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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.

In today’s rapidly evolving healthcare landscape, standing still isn’t an option. Health plans relying on legacy care management platforms, whether vendor-supported, homegrown, or heavily customized, are increasingly feeling the strain of outdated technology, limited visibility, and escalated compliance demands.

Across the industry, health plans are prioritizing operational efficiency, regulatory alignment, and data-driven care delivery as top priorities for 2026. Recent HealthEdge® research shows intensifying regulatory pressures are forcing a seismic shift in health plan priorities, with technology and IT-business alignment emerging as critical levers for managing cost and risk.

If rising costs, shrinking margins, and complex compliance requirements are weighing on your organization, you’re not alone. Many health plans are increasingly focusing on aligning IT and business strategies and leveraging technology as key approaches to address regulatory challenges and cost pressures.

Here are five unmistakable signs your legacy care management system may be holding your organization back—and why now is the perfect time to evaluate a modern alternative like HealthEdge GuidingCare® for care management.

1. Compliance Is a Constant Struggle, Not a Confidence Point

Legacy care management systems weren’t designed for today’s rapidly evolving compliance landscape.

Between federal and state regulatory changes, evolving quality metrics, and increasing reporting requirements, care management platforms must adapt quickly. Yet legacy platforms often require manual updates or custom patches just to stay compliant, creating risk and operational drag.

Modern industry outlooks call this period one of reinvention, where organizations must operate on systems that are stable yet adaptable to shifting requirements.

2. Reporting Takes Days—or Even Weeks

Legacy care management systems often store data in silos, forcing teams to extract data manually across systems, cleanse it, and stitch reports together. This results in:

• Long turnaround times for leadership reporting
• Delayed insights into utilization trends
• Reduced confidence in data accuracy

Healthcare leaders are increasingly focused on operational execution powered by data and automation. Modern platforms, like GuidingCare, provide near-real-time reporting with integrated data models, empowering users to generate actionable insights without relying on IT handoffs or manual processes.

3. Inefficient Workflows Are Draining Resources

Care managers and clinical staff play a critical role in delivering high-quality outcomes, yet many legacy systems prioritize documentation over workflow efficiency. Common pain points include:

• Duplicate entry across programs
• Complex navigation and context switching
• Manual coordination between utilization management, care management, and quality teams

Industry research shows that aging IT infrastructure not only consumes valuable resources but also limits organizations’ ability to innovate and deploy emerging capabilities such as AI and automation. GuidingCare addresses these challenges by streamlining workflows with intuitive user experiences and automation, enabling care teams to focus on what truly matters—delivering exceptional member care rather than navigating system workarounds.

4. Your System Can’t Scale with Your Growth or Strategy

Whether expanding into new lines of business, launching new care programs, or adopting value-based care models, scaling your care management platform should be straightforward, not bogged down with technical debt.

However, legacy systems often:

• Require costly customizations for new programs
• Complicate integrations with external systems
• Limit the ability to adopt new operating models

According to broader industry outlooks, systems must be agile, integrated, and data-ready to support evolving care delivery models and competitive strategies in 2026 and beyond. GuidingCare is purpose-built for growth, offering rapid configuration, extensibility, and cross-program scaling without the need for costly overhauls.

5. Member Satisfaction Is Suffering

Your care management system should ultimately drive better member outcomes and experiences. Yet, legacy platforms often fall short, offering limited visibility into engagement and lack cohesive care coordination capabilities, which can negatively impact:

• Member satisfaction scores
• Adherence and outcomes
• Trust and loyalty

As industry shifts toward adaptive care models and integrated delivery, the need for systems that support seamless engagement across care journeys has never been greater.

Care solutions like GuidingCare and HealthEdge Wellframe™ deliver integrated member experiences and advanced measurement capabilities that help care teams personalize support, drive adherence, and deliver outcomes that matter, boosting both satisfaction and retention.

The Cost of Standing Still Is Too High

In a healthcare landscape defined by cost pressures, regulatory complexity, workforce strain, and rising expectations for outcomes, health plans can no longer afford to let outdated care management hold them back.

By transitioning away from legacy platforms to a modern solution like GuidingCare, health plans can:

• Improve compliance with less operational strain
• Access faster, more actionable analytics
• Enable efficient workflows that allow your clinical staff to work at the top of their licenses
• Scale with growth and innovation as you align with your organization’s growth strategy, goals, or expansion plans
• Deliver superior member experiences and outcomes

The time to act is now.

Discover how GuidingCare helped transform Nascentia’s outdated system into a modern care management solution that improves outcomes and drives operational excellence. Read the full case study: Disjointed to Dynamic — How Nascentia Health Modernized Care with HealthEdge GuidingCare.