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Healthcare Consumers’ Rising Expectations: Four Key Themes from HealthEdge’s Fifth Annual Consumer Study 

Posted on by HealthEdge

HealthEdge® recently released its fifth annual Healthcare Consumer Study, one of the most comprehensive consumer surveys in the health insurance industry. This year, more than 4,500 healthcare consumers shared their views, providing valuable insights for health plans as they navigate a rapidly evolving market. 

Health plans today face a perfect storm of pressures: They must manage rising healthcare costs, meet growing consumer expectations for affordability, and adapt to new regulatory requirements around transparency and fairness. At the same time, healthcare consumers increasingly expect healthcare experiences that mirror the personalization, convenience, and clarity they encounter in other industries.  

Healthcare consumers are looking for more than transactional services—they want health plans that act as partners in their healthcare journey. In this environment, delivering a differentiated member experience is both more important and more challenging than ever. 

This year’s member survey highlights four key areas health plans must focus on to meet these rising expectations and build long-term member loyalty. 

1. The shift from ‘payers of claims’ to ‘partners in care’

This year’s survey revealed that 51% of healthcare consumers now view their health plan as a partner in care rather than just a payer of claims. Survey respondents who see their health plan as a partner report significantly higher satisfaction and loyalty. These members are: 

  • More likely to say they are satisfied with the personalized experiences their health plan provides (78% vs. 49%) 
  • More likely to recommend their health plan to others (75% vs. 58%) 
  • Less likely to switch health plans or cite costs as a primary switching factor 

When asked what would most help their health plan strengthen this perception of partnership, healthcare consumers prioritized: 

  • Helping members lower costs of care and coverage (56%) 
  • Offering benefits relevant to their individual needs (49%) 
  • Making it easier to understand and manage benefits (47%) 

The message is clear: Transparency, proactive support, and relevance drive members’ positive perceptions of their health plans. Payers that achieve this level of trust and satisfaction will be positioned to build lasting member relationships.

2. AI-powered experiences hold potential—but require member trust

Artificial intelligence (AI) tools can help health plans scale personalized member engagement and improve service without adding operational complexity. But the study shows that AI adoption within health plans is still in the early stages, and building member’s trust before using them is essential. 

Only 21% of healthcare consumers surveyed reported using AI-powered tools provided by their health plans. Among those who had not used such tools or were unsure if they had used these tools before, 64% said they would be open to doing so. 

When asked which AI capabilities they would value most, healthcare consumers pointed to: 

  • Chatbots and virtual assistants (94%) 
  • Personalized health education and resource recommendations (92%) 
  • Cost-saving benefit tools and provider suggestions (90%) 
  • Personalized tracking of health goals and progress (86%) 

However, survey respondents also identified their top concerns about AI that may limit adoption: 

  • Quality and accuracy of AI-generated information (26%) 
  • Privacy (20%) 
  • Data security (20%) 

For health plans, this represents both an opportunity and a challenge. AI can be an effective tool for enhancing the member experience, but it must be implemented with clear communication, strong safeguards, and a focus on value to the healthcare consumer. 

3. Member satisfaction and loyalty remain under pressure

The survey data indicate that member satisfaction is mixed, and loyalty cannot be taken for granted. While 34% of healthcare consumers reported being extremely satisfied with their health plan, 27% said they are somewhat or very likely to switch plans in the coming year. 

Survey respondents cited the following as top reasons for considering the switch to a new health plan: 

  • Out-of-pocket costs (23%) 
  • Monthly premiums (20%) 
  • Coverage limitations for specific conditions or procedures (15%) 
  • Network access challenges (14%) 

Additional pain points identified in the survey include: 

  • 57% of healthcare consumers experienced a claim denial in the past year, with 74% of those feeling the denial was unfair 
  • 27% of respondents delayed or went without care due to issues with their health plan 
  • 31% said they were not consistently able to access care in a timely manner 
  • 28% reported receiving a surprise bill 

In response, healthcare consumers are seeking more transparent communication, greater cost clarity, and easier administrative processes. Health plans that proactively address these issues can build stronger relationships and trust with their members. 

4. Digital engagement expectations continue to rise

Digital engagement is now a core expectation for many healthcare consumers. The survey found that 78% of respondents have used or are likely to use their health plan’s mobile app, an increase from 64% in the 2024 HealthEdge Consumer Survey. 

Healthcare consumers continue to look for tools that offer convenience and control across their healthcare experiences. Survey respondents reported a strong interest in using the following digital features from their health plans: 

  • Online appointment scheduling (79%) 
  • Incentive tracking (70%) 
  • Digital health assessments (68%) 
  • Chatbot-based support (60%) 

However, engagement preferences vary by population: 

  • Younger members are more likely to prefer mobile-first interactions 
  • Older adults tend to favor web portals 
  • Medicaid members expressed a stronger interest in text messaging compared to other populations 

For health plans, offering flexible, omnichannel engagement options is now essential. Healthcare consumers want the ability to engage with their health plan in ways that are timely, intuitive, and personalized, mirroring the digital experiences they encounter in other parts of their lives. 

Looking ahead: Becoming a partner in care 

The fifth annual HealthEdge Healthcare Consumer Study highlights the growing gap between what healthcare consumers want and what many health plans are currently delivering. It also shows that health plans have a clear opportunity to differentiate themselves by becoming true partners in care. 

At HealthEdge, we are helping health plans transform their capabilities to meet these evolving expectations and strengthen member relationships. 

Download the full 2025 Healthcare Consumer Study report to explore the findings in more detail and learn how your health plan can take the next step in delivering a member experience that drives loyalty and trust. 

 

Enhance Medicaid Program Management with Advanced Payment Integrity

Posted on by HealthEdge

Table of Contents 

 

The Medicaid population across the United States has reached unprecedented levels in the years following the COVID-19 pandemic. Years of Medicaid expansion under the Affordable Care Act (ACA), combined with rising unemployment and economic instability, have contributed to the surge in enrollment. According to the most recent data from the Centers for Medicare & Medicaid Services (CMS), more than 78 million Americans are now enrolled in Medicaid.  

Medicaid plays a vital role in supporting the nation’s most vulnerable populations, and its expansion offers payers an opportunity to better serve new beneficiaries. Many payers are reinvesting in their technology ecosystems to appeal to potential members, creating new offerings and adopting cutting-edge tools, like advanced payment integrity solutions. 

Creating and delivering effective Medicaid programs requires significant expertise and resources from health plans. Payers often encounter unexpected obstacles when it comes to operational complexity, financial investment, and administrative effort. Addressing these issues requires a comprehensive, well-structured approach to ensure both compliance and long-term success. 

 Top 5 Challenges in Managing Medicaid Programs 

A study conducted by HealthEdge Source revealed some of the biggest challenges payers face in managing Medicaid programs. The research highlighted issues like fragmented data from multiple vendors, high rates of claims rework, and workforce shortages. It also revealed that misaligned departmental goals and outdated technology make it even harder for payers to improve efficiency and accuracy in their programs. 

Here are 5 of the top challenges healthcare payers face—and why addressing them is critical for your health plan’s success.  

1. Constantly changing fee schedules and reimbursement policies

Each state Medicaid program operates with its own unique fee schedules, reimbursement methodologies, and regulatory requirements. These program changes are updated frequently—and usually implemented retroactively. The updates often require payers to manually review and identify changes from published files or websites, an expensive, time-consuming process. Workflow automation can help streamline change implementation, reducing the inaccuracies that lead to payment errors and inefficiencies.

2. Heavy reliance on manual processes

Despite advancements in healthcare technology, many health plans still rely on manual workflows to manage Medicaid updates like fee schedules, a process that is both time-consuming and prone to errors. In fact, 70% of those who responded to the HealthEdge Source study reported dedicating more than 10 full-time employees (FTEs) to managing Medicaid fee schedules and payment policies, while another 45% rely on over 25 FTEs for these tasks. This heavy dependence on manual labor not only slows down the implementation of change, but also increases the risk of costly errors in claims processing. 

3. Workforce shortages strain operations

The healthcare industry, like many others, is grappling with a nationwide shortage of skilled workers. Managing complex Medicaid programs demands specialized expertise, but 58% of survey respondents reported struggling to retain and recruit adequately qualified staff. This resource gap strains existing teams and can have a negative impact on the quality and timeliness of Medicaid claims management. 

Ongoing challenges with workforce retention, combined with the increasing complexity of state Medicaid programs, make it harder for payers to run effective and profitable Medicaid operations. 

4. Fragmented systems and siloed data

Healthcare payers frequently use multiple technology platforms and third-party vendors, resulting in fragmented data systems with limited interoperability. This fragmentation makes it harder to analyze claims data, uncover root causes of errors, and achieve operational efficiency. Without an integrated technology platform, payment issues and inefficiencies persist across departments. 

5. Increasing Medicaid program complexity

Medicaid programs grow more intricate every year, driven by state-specific regulations, changing reimbursement models, and evolving compliance requirements. Keeping up with these complexities manually is becoming increasingly unsustainable. Payers frequently face challenges ranging from maintaining regulatory compliance to reducing provider disputes while ensuring member satisfaction. 

Addressing these challenges requires healthcare payers to invest in advanced, interoperable systems that simplify workflows, enhance data visibility, and improve accuracy. By adopting forward-thinking solutions, payers can optimize Medicaid program management and position themselves for long-term success. 

The Consequences of Falling Behind in Medicaid Offerings 

Failing to keep up with Medicaid updates can have serious consequences for payers. In the HealthEdge Source study, 55% of payers reported that more than 1 in 4 claims require rework due to inaccurate first-pass adjudication. These errors, often due to outdated systems and lack of automation, result in extensive downstream rework and drive up costs for payers over time.  

Errors like under- and overpayments not only cost payers time and money to correct, but consistently submitting inaccurate payments damages payers’ relationships with members and providers. Payers must also stay up-to-date with fee schedules, with many turning to automated tools that reduce improper payments and claims rework. 

Solve Key Medicaid Challenges with Advanced Payment Integrity

HealthEdge Source is an advanced payment integrity solution that simplifies the management of Medicaid programs by addressing inefficiencies and streamlining complex processes.

Automate Medicaid Reimbursement 

By automating the tracking of Medicaid fee schedules and reimbursement policies, HealthEdge Source eliminates payer reliance on manual processes. This helps ensure accurate claims processing and compliance with state-specific rules, saving time and reducing administrative burden. The platform uses advanced algorithms to identify changes, flag discrepancies, and update fee schedules to reflect the latest policies—reducing payment errors and improving operational performance.  

Manage Retroactive Changes Proactively 

HealthEdge Source Retroactive Change Manager automatically detects and analyzes retroactive updates. It continuously monitors for updates that impact historical claims and recalculates affected claims using the correct pricing logic. This approach minimizes payment errors, reduces rework, and helps maintain compliance with state Medicaid requirements, ensuring transparency and accuracy.  

Address Workforce Shortages with Automation 

Automation reduces the need for manual labor in managing Medicaid workflows. This is crucial in an environment with workforce shortages. Leaner teams can manage programs more efficiently and accurately, reallocating resources to more strategic tasks. The platform’s intelligent automation capabilities streamline claims processing, fee schedule updates, and policy management, reducing human intervention and improving operational efficiency.  

Centralize Data for Better Decisions 

HealthEdge Source consolidates all data and features in a single platform, enhancing data visibility and collaboration. This integration helps enable faster, more informed decision-making. By providing a comprehensive view of Medicaid operations, the platform facilitates accurate analysis, identifies root causes of errors, and implements effective solutions. Better data visibility and accessibility empower payers to make strategic decisions quickly, leading to improved outcomes for the organization and its members. 

Create an Intelligent Payment Ecosystem 

As Medicaid programs grow more complex, reducing inefficiencies and enhancing operational processes becomes critical. HealthEdge Source empowers payers by automating Medicaid reimbursement and policy updates, allowing them to streamline workflows and free up resources. This focus on efficiency enables payers to concentrate on delivering better care and improving outcomes for their members. 

Ready to tackle the challenges of Medicaid program management? Check out our resources to learn more about how to optimize your processes, enhance compliance, and drive better outcomes with an advanced payment integrity solution.

Transform Health Plan Operations with AI-Powered Core Administration 

Posted on by HealthEdge

Artificial intelligence (AI) has become the catalyst for transformation across various industries, and healthcare is no exception. For health plans, the integration of AI is no longer just a future aspiration; it is a present-day necessity. From enhancing operational efficiency to improving member outcomes, AI-powered core administration solutions are reshaping how health plans operate on virtually every level.  

HealthEdge® endeavors to be at the forefront of this transformation by thoughtfully integrating AI tools across our suite of digital solutions. Within HealthRules® Payer, our core administrative processing system (CAPS), we’re leveraging AI to help payers streamline workflows, reduce administrative costs, and modernize member experiences.  

Explore a few of the ways AI-powered core administration solutions are transforming healthcare operations and how HealthEdge is developing digital solutions to put health plans at the forefront.  

The Growing Role of AI in Healthcare  

Healthcare organizations across the industry are adopting AI at an unheralded pace, largely driven by the promise of improved operational efficiency, reduced costs, and better care outcomes. According to one McKinsey analysis, for every $10 billion of payer revenue, AI solutions could save $150 million to $300 million in administrative costs.
And more than 80% of health plans are already integrating AI into their workflows. 

AI-driven solutions can enable health plans to achieve critical business goals such as:  

  • Facilitating Intelligent Claims Operations. Using AI, payers can automate more of the claims process to enhance accuracy, improve fraud detection, and reduce payment friction. 
  • Delivering Proactive and Integrated Care. AI tools can surface predictive insights that enable providers to deliver personalized care that meets members’ holistic needs. 
  • Elevating Member and Provider Experiences. AI-enhanced solutions can make it easier for payers to personalize interactions at scale with intelligent tools. 
  • Enhancing Cost Efficiency. Automating data validation, streamlining workflows and reducing the need for manual intervention can help payers lower administrative costs without sacrificing scale. 
  • Ensuring Regulatory Compliance. AI-powered tools can help track and organize essential information necessary for reporting and other regulatory guidelines. 

AI-Driven Innovation in the HealthRules Payer CAPS Solution 

HealthRules Payer exemplifies how AI can revolutionize healthcare operations. Designed with automation, agility, and intelligence in mind, HealthRules Payer enables health plans to adapt to the rapidly evolving market. 

HealthRules Payer is driving transformation across health plan operations with targeted AI-powered tools:  

Automating Claims Administration  

With intelligent claims processing, steps such as claims adjudication, contract management, and financial validation are automated to achieve consistently high accuracy. For example, HealthRules Payer helped one health plan achieve a 90% first-pass auto-adjudication rates, significantly reducing manual intervention and associated costs.  

Real-Time Decision-Making  

AI-enabled tools within the proprietary HealthRules Language helps simplify benefits configuration and enhance accuracy through real-time recommendations. This feature allows health plans to streamline decision-making processes while maintaining flexibility in adapting to market demands. 

Unstructured Data Automation  

Extracting and structuring data from documents, faxes, and forms is traditionally a time-consuming process. By automating this task, HealthRules Payer removes administrative bottlenecks and accelerates workflows.  

Claims Summarization and Support  

The Claims Summarizer, an AI-powered feature, offers concise summaries of pending or denied claims. This helps claims processors quickly identify issues and make informed decisions, further enhancing efficiency.  

Elevating Member Interactions  

Through AI-powered chatbots, HealthRules Payer supports members and customer service teams with instant, accurate answers to questions about claims, benefits, and membership. This strengthens member satisfaction and engagement.  

HealthRules Payer also integrates seamlessly with other solutions in the HealthEdge digital ecosystem, creating a unified platform that leverages automation and real-time data to deliver unmatched value.  

How HealthEdge AI Tools Can Transform Core Healthcare Functions 

The power of AI-driven solutions extends well beyond claims processing to other critical areas of healthcare operations. HealthEdge integrates AI capabilities across its suite of solutions to fully realize its potential. Key applications include: 

Payment Integrity 

HealthEdge Source™ enables payers to drive payment accuracy and integrity through customizable edits and automated contract setup to help reduce payment friction, maintain compliance, and improve payer and provider experiences.  

Provider Network Management 

AI simplifies the management of provider data with tools that intelligently match and merge records, reducing the need for manual reconciliation. The HealthEdge® Provider Data Management solution acts as a single source of truth for accurate and consistent provider information.  

Care Management 

HealthEdge GuidingCare® uses AI to automate tasks for care teams and surface actionable insights to facilitate proactive outreach. Tailored care recommendations help prioritize next steps and improve care outcomes.  

Member Engagement 

HealthEdge Wellframe™ combines real-time insights with intelligent automation to create personalized, seamless experiences for members. AI supports care managers by suggesting message responses and flagging high-risk members based on their interactions.  

By addressing these operational pain points, HealthEdge is helping to set a strong foundation for the future of healthcare operations. 

Responsible AI Development at HealthEdge 

HealthEdge understands that deploying AI in healthcare must include a commitment to transparency and ethical practices. That’s why HealthEdge has built a robust framework focused on responsible AI that prioritizes security, fairness, and compliance.  

HealthEdge’s approach to responsible AI development includes: 

  • Transparency and Risk Mitigation: Proactively addressing concerns related to data privacy, governance, and algorithmic biases. 
  • Alignment with Industry Frameworks: Following guidelines such as the Artificial Intelligence Risk Management Framework (AI RMF 1.0) and the Coalition for Health AI (CHAI). 
  • Collaborative Innovation: Partnering with health plans, end users, and industry stakeholders to align AI capabilities with real-world needs. 

By adhering to these principles, HealthEdge is helping ensure that our solutions are not only innovative but also trusted by our customers. 

The Future of Healthcare Operations  

With its cutting-edge AI capabilities, HealthRules Payer is empowering health plans to redefine how they operate, serve members, and deliver care. Whether it’s managing claims, engaging members, or facilitating care coordination, the opportunities AI presents are immense. 

Are you looking for a new CAPS solution, but aren’t sure which vendor is the right partner for your organization? Download your complimentary copy of the Gartner® Market Guide for U.S. Healthcare Payers’ Core Administrative Processing Solutions. 

 

 

 

Strengthen HEDIS Performance with Digital Member Engagement

Posted on by HealthEdge

Quality performance expectations have reached a turning point in 2025. This year’s Healthcare Effectiveness Data and Information Set (HEDIS) measures, developed and maintained by the National Committee for Quality Assurance (NCQA), place greater emphasis on preventive care, chronic disease management, and social determinants of health (SDOH). These updates require health plans to adapt quickly to remain competitive. 

To meet these elevated expectations and strengthen HEDIS performance, health plans must engage members as active partners in whole-person care. This means going beyond clinical interventions to promote preventive screenings and address social barriers. The HealthEdge Wellframe™ member engagement platform supports this shift by enabling health plans to transition from reactive workflows to proactive, measurable quality improvement strategies using digital tools. 

Adapting to A Shifting Quality Measurement Landscape 

NCQA continues to evolve HEDIS to better reflect whole-person care, with three core areas defining 2025’s elevated standards: 

  • Engagement-Driven Prevention. New metrics measure how effectively health plans engage members to follow through on preventive care, including screenings, immunizations, and early interventions. Documenting that services occurred is no longer sufficient—health plans must demonstrate improved health outcomes and health risk reduction. This shift rewards organizations that foster relationships and use tools such as digital engagement to promote preventive clinical best practices. 
  • Whole-Person Quality Metrics. HEDIS measures now incorporate SDOH, such as housing, food access, and transportation. Health plans are expected to address medical, behavioral, and social factors of members’ lives. Through partnerships with community-based organizations (CBOs) and the use of closed-loop referrals, health plans can reduce barriers to quality care. 
  • Real-Time Performance Standards. Expectations from NCQA and the Centers for Medicare & Medicaid Services (CMS) increasingly require standardized, real-time clinical quality data analysis. Health plans must refine their existing clinical quality and risk adjustment initiatives to show a commitment to improving outcomes, reducing disparities, and advancing value-based care across Medicare, Medicaid, and Marketplace programs. Similar to Star Ratings, HEDIS measures play a central role in health plans’ clinical quality strategy. To stay aligned, health plans must shift from batch reporting to continuous monitoring that identifies care gaps and tracks interventions as they occur. 

In this context, persistent operational and data analytic challenges remain for many health plans. Fragmented data sources limit visibility into members’ needs and delay outreach from care teams, making it difficult to close gaps in a timely manner. Many care teams rely on outdated manual processes that use multiple technology platforms, creating additional barriers and requiring an increasing amount of administrative resources. Traditional approaches cannot guarantee that care gaps are addressed before they negatively impact clinical quality measures. 

At the same time, the financial risks are growing. Low HEDIS performance can lead to significant penalties, while top-tier scores boost Star Ratings and member acquisition. As more value-based care contracts link payment to quality, the stakes for health plans are higher than ever. 

Transform Strategy & Strengthen HEDIS Performance with Wellframe

Wellframe helps health plans meet evolving requirements by embedding digital member engagement into clinical quality operations. This integration accelerates care delivery, enhances member support, and enables a more responsive, whole-person approach.  

Real-Time Intelligence Drives Early Action

Wellframe captures data as members interact with the platform, surfacing care gaps and risk signals earlier. Digital surveys, screening tools, and health assessments offer insights into both clinical and non-clinical needs. 

Predictive capabilities enable Wellframe to identify care gaps and surface them so care teams can conduct individual or group outreach.  For example, pregnant members may receive timely reminders to schedule prenatal visits, while members managing diabetes receive personalized nudges for HbA1c testing and eye exams. These early interventions help maximize impact within quality measurement windows. 

This intelligence enables care teams to take proactive steps to encourage screenings, address chronic conditions, and respond to emerging concerns before they escalate.  

Member-Centered Engagement Builds Stronger Connections 

Wellframe supports member engagement across multiple touchpoints, including two-way messaging with care teams, personalized push notifications, and tailored educational content delivered through the mobile devices members use every day. 

This model improves adherence to screenings, diagnostic testing, and treatment plans that influence HEDIS measures. By meeting members where they are and offering convenient, personalized experiences, Wellframe turns passive engagement into active participation. 

Personalized Programs Support Whole-Person Care 

Managing chronic conditions, maternal health, or preventive goals requires more than one-size-fits-all communication. Wellframe delivers customized digital care programs tailored to each member’s circumstances, including known social risk factors. 

Members experiencing food insecurity can be referred to community-based support. Individuals facing transportation challenges may be eligible for transportation assistance to attend in-person appointments. These personalized interventions drive better health outcomes and higher quality scores. 

Demonstrable Value Delivered by Wellframe

Wellframe delivers measurable results across quality metrics, operations, and member experience, such as: 

  • Enhanced Care Team Efficiency. Care teams using Wellframe can scale their outreach while continuing to deliver personalized support. According to HealthEdge data, health plans have doubled their active caseload capacity and increased member interactions up to sixfold by leveraging intelligent workflows that automate routine tasks, streamline documentation, and prioritize high-risk members. This enables care teams to facilitate care gap closure and enhance coordination across health plan clinical quality and compliance teams. 
  • Higher Member Satisfaction. Members consistently rate their experience with Wellframe highly (an average of 4.7 out of 5 stars in the App Store). For many members, digital communication lowers barriers to care and fosters stronger relationships with their health plan. Satisfied members are more likely to complete screenings, adhere to care plans, and engage long-term to strengthen overall performance. 

Building a Future-Focused Quality Strategy

HEDIS measures reflect how effectively health plans deliver quality, equitable, and consistent care. As expectations rise, digital transformation is essential. 

Wellframe enables timely outreach, tailored education, proactive reminders, and transparency in the care journey. Integrated with care management systems, these tools help health plans close whole-person care gaps more efficiently, engage members at risk, and align with top HEDIS priorities. 

As NCQA and CMS continue to evolve value-based care and clinical quality standards, Wellframe evolves alongside them. With HealthEdge, health plans gain a strategic partner committed to continually improving member outcomes and advancing equity, member engagement and operational performance. 

Strengthen HEDIS performance at your health plan with digital member engagement. Learn how Wellframe helps health plans deliver proactive outreach, close care gaps faster, and elevate the member experience. 

 

Enhance Automation and Cost Savings with EDGEcelerate Optimization Services

Posted on by HealthEdge

Your health plan is constantly growing and expanding—and your digital ecosystem should be able to keep pace and scale with your organization. Whether your health plan is adding new lines of business or adapting to new government regulations, it’s critical to regularly assess and optimize technology solutions. Periodic review of your digital ecosystem can help:

  • Automate and streamline workflows
  • Enhance cost savings
  • Adopt modern product capabilities
  • Ensure regulatory compliance

Digital optimization can have significant financial and operational benefits for health plans. According to the 2024 CAQH Index, the medical industry can reduce its administrative costs by $18B by moving from manual to electronic transactions. For example, it costs a payer $3.41 to manually process a prior authorization. When the authorization is processed electronically, it costs $0.05—a savings of 98% per transaction. Similarly, when a health plan pends a claim and works it manually, it can add 1-2 weeks to the claim’s processing time.

How Can Optimization Services Support Health Plan Strategy?

Many health plans are interested in strategic optimization but aren’t sure where to begin. The best place to start is with an optimization assessment. Delivered by HealthEdge® Global Professional Services (GPS) subject matter experts, an optimization assessment is a strategic engagement to evaluate your current HealthEdge system set up and workflows. Our team also provides a detailed, prioritized report of recommendations and next-step guidance. The goal of the assessment is to identify improvement opportunities, reduce operational costs, enhance the end-user experience, and ensure you realize the full value of your HealthEdge solutions.

Our Global Professional Services team can also support targeted optimization projects. For example, our GPS team partnered with a customer who was facing a common challenge: matching claims with authorizations. Our subject matter experts assessed their system and identified multiple opportunities to improve their claim-authorization matching. As a result, this customer achieved a 56% reduction in their pend rate for authorization-related claims—that’s a 56% reduction in claims requiring manual work!

Another key area for optimization and cost savings is automation. The 2024 CAQH report highlighted prior authorizations as a prime candidate for automation, noting that on average, providers and staff spend 24 minutes per prior authorization request when using phone, fax, or email. This past year, HealthEdge Global Professional Services released the Prior Authorization Catalog, an advanced rule processing engine that automates prior authorization decisions. This scalable solution is designed to handle high volumes of data, enabling payers to support complex decision automation while simplifying workflows for health plan administrators.

EDGEcelerate Optimization Services from HealthEdge

Our Global Professional Services Team is committed to helping our customers harness the power of optimization to ensure their technology evolves alongside their business. To achieve this, we offer EDGEcelerate, a flexible subscription-based GPS offering designed to help health plans unlock the full potential of their HealthEdge solutions. With EDGEcelerate, you gain a dedicated allocation of Global Professional Services support hours each year—allowing you to optimize, adapt, and innovate faster without the administrative burden of managing multiple contracts.

Why EDGEcelerate?

  • Optimization-Focused: Shift from reactive, one-off projects to a proactive, planful strategy that maximizes your technology investment.
  • Flexibility: Choose the level of support your organization needs and use your allocated hours across a wide range of initiatives—no need for separate contracts for every project.
  • Predictability: Simplified, subscription-based contracting gives you faster access to expert resources and greater control over your budget.
  • Dedicated Expertise: Partner with a consistent team of HealthEdge product and industry experts who know your systems, your business model, and your goals.

To learn more, read the full EDGEcelerate data sheet or contact your Customer Success Executive.

How an Integrated Digital Ecosystem Enables Success for Health Plans

Posted on by HealthEdge

Health plan executives face increasing demand to deliver frictionless experiences, from streamlined operations to a modern member experience, to stay competitive in a rapidly evolving market. At the core of health plan operations is the core administrative processing system (CAPS). To truly elevate performance, health plans need a next-generation CAPS solution that can support an integrated digital ecosystem.

While these integrations might feel like a technical headache, their importance cannot be overstated. Real-time, seamless connections between systems ensure businesses can operate efficiently and remain agile. When designed strategically, a health plan’s integrated ecosystem can provide significant operational, financial, and experiential benefits. Here’s how integrations within a health plan ecosystem align with business goals and drive success.

Why Integration Matters in a Health Plan’s Ecosystem

A best-in-class health plan ecosystem consists of critical solutions such as billing, claims processing, member services, provider networks, and more. If not properly integrated, each component operates in a silo, causing inefficiencies, data inaccuracies, and cumbersome workflows.

Integrating these systems offers competitive advantages, such as:

  • Real-Time Data Sharing: Critical data, such as claims information or member profiles, flows seamlessly across digital solutions, reducing errors and bottlenecks.
  • Improved Member and Provider Experience: Integration streamlines processes to provide faster responses, improved transparency, and personalized interactions.
  • Operational Efficiency: Automated workflows replace manual processes, reducing administrative burdens and overall operational costs.
  • Agility for Growth: Integrated ecosystems adapt easily to industry changes, such as evolving compliance regulations, value-based care models, or new product launches.
  • Better Decision-Making: Comprehensive, integrated data equips health plan leaders with actionable insights to make informed decisions.

A health plan ecosystem truly thrives when its core system and supporting components communicate seamlessly, creating a foundation for innovation and success.

The Role of Integration in Core Administrative Systems

At the center of health plans lies modern core platforms like HealthRules® Payer, which are purposefully built to integrate seamlessly with other systems. Here’s why integration with HealthRules Payer is paramount to achieving holistic ecosystem functionality:

Seamless Real-Time Connectivity

The HealthRules Payer Solution Suite leverages an enterprise-class integration layer that enables real-time and batch access to data. Stakeholders—including members, providers, brokers, and pharmacies—can interact with reliable, up-to-the-minute information for better service and collaboration.

Simplified Data Exchange with Industry Standards

Gone are the days of dealing with complicated APIs or legacy database systems. Standardized APIs and interoperability tools ensure HealthRules Payer integrates smoothly with partner systems and external exchanges while meeting compliance requirements like HIPAA.

Affordable Maintenance

One challenge of integration is the long-term cost, particularly when updates roll out. HealthEdge combats this with its Upgrade Assurance Program, ensuring that custom integrations remain functional after each update or release at no extra charge. This minimizes downtime and preserves investment longevity.

Streamlined Ecosystem with Proven Touchpoints

HealthEdge’s HealthRules Payer already supports nearly 100 integration touchpoints, from financial systems to provider data management platforms. By offering pre-built connections to common third-party solutions, health plans enjoy faster implementation, reduced costs, and a more robust ecosystem.

Integration in Action Across Key Functions

To better understand how system integration supports health plan goals, here are examples of its impact across critical business areas:

1. Customer Service

Integrated customer service platforms ensure that a member’s health history, claims data, and benefits information are easily accessible, empowering representatives to resolve issues quickly and efficiently. For example, virtual assistants powered by AI can retrieve and provide this information in real time, cutting call times and improving first-call resolution rates.

2. Human Resources (HR)

From talent acquisition to employee benefits management, integration allows HR systems to connect seamlessly with payroll platforms and benefit providers. This creates a more streamlined process for managing internal administrative needs, keeping employees satisfied and productive.

3. Claims Processing and Adjudication

Legacy claims systems often create bottlenecks, but integration reduces these inefficiencies. Claims data integrates directly with pricing, provider networks, and compliance systems, enabling faster adjudication for cleaner claims and higher auto-adjudication rates. HealthEdge clients, for instance, achieve first-pass auto-adjudication rates of over 90%.

4. Provider Collaboration and Network Management

Real-time provider API support ensures accurate payment processing and data-driven contract negotiations. More seamless communication between health plans and providers streamlines payments, strengthens relationships, and fosters trust[CY1] [AM2] . HealthEdge® Provider Data Management enables health plans to automate data ingestion and matching across multiple sources, streamlining validation processes and improving compliance.

5. Data Analysis and Reporting

Integrated systems empower health plans to unify siloed data for comprehensive reporting. Leaders gain actionable insights into member behavior, claim trends, cost efficiencies, and more through analytics dashboards supported by platforms like HealthRules Answers. This data fosters informed decision-making and enables better forecasting.

Building Future-Forward Solutions with HealthEdge

HealthEdge takes an innovative, modern approach to integration with its HealthRules Connector. Built on advanced architecture, this solution goes beyond enabling compatibility. It establishes a foundation for continual improvement by enabling health plans to adopt emerging technologies and industry best practices, whether these involve AI tools for claims adjudication or consumer engagement systems.

By reducing the costs and complexity of ecosystem management, HealthEdge not only helps health plans succeed today but also future-proofs their technology stack.

Harness the Power of Integration to Meet Your Goals  

Integrating systems within your health plan ecosystem is no longer optional—it’s essential to stay competitive, reduce costs, and improve member satisfaction. The ability to exchange comprehensive, real-time data while maintaining flexibility significantly enhances operational efficiency and enables your team to achieve and exceed critical business goals.

When selecting a partner for system integration, choose one that prioritizes both innovation and reliability. HealthEdge’s HealthRules Payer ecosystem offers a modern, fully integrated platform designed to surpass industry challenges while making your health plan more agile, efficient, and impactful.

Let’s build a smarter, more connected healthcare ecosystem together. To learn more about how the integrated HealthRules Payer solution can provide better data access across your organization and help your teams prepare for the future of healthcare. Read the case study, How One Regional Health Plan Created a Member-Centric Digital Ecosystem.