significantly improved operational efficiency. 

We also rely heavily on prepayable reports. After a claim completes its adjudication cycle but before it’s paid, we run analytics to identify potential errors. This is far more efficient than running reports after payment to process adjustments. Moving this analysis upfront prevents incorrect payments and eliminates the rework associated with them. We’re now starting to measure our rework rate to find additional opportunities to remove these inefficiencies from the system. 

Senior Vice President of Operations: We’re a Dual Eligible Special Needs Plan (D-SNP), and when we think about reducing administrative costs while maintaining the member experience, our top two member call reasons are requests for a physical ID card and a printed provider directory. So, how do we automate that? We’ve implemented a system where members can call, push a button, and have an ID card mailed to them without speaking to an agent. Similarly, they can request a provider directory for their specific zip code. This automation has significantly reduced call volume, which is a great way to lower administrative costs in the call center and maintain a positive member experience. 

“Within 6 months of introducing two-way messaging, average handle times dropped by 35%.” – Chief Performance Officer at an Arizona-based health plan 

 How have you improved member and provider service channels to drive efficiency? 

Chief Performance Officer: In April 2025, the primary service channel for both members and providers was phone-based support. Within 6 months of introducing two-way messaging between care teams and members, operational efficiencies increased significantly: Average handle times dropped by 35% in the member call center and by about 40% in the provider call center.  

Many provider inquiries focused on claim status, so resources have been dedicated to developing a digital ecosystem that enables self-service and real-time access to essential information. This digital transformation not only accelerates response times but also empowers users with direct access to the tools and data they need. 

The Role of Value-Based Care and Provider Collaboration 

What early successes can you share about bridging collaboration with providers? 

Chief Performance Officer: For value-based care (VBC) to succeed, providers and payers must work together. Success depends on establishing clear key performance indicators, tracking them regularly, and showing members the benefits of this payment model. We’ve seen per-member-per-month (PMPM) costs decrease with VBC providers compared to those not in VBC arrangements. Key metrics we monitor include primary care provider visits versus emergency room visits and PMPM rates for both medical and pharmacy, with weekly data exchanges that help ensure alignment and progress. 

With more members aging into Medicare Advantage who want digital tools for self-care, this collaborative focus is essential. We have an entire team organized around VBC to manage our Medicare Advantage population, and this collaboration helped us achieve a 4.5-star rating. It’s about giving providers the information they need and getting beneficial information from them in return. 

Leveraging Technology for Greater Efficiency 

What are some of the specific technologies you’re using that are really working to drive costs down? 

Senior Vice President of Operations: The first thing that comes to mind is Robotic Process Automation (RPA). Our third-largest call driver is members needing to change an address or phone number, so we use RPA for data-entry-heavy processes like claims and enrollment.  We also use RPA in credentialing, from information gathering to loading data into our system. This has been incredibly efficient, allowing us to launch in two new states without hiring additional staff to manage provider data. 

Beyond RPA, machine learning is powerful for population health activities. When it comes to AI integration, we recently implemented a solution to analyze cost drivers. With Medical Loss Ratios increasing significantly, we need data quickly. Now, we can ask our AI tools a simple question like, “How many childbirth claims did I have this year?” and get an accurate answer in seconds. These tools help us jump into trends and solve for cost drivers rapidly. We’ve also used large language models (LLMs) to write policies for new markets, which has phenomenally reduced the time it takes to stand up operations. 

Chief Performance Officer: We’ve dipped our toe into summarizing calls in our call center and have seen that help us significantly. Our organization has a pillar focused on AI for the next year, as it will be a huge driver for automation and efficiency. We’ve gone to all of our vendor partners to see their AI roadmaps and where they are adopting the technology. We saw some great things from HealthEdge with Agentic AI within claims processing that we’re hoping continues to grow and takes us where we need to go. 

“The cleaner your provider data is, the better your go-live will be. We went live in a new state and, two months later, had over 92% auto-adjudication. When you’re paying 92% of claims within 24 hours, you don’t get the phone calls asking about claim status. ” – Senior Vice President of Operations 

Expanding to New Markets While Driving Efficiency 

What was your strategy for expanding into new markets and lines of business? 

Senior Vice President of Operations: Provider data, one hundred percent. The cleaner your provider data is, the better your go-live will be. We went live in a new state and, two months later, had over 92% auto-adjudication. This was possible because we started analyzing provider data and reaching out to providers from day one of the project to understand their billing practices. 

Getting that data pristine across all platforms—clinical, CRM, and claims—is what differentiates the outcome. It means you don’t need to hire temporary staff or additional claims processors for manual work. When you’re paying 92% of claims within 24 hours, you don’t get the phone calls asking about claim status. 

Vice President of Operations: I’d echo that provider data is key. We’re sitting at a 94% auto-adjudication rate, and a lot of that is due to our partnerships with providers. Ensuring we get accurate and timely data as changes occur is critical to preventing logjams in claims processing. 

Chief Performance Officer: Provider data remains a significant challenge for us as we transition from a legacy system that has been in place for over 30 years. We are moving very old legacy provider data systems into new technology and working to resolve data integrity issues that frequently cause claims to fall into workbaskets for manual review. It’s very much an ongoing journey for us. Adding to the complexity, a new state regulation will require us to credential a provider in just 45 days, cutting our timeline in half from the previous 90 days. This change will require significant acceleration in our processes to meet the new requirements, so we’re actively working to address this. 

The Future of Health Plan Efficiency 

Navigating today’s complex health plan landscape requires collaboration, accurate data, and innovative solutions. By leveraging these strategies, organizations can better address challenges and adapt to the evolving needs of the healthcare industry, ensuring more effective and sustainable outcomes for all stakeholders. 

Learn more about how integrated AI tools can help health plans achieve measurable improvements in operational efficiency, care delivery, and member satisfaction. Download the data sheet: Achieve Superior Health Outcomes and Operational Efficiency with AI-Powered Care Solutions. 

When health plans implement new software, upgrade existing platforms, or roll out new features, one factor is key to achieving success is effective testing.`

While testing may not always grab headlines, it plays a foundational role in delivering the reliable, compliant, and high-performing systems that health plans need. Whether you’re launching a claims adjudication engine, enhancing care management workflows, or integrating third-party solutions, testing ensures everything works together as intended, before your teams and members rely on it in the real world.

What is Software Testing for Health Plans?

Software testing for health plans is, at its core, the process of evaluating a system or application to ensure it functions as expected, meets business requirements, and performs reliably and securely. It identifies gaps, defects, or missing requirements before the software reaches production.

In short: testing confirms that your technology delivers on its promises.

Among health plans, that could mean validating that a claim adjudicates correctly, that a member’s eligibility is reflected accurately, or that provider data flows seamlessly across integrated systems.

When Is Software Testing Conducted?

Testing isn’t just a final checkbox before go-live. It is a continuous discipline. At HealthEdge, testing is embedded throughout the software lifecycle:

• During implementation: To ensure the solution is configured to meet a health plan’s unique business needs.
• With each upgrade or enhancement: To verify new functionality works and doesn’t disrupt existing workflows.
• When integrating systems: To validate seamless data exchange across modules and third-party platforms.
• After configuration changes: Even small updates to business rules or workflows require validation.
• During data migrations: To confirm that legacy data is transferred accurately and remains usable.
• Post–go-live: Monitoring and testing continue to safeguard performance and compliance.

Whether it’s a major platform overhaul or a minor update, every change introduces risk, and proper software testing mitigates that risk.

Types of Software Testing: Categories and Levels

To fully appreciate the value of software testing, it’s important to understand both why we test and how much we test. HealthEdge employs a multi-layered testing strategy that includes testing categories and testing levels, each playing a distinct role in validating system quality and performance.

A testing category explains the purpose of the test. Common testing categories include:

• Functional Testing: Verifies that the system performs intended tasks correctly, such as processing a claim or authorizing a service.
• Non-Functional Testing: Assesses how well the system operates under real-world conditions: speed, scalability, reliability, and security.
• Regression Testing: Ensures that new changes haven’t broken existing functionality, especially important during upgrades or patch releases.

A testing level describes the scope of the test being performed or how much is being tested.

Each level of testing increases in scope and complexity. Together, they ensure that everything from individual modules to full workflows is working properly across the system. 

Unit Testing

This is the most granular level of testing, focused on the smallest functional components of an application. A “unit” might be a single module or a specific calculation logic. The purpose of unit testing is to validate that each piece works in isolation, based on its defined business logic.

Why it matters for health plans: Catching and resolving issues early prevents them from escalating into more complex integration problems down the line. For example, ensuring that pricing logic correctly interprets a provider contract before it’s incorporated into the larger claims system.

System Integration Testing (SIT)

SIT tests the interaction between integrated units or modules of a system. Even if each component functions correctly on its own, they may not work together properly. This level ensures that components communicate effectively and behave as expected when combined.

Why it matters for health plans: Think of SIT as validating the handshakes between components of a system, which is critical in healthcare, where disparate modules, such as enrollment and assessments, must work together flawlessly to enable a care manager to create a new care plan.

End-to-End Testing (E2E)

E2E testing simulates real-world workflows from start to finish across all integrated systems and touchpoints. It validates that the entire application behaves correctly in a complete business scenario. For example, a test that starts with a member eligibility check, proceeds to service authorization, moves to a claim submission, and ends with adjudication and payment.

Why it matters for health plans: For health plans, this is a critical step to confirm that the member, provider, and payer experiences align and that data flows without interruption or error across all phases of the business process.

User Acceptance Testing (UAT)

UAT is the final gate before go-live. It’s where real users (business stakeholders, operations staff, or clinicians) test the system in scenarios that reflect actual business operations. Unlike earlier stages, this isn’t about code correctness—it’s about usability, practicality, and business fit.

Why it matters for health plans: UAT confirms that the system supports real business operations as intended, not just technical requirements. For example, business users may validate that benefit accumulators calculate correctly across benefit tiers before go-live.

What Testing Requires: Scenarios, Cases, and Data

Behind every successful testing strategy is a solid foundation of well-defined artifacts: test scenarios, test cases, and test data. These components ensure that testing is not only comprehensive but also replicable, traceable, and tied to real-world use.

• Test Scenarios
• A test scenario describes what is being tested at a high level. It’s typically aligned with a business workflow or functional goal, such as “submitting a healthcare claim” or “checking member eligibility.” Scenarios help ensure that critical business processes are covered.
• Test Cases
• Test cases define how a test scenario will be validated. They include specific steps, input values, and expected outcomes to verify that a function performs correctly. For example, a test case for claim submission may include logging into the portal, entering claim details, and verifying a submission confirmation.
• Test Data
• Test data consists of the input values used during test execution—such as member IDs, policy numbers, claim amounts, or provider credentials. Using realistic, representative data that has been de-identified for privacy is essential for simulating actual conditions and uncovering edge cases or errors.

Together, these testing artifacts help teams validate software behavior, trace issues back to requirements, and demonstrate that systems are ready for production use.

The Value of Software Testing

Ultimately, testing isn’t just about identifying bugs. It’s about delivering confidence. Comprehensive testing minimizes risk and prevents costly disruptions by identifying issues early in the process. It ensures that the system is aligned with business needs, validates critical workflows, supports compliance with industry standards, and safeguards the accuracy of member and provider data. Perhaps most importantly, it builds trust across the organization.

When testing is done right, health plans experience smoother go-lives, faster user adoption, and greater assurance that their technology will perform reliably in real-world scenarios.

Ready to Strengthen Your Testing Strategy?

From implementation to upgrades, the HealthEdge Global Professional Services team brings best-in-class testing frameworks, tools, and expertise to every engagement. Let us help you launch with confidence, upgrade without disruption, and deliver reliable results to your members and providers. Read our case study to learn more: From Bottleneck to Breakthrough — How Health Plans are Automating Prior Authorization with HealthEdge.

Recently, the HealthEdge® Chief Solutions Officer hosted a discussion with four health plan executives to discuss how they’re using advanced, integrated technology solutions to enhance claims processing, enrollment, payment accuracy, and provider data management at their organizations.

Panelists included:

• Vice President (VP) of a New York City-based plan serving low-income members
• Director of Operations Management of a Utah-based health plan
• Director of Vendor Management of a nonprofit health plan serving Medicaid and CHP+ members
• Senior Vice President (SVP) of Health Plan Information Services of a New York-based payer serving Medicare and Medicaid members

For the past 30 years, conversations about core processing have centered on auto-adjudication rates. While this metric is still important for controlling costs, health plan leaders are now expanding their focus to a broader set of operational goals. The rapid pace of change in healthcare requires a more holistic approach to claims management and processing.

Data Architecture that Supports Interoperability

The SVP of Health Plan Information Services noted that interoperability mandates like the Interoperability and Prior Authorization Final Rule (CMS-0057-F) from The Centers for Medicare and Medicaid Services (CMS) drove his organization to adjust its data architecture so both care providers and customer service teams have the data they need to support health plan members.

“55% of our membership is in an Independent Physician Association (IPA),” said the SVP. “We’re trying to measure and grow that number. Utilizing the [HealthEdge Source™] platform to get data and work with those IPAs grow our membership, I think will bring better quality and experience to our members.”

By investing in application programming interface (API) integration tools to connect disparate systems, the plan has already seen significant improvements in its customer service operations. Integrating issue tracking within their CRM with the core system has provided member services teams with greater visibility and created a better call center experience for members.

“We have a number of complicated relationships between entities in our metro area, with complicated risk and financial arrangements,” said the Vice President. “All of that business logic has to exist in a provider data hierarchy that makes sense for us.”

By using APIs and web services to automate inbound information, the plan is successfully reducing turnaround times and lowering costs per transaction. This transition represents a multi-year journey from an inefficient legacy state to a modernized system that is transforming operational efficiency.

Taming the Provider Data Challenge

Provider data management remains a persistent and universal challenge for health plans, according to our panelists. Inaccurate provider data leads to downstream issues like claims and payment errors, which negatively impacts health plan costs as well as provider and member satisfaction.

“Our members experience us the most through our providers,” said the Vice President. “So when we get claims wrong…when we get the check wrong, when we get the directory wrong, our members feel that. Our providers feel it first, our members feel it through them, they see our name on the card and they groan. So it’s really important we improve that experience.”

As a customer of the HealthRules® Payer, HealthEdge Source, and HealthEdge Provider Data Management solutions, the Vice President also emphasized the importance of data transparency.

“Provider data flows through both systems,” he said. “Having that data flow through our ecosystem in a tightly coupled manner is what’s going to drive higher quality—and that’s what we really need at the end of the day.”

The Director of Operations Management also shared his experience navigating regulatory hurdles, as the payer’s state contract requires written approval for any AI application using state data. To address this, the organization established an AI governance committee and internal policies to streamline compliance.

“Now that we have the [HealthEdge® Provider Data Management] platform, we can do everything we wanted to do,” said the Director of Operations Management. “We can take data from every different source, we can give them APIs that say, ‘this is how you can give us the data we need.’ We can have that data governance to say, ‘this is what we keep, this is what we have to have, this is how we have to have it to make the data auditable.’”

The Strategic Role of AI and Automation

The conversation around AI is evolving from a data-centric view to a focus on automation and efficiency.

“What we’re focusing on right now is turnaround time on issue resolution and data exchange—when we take data in, how quickly can we get it processed?” said the Director of Operations Management. “We had so much manual functionality from enrollment to authorizations, and the question now is ‘How do we automate that?’”

Similarly, another panelist emphasized the abilities of AI-powered tools that give more time back to the humans in charge of payer operations.

“We’re planning to use AI and agentic AI to help bolster our quality overall,” said the Vice President, “and free up our FTEs to focus on more skilled, necessary activities and decision-making to keep things up-to-date. There’s a lot of advancement there, and it’s really exciting.”

But adopting AI solutions can be challenging for many health plans. For the Director of Vendor Management, strict state guidelines hinder the payer’s ability to leverage AI-powered tools. The health plan sought to leverage an AI solution to automate note-taking for conversations between interdisciplinary care teams—but it took six months to get approval, delaying their abilities to hold engaged conversations without breaking focus. Ultimately, this challenge led the payer to form its own AI governance procedures and trainings to try and innovate internally while staying in adherence with state regulations.

Integrating the Digital Health Ecosystem

The forward-thinking strategies shared by these leaders emphasize the importance of innovation and a proactive approach to addressing the evolving landscape of healthcare. By using automation, advanced data management and enhanced architecture, health plans can stay flexible while navigating regulatory demands and industry pressures. These insights show that collaboration and adaptability are key to driving meaningful change in healthcare.

“We’ve got 30 years of legacy systems on an antiquated core platform that had band-aid after band-aid built upon it, and that’s not a sustainable model,” said the Vice President. “So going to the HealthEdge ecosystem is a strategic move for us to bring our data assets closer together.”

Discover how the Public Employees Health Program (PEHP) leveraged the integrated HealthEdge Provider Data Management solution to improve data matching, regulatory compliance, and operation efficiency. Read the case study: Provider Data Management Enhances Value of Data and Employees Alike.

Health plans are racing ahead with artificial intelligence (AI). Members are moving more cautiously. In 2026, the question is no longer whether AI will shape healthcare. It’s whether payers and members are aligned on how it should.

According to the 2026 Healthcare Payer Survey Report from HealthEdge®, 94% of payers are either live with or actively adopting AI, and nearly half (47%) report widespread or departmental use. But as adoption accelerates inside health plans, a critical question emerges:

Are members ready for the AI-powered experiences payers are building?

And more importantly, what will it take for health plans to succeed with AI in 2026 and beyond?

Where the Industry Stands: AI Is Moving Fast

The survey data makes one thing clear: AI momentum is strong among healthcare leaders.

• 47% of executives reported widespread or departmental use.
• Mid-size payers (supporting 2-10M lives) are 30% more likely than their peers to report widespread adoption of AI.
• Executive leaders report the highest confidence in AI maturity, with 31% claiming widespread adoption of AI vs. only 3% of operational and regulatory leaders.

 

Health plans are not just using AI to improve internal efficiency—they are applying it to member-facing experiences. Member engagement is tied with claims processing for the highest reported use of AI, signaling that personalization and digital interaction are central to payer strategy. Yet adoption alone does not define readiness.

Where Is AI Being Applied Most Often?

AI Adoption Is Outpacing Governance

While nearly all payers are deploying AI, only 31% report having fully defined governance models and controls in place.

This governance gap introduces strategic tension. AI is being deployed into high-impact workflows (claims adjudication, prior authorization, engagement), but oversight frameworks are still maturing.

Without governance clarity, transparency, and cross-functional alignment, even well-intentioned AI initiatives risk eroding trust or creating compliance exposure. When trust begins to erode, the effects don’t stay contained within a single workflow. Member satisfaction declines. Call center volumes increase. Complaints rise. And during open enrollment, members who feel uncertain or unsupported are more likely to explore alternatives.

Over time, that erosion shows up in retention rates, HEDIS and Star ratings, and organizational growth. AI initiatives that lack transparency or governance can unintentionally create the very friction they were meant to eliminate.

This brings us to the member side of the equation.

 

The Member Perspective: Open to AI, But Not Fully Convinced

While payer adoption is accelerating, member adoption is more measured.

According to the 2025 HealthEdge Healthcare Consumer Study:

• Only 21% of members report using AI-powered tools offered by their health plan
• 58% have not used AI tools
• 21% are unsure whether they’ve used AI tools
• Among non-users, 64% say they would be open to using AI tools in the future

Members are not rejecting AI. But they are not embracing it at the pace at which payers are deploying it.

When asked what types of AI tools they would most likely use, members expressed strong interest in:

• Chatbots and virtual assistants
• Personalized education and resource recommendations
• Cost-saving benefit and provider tools
• Health tracking and coaching tools

The demand signal is there. But so is hesitation.

The Trust Barrier: What Members Need

While 23% of members report no concerns about AI use by their health plan, the majority cite specific issues:

• 26%: Quality and accuracy
• 20%: Privacy
• 20%: Data security
• 11%: Not knowing how to use it

More revealing is what would increase consumers’ comfort, as shown in this chart. This is where the readiness gap becomes clear. Payers are accelerating deployment. Members are asking for transparency and guardrails. Adoption appears to be ahead of trust.

 

Where Payer and Member Readiness Diverge

Comparing the two surveys reveals three critical gaps.

1. Operational Readiness vs. Experiential Readiness: Payers are embedding AI into claims, care management, and engagement workflows. Members are still deciding whether AI improves or complicates their experience.

2. Efficiency vs. Confidence: Health plans prioritize efficiency, automation, and cost containment. Members evaluate AI through accuracy, fairness, privacy, and clarity.

3. Investment vs. Communication: Payers are investing heavily in AI capabilities. Members are asking to be informed when AI is used, and why. This is not a technology gap. It is a perception gap.

What Will It Take to Succeed with AI in 2026 and Beyond?

The data from both surveys point to four imperatives for health plans:

1. Strengthen governance alongside deployment. AI maturity must include oversight, ethical controls, and auditability.
2. Make AI visible and explainable. Members want transparency, not hidden automation.
3. Focus on high-friction use cases. Cost clarity, claims accuracy, and benefit navigation are where AI can immediately build trust.
4. Balance AI and human collaboration. Technology should reinforce—not replace—the human relationship between a health plan and its members.

The Bottom Line: Readiness Needs to Even Out

AI adoption across health plans is accelerating. But technology readiness and trust readiness are not the same thing.

The fact is: Members stay with plans they trust. They leave when they don’t. If AI makes it easier to understand benefits, resolve a claim, or get timely support, it strengthens that trust. If it feels confusing, inconsistent, or opaque, it creates friction, and that friction shows up during open enrollment.

The risk isn’t that health plans are moving too fast with AI. The risk is deploying it in ways that outpace governance, transparency, and operational alignment. That’s where execution matters.

At HealthEdge, we focus on embedding AI directly into core workflows — not as a bolt-on, but as part of how claims are adjudicated, care is managed, and payment integrity is enforced. That means building governance into the system, designing for auditability, and aligning automation with real operational outcomes.

Download the Full Research Reports

To explore the complete survey findings, including adoption trends, governance maturity insights, and detailed consumer sentiment, download the full report, The Great Rebalancing: Inside the New Realities Shaping Health Plan Performance, 2026 Healthcare Payer Survey Report.