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Implementing new care management technology is about more than just meeting a go-live date. For Medicaid and Long-Term Services and Supports (LTSS) plans navigating evolving state mandates, success hinges on achieving regulatory compliance agility—the ability to adapt swiftly and confidently to continuous change.

This theme was the focus of a recent webinar hosted by the Association for Community Affiliated Plans (ACAP), hosted by implementation and regulatory leaders from HealthEdge® and Nascentia Health. They shared how Nascentia completed a nine-month, compliance-focused implementation of HealthEdge GuidingCare® that strengthened care management operations, reduced risk, and empowered its care management teams.

In the webinar, speakers also highlighted five key lessons the Nascentia team learned from their experience, and how HealthEdge implementation best practices helped embed regulatory compliance agility into every stage of the process.

Five Key Implementation Lessons from Nascentia Health

1. Start with compliance as a priority on day one

Nascentia made regulatory compliance the foundation of its implementation. The plan’s compliance team was involved from the first assessment through post-go-live evaluation, ensuring every workflow, form, and report aligned with state and federal requirements.

“Start with compliance as a priority on day one,” said Brian Davey, Vice President of Health Plan Operations at Nascentia. “One of the main reasons we achieved a nine-month timeline was because there was not much rework. Compliance was involved every step of the way.”

Implementation Best Practices

• Integrated compliance and regulatory leaders into each phase, from discovery through testing.
• Mapped all regulatory touchpoints early and defined measurable compliance outcomes.
• Used the proprietary HealthEdge Transform Framework to connect compliance requirements directly to solution delivery.

The most successful health plans treat compliance as an enterprise-wide foundation rather than a separate workstream. Compliance serves as a governing focus that spans the entire program and supports the organization’s broader goals.

2. Build shared accountability between your health plan and technology partner

Nascentia and HealthEdge adopted a “one-team” model, fostering transparency and mutual accountability through daily communication, shared milestones, and joint decision-making—key elements for a rapid and compliant rollout.

Implementation Best Practices:

• Established shared project dashboards and escalation paths to track progress.
• Embedded compliance checkpoints into project governance for joint approval at each stage.
• Maintained open communication through regular stand-ups and weekly syncs.
• Treated implementation as a collaborative transformation, not a handoff.

This model helped Nascentia stay on schedule and ensure compliance remained central. “It was a true partnership from the beginning,” said Davey. “We trusted each other and problem-solved in real time.”

3. Strengthen internal capacity early

From the outset, Nascentia prioritized sustainability by employing a “train-the-trainer” approach. This strategy empowered internal champions to manage configuration, updates, and training well beyond go-live. This focus included the following results:

• 20 internal champions trained
• 90% of configuration changes now handled in-house
• Approximately 7 full-time equivalents (FTEs) saved through automation and efficiency gains

Implementation Best Practices:

• Provided hands-on training and documentation during implementation to build lasting in-house expertise.
• GuidingCare’s configurable technology enabled quick workflow and form updates without HealthEdge support, supporting internal capability rather than vendor dependence.
• Paired plan leaders with HealthEdge subject matter experts to ensure smooth knowledge transfer.

4. Select a partner with proven regulatory experience

Nascentia needed a technology partner that understood New York’s Medicaid and LTSS environment, including Department of Health (DOH) requirements for Uniform Assessment System (UAS) assessments, Person-Centered Service Plan (PCSP) workflows, and SmartComm letters. HealthEdge brought deep experience in state-specific mandates and a proven record of compliance-ready implementations.

Implementation Best Practices:

• Used pre-built, audit-tested assets aligned to the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and state requirements.
• Leveraged HealthEdge’s Regulatory Change Management Model, which tracks mandates and crosswalks them to product capabilities.
• Offered transparency through the HealthEdge Trust Portal, with SOC2, HITRUST, and HIPAA documentation accessible to the health plan and auditors.
• HealthEdge maintains a regulatory pipeline incorporating learnings from emerging changes and customer advisory boards.

Choosing a partner with deep regulatory expertise allowed Nascentia to reduce implementation risk and accelerate go-live—achieving a timeline “about 40% faster than the industry average,” according to Davey.

5. Track early wins and share them across the organization

Nascentia measured and shared progress from day one, building internal momentum. Early wins—like improved audit readiness and faster updates—reinforced the platform’s value across teams. Outcomes achieved include:

• 15% increase in nurse capacity
• Reduced burnout and manual workload
• Real-time adaptability to DOH guidance changes
• Seamless integration across lines of business

Implementation Best Practices:

• Defined early success metrics tied to compliance, efficiency, and user adoption.
• Shared dashboards and reports with leadership to maintain visibility and confidence.
• Continued optimization after go-live to build on early gains.

Nascentia’s success demonstrates how measurement and transparency foster engagement, ensuring that compliance improvement becomes an integral part of daily operations rather than just a project milestone.

A Model for Compliant Care Management Implementations

The partnership between HealthEdge and Nascentia showcases the transformative potential of embedding compliance into every layer of technology and teamwork. Starting with compliance, shared accountability, and measuring shared outcomes provide a clear blueprint for health plans who want to modernize their care management systems.

The lessons proven through this partnership validate HealthEdge’s best practices for implementation success, including:

• Embed compliance into design and testing.
• Operate under a one-team model.
• Empower health plan staff with configurable tools.
• Leverage regulatory expertise and prebuilt assets for rapid, compliant and effective implementation.
• Measure, communicate, and sustain improvement for material business improvement.

Compliance agility extends far beyond audit readiness. It serves as a protective foundation for the organization, strengthens teams, and enables better care delivery.

Want to watch the full discussion between leaders from Nascentia and HealthEdge? Watch the webinar on-demand: “Care Management Software Implementation Best Practices.”

The healthcare payer landscape is undergoing a seismic transformation, as revealed by the 2026 HealthEdge® Annual Payer Report. HealthEdge surveyed more than 550 health plan executives, including 348 leaders focused on Medicare, Medicaid, and Dual-Eligible populations. This year’s findings highlight business growth and competitive pressure – as well as costs—as the top challenges for government plans.

Challenge 1: Growth, Competition, and the Cost Crunch

For the second consecutive year, “managing rising costs” remains the leading concern across all payers surveyed (52%). However, “business growth and competitive pressure” have surged, up 16 percentage points year-over-year, to tie as the top challenge.

Among government plans, “business growth and competitive pressure” is the number one challenge. This is a 47% increase from the previous survey, signaling a maturing market where differentiation, retention, and strategic partnerships are critical for long-term viability. According to respondents, workflow automation, artificial intelligence (AI), and advanced analytics are favored strategies for achieving a competitive advantage.

Challenge 2: Regulatory Pressures and Technology Modernization

The regulatory landscape has intensified, especially following the enactment of the One Big Beautiful Bill Act (OBBBA). Nearly 90% of payers focusing on government plans report “moderate to significant” impacts on their costs and overall margins due to changing regulatory requirements.

When it comes to technology, the biggest compliance challenge is no longer fee schedules but a lack of internal IT staff and resources. Only about half of health plan leaders report being fully operationalized or making progress to meet key regulatory guidelines—underscoring the urgent need for vendor partners that can deliver foundational offerings that can automate new rule integration and improve regulatory compliance.

Challenge 3: Value-Based Care and Provider Engagement

Siloed data and legacy systems continue to hinder the scalability of value-based care (VBC) models. While 93% of payers who focus on Medicare, Medicaid, and Dual-Eligible populations have VBC arrangements in place, and 72% expect these contracts to increase, integration challenges persist.

Thirty percent of payers cited “integrating provider data across systems” as their biggest challenge in provider data management. VBC growth now depends on breaking down data silos and modernizing digital infrastructure. When it comes to improving provider relations, government plans place the highest priority on increased provider collaboration and VBC contracting (26%).

Challenge 4: Member Satisfaction—Vulnerability and Opportunity

Member satisfaction is both a growing vulnerability and a strategic opportunity. Seventy percent of government health plans cite high out-of-pocket costs and premiums as the top challenge to member satisfaction, followed by claims denials (55%), and network access issues (53%). To address these pain points, 42% of health plans are prioritizing faster, more accurate claims payments to boost engagement.

Yet, a perception gap persists: only 53–60% of government plan members view their health plan as a partner as reported in the 2025 HealthEdge® Consumer Survey, compared to 77–81% of payers who believe they are perceived that way. Improving member experience is the first step for closing the trust gap and driving long-term engagement.

The Path Forward: Modernization, Personalization, and Partnership

To stay competitive, health plans must modernize their technology ecosystems and leverage business models such as BPaaS (business process as a service) to help streamline workflows, scale operations, and maintain compliance readiness.

In addition, prioritizing member experience through personalized outreach, digital tools like mobile apps and chatbots, and clear communication is vital to long-term improvements in clinical outcomes and member retention.  Ultimately, success hinges on transforming operations from transactional to relational, delivering value at every touchpoint and securing sustainable growth.

To explore the full findings and actionable insights specifically for leaders of government plans from the 2026 HealthEdge Annual Payer Report, watch our webinar with ACAP on-demand now: The Shifting Priorities of Health Plan Leaders: Key Insights from the 2026 HealthEdge Payer Survey.

As the healthcare industry prepares for the ripple effects of the One Big Beautiful Bill Act (OBBBA), few payer segments face more immediate challenges than health plans focused on Medicaid populations. The OBBBA increased focus on eligibility verification, member accountability, and real-time reporting—all of which can intensify administrative workloads as well as amplify the risks of member churn and coverage loss.

For health plan executives, the stakes are clear: maintaining compliance and continuity of care under OBBBA will require not just operational discipline but new levels of digital engagement. As payers already know, encouraging consistent digital engagement can be challenging with Medicaid populations that already face barriers to communication and access.

Understanding OBBBA’s Impact on Medicaid

While the full implications of OBBBA continue to unfold, early analyses suggest the law will heighten scrutiny on Medicaid eligibility and redetermination processes. Similar to the Medicaid “unwinding” period that followed the end of continuous enrollment, health plans are likely to see recurring cycles of administrative reassessment and potential disenrollments due to missed paperwork or outdated contact information.

According to the Kaiser Family Foundation (KFF), more than 21 million Medicaid enrollees were disenrolled during the 2023–2024 unwinding period, and roughly 70% of those losses were due to procedural issues rather than eligibility. These trends highlight a systemic vulnerability: many members who still qualify for coverage are losing it because health plans cannot reach or re-engage them in time.

OBBBA’s new verification and reporting mandates could widen those gaps unless plans take proactive steps to modernize their outreach and engagement infrastructure.

The Medicaid Challenge: High Need, High Complexity, Low Connectivity

Engaging Medicaid members has always required more than standard outreach. This population often faces multiple barriers related to non-clinical aspects of health, such as unstable housing, limited internet access, or language obstacles, that make consistent communication a persistent challenge.

The Centers for Medicare & Medicaid Services (CMS) reports that one in three Medicaid enrollees changes their address or phone number each year, creating ongoing challenges with data accuracy and outreach. In addition, CMS estimates that administrative “churn” results in $500–600 million annually in avoidable administrative costs for states and managed care organizations.

At the same time, care teams and their resources are often stretched thin. Case managers and engagement specialists often spend hours locating or recontacting members, leaving less time for proactive care coordination and education. The result is a system strained by manual effort and fragmented communication, right as OBBBA is demanding greater precision and accountability from health plans.

The Administrative Squeeze: Compliance Meets Capacity

OBBBA’s operational requirements will compound existing pressures on Medicaid plans. The combination of new documentation rules, work requirement tracking, and timelier redetermination cycles means that administrative staff must manage larger caseloads, faster turnaround times, and higher expectations for accuracy.

According to the 2026 HealthEdge Payer Survey Report, most health plan executives are prioritizing technology modernization and workflow automation to reduce manual work and improve member support—especially in complex lines of business like Medicaid.

For Medicaid plans, the challenge isn’t just volume. It’s variability. Eligibility, benefits, and compliance rules vary by state, and data silos between enrollment, care management, and member communication tools make coordination even harder. Without digital integration and workflow automation, each redetermination cycle risks unnecessary disenrollments, frustrated members, and escalating costs.

A Digital Approach to Member Engagement

Digital transformation and strategic investment offer a path forward for payers. By centralizing communication and automating outreach, integrated digital solutions can help Medicaid plans reduce administrative burden while improving member retention and experience.

Digital care management platforms like HealthEdge® Wellframe exemplify this approach. With a 4.8/5 App Store rating and over 70% of onboarded members engaging in the first 30 days, Wellframe™ enables higher member adoption and sustained engagement across diverse member populations. Its mobile-first design allows Medicaid members, many of whom rely primarily on smartphones for connectivity, to receive personalized guidance, educational content, and HIPAA-compliant two-way communication from care teams.

Wellframe’s AI-powered workflows, integrated with the HealthEdge GuidingCare®, helps care managers more on member outreach and interaction and less on administrative processes. Automated care management processes (like message prompts and critical alerts) can save an average of 8–10 minutes per member interaction, freeing capacity while enabling consistent follow-up and documentation. That efficiency is critical for Medicaid teams facing redetermination surges or tighter reporting windows under OBBBA.

A recent Wellframe case study illustrates the impact. When a regional Blue Cross Blue Shield plan adopted the platform, its care teams achieved a 91% increase in successful outreach calls and 6 times as many member interactions as with traditional methods. Those gains translated directly into improved member engagement and continuity of care.

Building Resilience and Retention

For Medicaid plans, digital member engagement is no longer a “nice to have”—it is a necessary capability. OBBBA raises the operational stakes, but it also creates an opportunity to reimagine how plans connect with their most vulnerable members.

Wellframe enables Medicaid plans to maintain consistent member contact throughout every phase of the eligibility and care journey by combining care management, education, and outreach into a single digital experience. This connected approach helps reduce administrative overhead, improve care team productivity, and build stronger relationships with members who need the most guidance.

Redefining Medicaid Engagement for the OBBBA Era

The path to success under OBBBA will not be defined by compliance alone. It will be defined by connection. Medicaid plans that invest in scalable digital engagement will be better equipped to balance regulatory rigor with human connection, reducing disenrollments while improving overall plan performance.

Digital platforms like Wellframe help make that possible by empowering plans to engage members proactively, operate more efficiently, and deliver continuous support that sustains trust, compliance, and health outcomes across vulnerable populations.

Read the Q&A with regulatory expert Jennifer Vicknair, RN, MBA to learn more about how the OBBBA could impact care management & member engagement.

The HealthEdge® 2026  Annual Payer Report, “The Great Rebalancing: Inside the New Realities Shaping Health Plan Performance,” reveals how health plans are navigating growing financial pressure, complex compliance demands, and rising expectations from both members and providers.

Based on responses from more than 550 executives across commercial, government, and dual-eligible plans, the report highlights how today’s leaders are rethinking investment strategies to stay competitive in an increasingly unpredictable environment.

5 Key Priorities for Healthcare Payers in 2026

Survey responses indicated that there are five key areas where health plan leaders are focusing their strategic attention in the year ahead. Instead of waiting to react to industry changes, executives are investing in tools that empower their teams to be proactive in addressing market demands.

1. Cost Pressures Reach a Tipping Point

For the second year in a row, cost containment is the top priority for payers, driven by the projected rise in U.S. healthcare spending to $7.7 trillion by 2032. With financial pressure mounting across all corners of the system, from shrinking plan margins to increasing member cost-sharing, executives are focusing their strategies on operational transformation.

• 34% are using artificial intelligence (AI) and analytics to automate manual work and reduce rework
• 27% are prioritizing core system modernization to eliminate inefficiencies
• 26% are investing in digital engagement tools to scale service and improve efficiency

These strategies signal a shift toward structural change, not just incremental savings.

2. OBBBA Drives Enrollment Uncertainty and Strategic Realignment

With the One Big Beautiful Bill Act (OBBBA) introducing more dynamic eligibility requirements and real-time enrollment validations, payers are navigating a new level of scrutiny. These changes are prompting leaders to rethink how they manage data, collaborate with providers, and assess risk.

Key payer responses include:

• 25% are expanding provider collaboration to enable real-time clinical data sharing
• 19% are enhancing risk assessment models to stay ahead of eligibility disruptions
• 17% are tightening data validation controls across administrative systems

As enrollment data becomes more fluid and more consequential, payer success will increasingly depend on infrastructure that can respond in real time with accuracy, transparency, and flexibility.

3. The Member Experience Perception Gap

The 2026 Payer Survey also revealed a clear disconnect between how payers and members view the plan-member relationship. According to the 2025 HealthEdge Consumer Report, 76% of payers believe they’re seen as true partners in care—while only 51% of members say the same. This 25-point gap has business implications: 27% of consumers say they’re likely to switch plans this year.

Based on their responses, health plans are taking steps to strengthen engagement, including:

• Investing in omnichannel communication and mobile tools
• Offering self-service options and virtual assistants
• Increasing personalization with health recommendations and incentive programs

While digital solutions are expanding, the challenge is ensuring they translate to meaningful connections and long-term loyalty.

4. Provider Engagement: Payers Focus on Self-Service and Accuracy

The survey highlights persistent challenges in provider engagement, with many health plans struggling to streamline interactions and reduce administrative burden. When asked about the biggest barriers to effective provider collaboration, payers cited the following challenges:

• Delays in claims processing
• Delays in responding to prior authorization requests
• Lack of self-service tools
• Limited access to real-time data

In response, payers are taking practical steps to improve operational efficiency and rebuild trust. The most common actions include improving payment accuracy (38%), expanding value-based care contracts (35%), and investing in modern provider data management systems (33%).

While provider relationships are not always viewed as a top strategic priority, these efforts show that many payers recognize the connection between strong provider collaboration and their ability to meet broader goals around compliance, cost containment, and member satisfaction.

5. AI Adoption Accelerates and the Gaps Are Becoming Clearer

AI is rapidly becoming embedded in health plans’ day-to-day operations. According to the survey, 94% of payers have gone live with AI tool or are actively adopting one, demonstrating how quickly the industry has moved past pilot experimentation. Nearly half of executives (47%) reported either widespread adoption or active departmental use across their organizations.

Yet while AI usage is accelerating, adoption is not uniform across the industry. Mid-sized plans (2–10M lives) are 30% more likely than their peers to report widespread AI adoption. Plans serving Dual-Eligible and Military/Veteran populations lead adoption by more than 10 percentage points over other segments.

Confidence in AI tool use also varies by role: 31% of executive leaders believe their organizations have achieved widespread AI adoption, compared with only 3% of operational and regulatory leaders, revealing a notable perception gap between leadership expectations and on-the-ground implementation.

While AI adoption rates may be high, operational readiness is uneven. Only 31% of payers report having a fully defined AI governance model with standards, guardrails, and accountability structures in place. The remainder are at varying levels of maturity:

• 44% have established some guidelines but are still refining them
• 28% are in exploratory or early pilot phases
• 16% are researching use cases without live implementations
• 6% have no governance in place at all

This gap underscores a growing operational risk for some payers. As AI becomes more deeply woven into claims workflows, care management, member engagement, and payment accuracy, health plans will need robust oversight to avoid compliance issues, algorithmic bias, and unintended administrative impacts.

The Next Phase: Agentic AI and BPaaS Models

The report highlights that AI’s momentum is pushing the industry toward a new operational paradigm. Future-state BPaaS models, powered by agentic AI systems capable of autonomous action, are expected to shape the next era of automation. According to the research, these models will help payers streamline end-to-end workflows, improve accuracy, and achieve real-time responsiveness across high-volume processes.

For payers, this shift represents more than a technology upgrade. It marks a transition toward adaptive, continuously learning operations, where AI augments human expertise and supports the demands of cost containment, compliance, and service excellence.

Looking Ahead to 2026

This year’s survey reveals an industry reshaping its foundations in response to economic, regulatory, and stakeholder demands. As payers work to modernize technology, streamline operations, and deepen collaboration with members and providers, those who invest in agility and connected infrastructure will be best positioned for sustainable growth.

Download the full 2026 report to learn more about how health plan leaders are preparing for the pressures and demands of the year ahead.

At HealthEdge, we partner with more than 130 health plans to support that transformation. Explore how we can help you move faster, reduce costs, and build stronger relationships across your ecosystem. Request a demo to see how the integrated HealthEdge solution suite can support your organizational goals.

As health plans become increasingly reliant on complex software platforms to manage operations, timely access to accurate product information is essential. Yet traditional documentation search tools often fall short. Users face dozens of potentially relevant topics, forcing them to click through multiple pages and piece together answers manually—a time-consuming process that slows down critical operational workflows.

At HealthEdge®, we recognized this growing challenge and responded with askHE: an AI-powered documentation assistant that transforms how users interact with HealthRules® Payer product knowledge.

The Documentation Discovery Problem

Standard search functionality across HealthRules Payer help center modules works well for simple lookups, but breaks down when answers span multiple documentation sources. A claims processor investigating records and rule definitions might retrieve 15-20 relevant topics through fuzzy matching, then spend valuable minutes reading each one to find the specific information needed.

This scattered approach to information retrieval created operational friction. Staff needed a way to ask natural language questions and receive synthesized answers that pull context from across the entire documentation landscape, not just a list of potentially relevant pages.

Building the AI-Powered Answer Engine

Figure 1: Architecture: RAG System with Azure AI Search and OpenAI Integration 

The askHE implementation leverages a modern Retrieval-Augmented Generation (RAG) architecture built on Microsoft Azure infrastructure:

• Vector-Powered Document Retrieval: Azure AI Cognitive Search stores document indexes and vector embeddings, connecting to Azure Blob Storage for efficient document retrieval.  When users submit questions, our RAG system identifies relevant documentation chunks through semantic similarity matching rather than simple keyword searches. Azure AI Cognitive Search stores document indexes and vector embeddings, connecting to Azure Blob Storage for efficient document retrieval.
• Intelligent Response Synthesis: Retrieved documents feed into OpenAI’s GPT-3.5 model, which synthesizes information across multiple sources into coherent, conversational responses. Unlike traditional search that returns document lists, askHE processes content in the background and delivers ready-to-use answers.
• Microservices Architecture: Azure Functions running Python 3 provide the application backbone. The microservice ingests requests through an API Gateway, transforms user queries to call the indexer for matching documents, and orchestrates OpenAI API calls to generate synthesized responses—all with minimal latency.
• Seamless User Experience: Integration with MadCap Flare, the external documentation hosting platform, embeds askHE directly within the help center application. Users access the chatbot where they already work, eliminating context switching between search tools.
• Citation-Driven Transparency: Every askHE response includes citation links to source topics, allowing users to verify information or explore concepts in greater depth. Users can click through to specific topic pages or navigate directly to relevant sections of product PDF guides.

Rapid Adoption Validates the Approach

Figure 2: askHE Query Volume and User Engagement Trends 

The numbers tell a compelling story: 23,000 queries from 890 unique users in October alone demonstrate that askHE has become the go-to resource for anyone accessing HealthRules Payer help documentation, from claims processors and customer service representatives to providers and members seeking product information.

This adoption occurred organically, driven by the fundamental value proposition: instant, synthesized answers instead of manual documentation hunting. While formal time savings haven’t been quantified yet, user behavior speaks clearly—staff consistently choose askHE over traditional search when they need answers quickly.

The early metrics validate the strategic decision to invest in conversational AI for documentation access, positioning HealthEdge to scale this capability as user needs continue to evolve.

The Strategic Path Forward: Scaling RAG Beyond Documentation:

The askHE success establishes a proven foundation for HealthEdge’s AI Platform, enabling rapid development of AI agents leveraging the RAG architecture. This same approach is being explored for care plan summaries that synthesize member health information and claims adjudication decision support that provides real-time guidance to processors by retrieving relevant policy documentation, medical necessity criteria, and historical precedents.

The askHE foundation creates opportunities for continuous improvement and measurement. Future iterations will focus on quantifying time savings per query, measuring user satisfaction through embedded feedback mechanisms, and tracking response accuracy to optimize the RAG pipeline.

RAG architecture’s flexibility allows for expansion—adding new documentation sources, fine-tuning retrieval algorithms, and potentially upgrading to more powerful language models as business needs and investment justification evolve. The vector database infrastructure scales efficiently, supporting growing documentation volumes without degrading performance.

By removing barriers to information access, HealthEdge is empowering users across the enterprise to make faster, more confident decisions. As we continue to expand AI capabilities across our product suite, we remain focused on practical solutions that reduce friction and improve user experience. To explore more about how HealthEdge is leveraging AI across the health plan lifecycle, visit our AI Resource Center or contact us for a personalized demo.

Managing payments for a health plan is not as simple as it was a few decades ago. Updated billing models, new compliance mandates, and complex provider networks can make it challenging for payers to align their processes and effectively manage payments.

In this blog, we unpack three common barriers to payment efficiency and what to look for in a payment integrity solution.

3 Key Barriers to Healthcare Payment Integrity

1. Disparate vendor network

To deal with complex healthcare payments, health plans often work with multiple vendors and disparate solutions. Often, each vendor focuses on one part of the process, like pricing, policies, or reviewing payments after they’ve been made. While this approach offers specialized support, it can lead to a tangled system where similar tasks are repeated by different partners. This setup makes it hard for health plans to make changes quickly or respond to new challenges.

2. Disconnected data sources

When each vendor keeps data within their own systems, information is siloed and hard for health plans to piece together in a meaningful way. In addition, any errors in the process are often handled on an individual basis, making it difficult to see bigger trends or identify recurring problems. This can lead to health plans taking action without a clear, unified view of the process.

3. Workflow inefficiency and payment errors

Most existing payment integrity systems work backwards: They try to find and recover funds from incorrect payments after the payment request is sent. This means health plans pay third-party vendors to track down mistakes that were made in-house – and likely could have been avoided. The payment recovery process can also be slow and expensive, leading to wasted resources and frustration.

A Unified Approach to Health Plan Payment Integrity

The team behind HealthEdge Source™ recognized that healthcare payers didn’t need another third-party editor or another pricing tool. Instead, health plans needed a way to integrate and streamline claims processing.

With the HealthEdge Source payment integrity solution, health plans have access to custom configuration, editing, and advanced analytics tools all in one place for greater visibility and catch errors before payments are sent.

4 Key Features of HealthEdge Source

• Easy Edit Building: HealthEdge Source includes a no-code edit builder, allowing users to create and update payment edits without special requests from engineering teams. An edit can be built and published in minutes.
• Automatic Updates: The platform automatically incorporates new rules based on regulatory changes from agencies, like the Centers for Medicare and Medicaid Services (CMS). New rules are built in every two weeks, with no manual work for your team.
• Test Before Going Live: A built-in Monitor Mode allows users to test new edits on real claims without affecting actual payments. This allows teams to see the impact of a new rule before fully implementing it.
• Clear Tracking and Analytics: Every claim is tracked with a detailed audit trail, and the system offers advanced analytics to help health plans spot trends, track performance, and make better decisions.

By uniting these tools in a single solution, HealthEdge Source helps turn payment accuracy from a guessing game into a straightforward, proactive process.

Innovations in Payment Integrity: Edit Management Enhancements

The HealthEdge Source team is always working on new solution enhancements based on user feedback and changes in the industry. Recently, we implemented two key improvements to make managing edits even more efficient.

1. Simplified Edit Configuration

Managing edits used to mean navigating multiple screens and manually updating rules for each provider type—a tedious and error-prone process. Now, HealthEdge Source offers a single, consolidated interface where all configurations happen in one place.

For example, if a health plan wants to require prior authorization for high-cost imaging services, this can be enabled with a single click for every relevant facility or provider group. If there’s a need for an exception, such as excluding emergency services, it takes only a few seconds to adjust.

This approach to configurations helps improve efficiency for policy management. Health plan teams can view, enable, adjust, or turn off edits for different provider types using simple checkboxes across the same dashboard, rather than tracking changes across separate screens. Centralizing these functions saves time while reducing the risk of manual errors and helps ensure updates are reflected in the proper places.

2. Global Edit Exceptions

With global edit exceptions, users can create exception rules in one central location, then apply them across as many edits as needed. If a particular provider, like a large hospital network, should be exempt from certain claim edits, a health plan only has to set up their tax ID or configuration details once. This rule can then be linked to every relevant edit, instead of repeating the same exclusion logic each time. This centralized approach reduces duplicate work and makes it easier to standardize processes across the organization.

When a contract changes or another provider needs a similar exception, users simply update the global exception in the central library, and the change automatically applies to the connected edits. This helps reduce the risk of missing updates or implementing inconsistent rules across a single system. For example, if a health plan wants to adjust exclusion criteria for a set of specialty providers, those updates can be handled quickly and accurately by revising a single rule, rather than searching for and editing each instance individually.

Ultimately, this approach helps deliver a stable, scalable foundation for managing edits, empowering health plans to manage regulatory shifts and network changes as a controlled process.

Watch our on-demand webinar, “Edit Smarter Not Harder with HealthEdge Source™” to get an inside look at how connected, automated payment integrity can work day to day.