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Artificial intelligence (AI) is moving beyond the experimental phase, and its applications are certainly no longer reserved for very large enterprises. In healthcare, applying AI to improve workflows and outcomes has evolved to be a strategic imperative, especially for health plans. From managing claims to supporting care teams and engaging members, AI is reshaping how health plans operate. To unlock the potential of AI, health plans must embrace AI as a core capability that changes how work gets done rather than just a bolt-on tool.

The Imperative for AI in Healthcare

Administrative complexity, workforce constraints, and rising expectations for access and personalization are straining health plan operations. These pressures are quantifiable and increasingly urgent. Nearly 30% of healthcare spending in the U.S. is tied to administrative activities. Meanwhile, staffing shortages and evolving compliance requirements limit health plans’ ability to scale support without significantly raising costs.

Artificial intelligence offers a practical response to this challenge. By targeting redundant tasks, enhancing decision-making, and enabling more precise interventions, AI can deliver operational benefits where traditional methods fall short.

According to a McKinsey analysis, AI solutions could save health insurers between $150 million and $300 million in administrative costs for every $10 billion in revenue. These tools also offer the potential to reduce medical costs and improve profitability by accelerating interventions and promoting consistency in how services are delivered.

The Path to AI Transformation

The integration of AI into healthcare operations is a progressive evolution, not a single event. AI is a foundational technology with many applications and various degrees of complexity. Advancing AI adoption requires a deliberate approach that aligns technology with each organization’s readiness and strategy. Each phase of AI maturity delivers greater value and, as adoption progresses, there are greater demands on data infrastructure, governance, and change management.

As organizations move from basic predictive capabilities to fully orchestrated, intelligent workflows, the level of operational transformation increases—and the potential value grows in tandem.

As health plans advance AI adoption, more transformational capabilities unlock greater opportunities for impact. Predictive analytics, for example, offers early wins with minimal rework of common processes. More advanced AI capabilities, such as agentic AI assistants or multi-agent orchestration, can significantly reduce administrative burden, enhance coordination, and augment human situational assessments. These innovations allow health plan staff to minimize manual work, focus on higher-value work, and improve outcomes across the enterprise.

The following five areas represent key opportunities where AI can deliver measurable impact across core health plan operations:

1. Predictive Insights

Predictive insights represent an established and widely adopted AI pattern in healthcare. These capabilities enhance visibility into future risks, utilization patterns, and member needs. Traditional machine learning models help health plans synthesize historical and real-time data to forecast trends, identify high-risk individuals, and anticipate operational bottlenecks.

Example use cases: AI can be used for risk and member scoring to prioritize care management efforts and to analyze claims and payment trends to detect outliers and optimize financial performance.

2. Workflow Automation

Workflow automation is an immediate and practical application of AI for health plans. With AI embedded into routine processes, organizations can streamline repetitive tasks, reduce errors, and accelerate operational throughput. These capabilities are especially valuable in areas where data exchange and administrative review slow taking action and increase overhead.

Example use cases: Health plans can embed AI into claims workflows, such as intake, validation, adjudication, and denial management, to streamline repetitive, rule-based processes. This reduces manual effort, improves accuracy, helps ensure compliance, and accelerates end-to-end processing. Additionally, some plans are using Optical Character Recognition (OCR) and Intelligent Document Processing (IDP) to auto-map prior authorization forms from providers and patients into care management workflows to ease administrative overhead and improve throughput.

3. Embedded Generative AI

Generative AI expands user efficiency and decision-making by introducing models that can summarize, synthesize and generate content based on unstructured or semi-structured data inputs. When embedded into health plan workflows, generative AI can reduce staff cognitive burden, support faster documentation, and improve access to vast amounts of critical information during time-sensitive moments such as member interactions.

Example use cases: Generative AI can quickly summarize care notes, complex multi-line claims, clinical histories, and multi-page faxes to help care managers surface essential details and determine next steps without manual review. It can also extract structured data from scanned documents, enabling faster intake and configuration processes across clinical and operational workflows.

4. Copilots and Assistants

AI-powered “copilots” act as intelligent, user-friendly assistants that respond to natural language input, surface relevant information, and guide staff through complex tasks. These copilots offer immediate efficiency gains by reducing the need to switch between systems and lowering cognitive load. They also improve accuracy and responsiveness in member and provider interactions. This functionality reflects applications of agentic AI, in which the system acts with some degree of autonomy to interpret requests, retrieve relevant data, and guide users through workflows.

Example use cases: Plans use AI-powered assistants to enable natural-language member self-service experiences in chat and to support call center representatives with real-time responses to eligibility and benefit inquiries.

Health plans are also deploying chat-based copilots integrated with core workflows to help staff and members interact with plan data, explain adjudication logic in plain language, and surface insights from complex documents like provider contracts. These copilots can extract key details to populate core administrative processing or provider data management systems, easing administrative burden and accelerating resolution times.

5. Multi-Agent Orchestration

Multi-agent orchestration represents an advanced application of AI in health plan operations. Unlike automation that handles discrete tasks, multi-agent systems enable AI to coordinate multiple actions, systems, and decisions without requiring manual triggers. These AI agents complete complex, multi-step, yet clearly defined, tasks across different systems using logic that is pre-programmed or guided by rules and workflows defined by domain experts and engineers. The goal is not just automation but orchestration of the processes that are most complex and expensive in terms of time, energy or accuracy so that the right task is completed by the right system, in the right order, with minimal human intervention.

This approach is especially powerful in areas where workflows span multiple applications or departments, and where delays or handoffs are common. Multi-agent orchestration supports real-time decision-making, enables personalized member journeys, and can help close the loop on tasks that traditionally stall due to complexity or fragmentation.

Example use cases: In claims processing, an orchestrated system of AI agents can automatically gather data from member records, validate information across systems, apply plan-specific rules, and adjudicate the claim. This can occur without requiring manual re-entry or oversight. This reduces cycle time, minimizes errors and improves consistency in outcomes.

The Solutions That Support AI Transformation

To support the delivery of AI capabilities across products and customers, HealthEdge has developed a unified enterprise AI strategy. Our strategy is designed to scale and evolve with customer needs and emerging opportunities across HealthRules® Payer, HealthEdge Source™, HealthEdge® Provider Data Management, GuidingCare®, and Wellframe™.

AI-enabled solutions are generating measurable impact today for HealthEdge customers. For example, summarization capabilities embedded in care management workflows help surface relevant member history in seconds, reducing cognitive load and enabling faster, more informed choices.

Responsible AI Innovation 

HealthEdge is committed to responsible AI development that ensures transparency, security, fairness, and enhanced compliance while proactively mitigating risks associated with new technology adoption. Our approach balances innovation with accountability, helping health plans confidently implement AI-enabled features that enhance efficiency and improve outcomes without compromising trust within their organizations or with their partner or member communities.

To support this, HealthEdge has established a robust framework that ensures AI is deployed ethically, securely, and in alignment with industry best practices:

• AI Principles: Alignment with emerging healthcare industry AI standards and frameworks, including the Healthcare AI Commitments and the Coalition for Health AI (CHAI™).
• Responsible AI: A dedicated enterprise risk governance model that addresses regulatory compliance, safety, security, bias, privacy, transparency, and fairness. This includes adherence to the NIST AI Risk Management Framework (AI RMF 1.0).
• Collaboration & Partnership: Active engagement with customers, end users, and industry stakeholders to co-develop AI-enabled capabilities that reflect evolving real-world needs.
• Operational Value: A focus on AI innovations that deliver tangible improvements in care delivery, operational efficiency, and the member experience.

Responsible AI requires more than technical capability. Health plans need solutions they can trust. These solutions must deliver value while meeting the highest standards of security, fairness, and transparency. Health plans deserve AI solutions that are not only powerful, but also principled, safe, and trusted.

Transform how your health plan operates with AI  

AI adoption is accelerating across the healthcare landscape. However, realizing measurable impact requires more than experimentation. It takes a clear strategy, scalable technology, and a partner that understands how to embed AI into health plan operations.

HealthEdge supports health plans at every stage of their AI journey. Whether building new capabilities or scaling proven ones, we can help you move forward with focus, speed, and measurable results.

Connect with HealthEdge to explore how our enterprise AI approach and capabilities can help you accelerate impact and innovate responsibly.

Accurate and reliable data is the backbone of efficient healthcare operations, facilitating key operations—from claims processing to enhanced member engagement. Yet, for many health plans, managing provider data remains a daunting challenge. Poor data quality leads to inaccuracies, inefficiencies, and regulatory breaches, all of which negatively impact member satisfaction.

Enter HealthEdge® Provider Data Management, a next-generation solution that optimizes provider data accuracy and automation, paving the way for seamless healthcare operations and improved member experiences.

The $3 Billion Problem with Provider Data Management

For many payers, integrating and validating provider data is a complex process that often relies on time-consuming manual processes. Physician practices alone spend $2.7 billion every year maintaining accurate provider directories according to a study from Council for Affordable Quality Healthcare (CAQH). The same CAQH study estimates that streamlining directory maintenance through a single platform could save physician practices at least $1.1 billion annually.

Maintaining an accurate provider data repository is essential for health plans looking to thrive in the competitive healthcare industry. Inaccuracies in provider information trickle down to members in the form of outdated provider directories and other misinformation, causing delays in care access, denials of coverage, and increased friction between health plans, members, and providers.

By combining advanced artificial intelligence (AI) capabilities with real-time data and automation, HealthEdge Provider Data Management offers a purpose-built solution to combat common data challenges and enable health plans to deliver better outcomes and experiences.

The Role of AI in Elevating Healthcare Operations

At the heart of HealthEdge Provider Data Management is advanced AI. By leveraging AI-driven intelligence, the solution enhances provider data workflows in the following ways:

• Data Enrichment: Automatically enriches provider directories, so members only encounter verified, up-to-date records.
• Matching and Merging: Eliminates duplicate records by intelligently matching and merging provider data from disparate sources.
• Prediction and Insights: Provides actionable data insights, helping health plans resolve discrepancies before they create downstream issues.

With AI enabling seamless data management and real-time automation, health plans can deliver the personalized engagement members expect while reducing operational complexity.

How HealthEdge Provider Data Management Enhances Member Satisfaction

HealthEdge Provider Data Management helps payers build a single source of truth for provider information by integrating with existing solutions to streamline data workflows and deliver real-time updates.

Based on our work with health plans so far, we’ve identified 5 key improvements made possible using our advanced provider data management solution:

1. Provide Accurate Provider Directories

Health plan networks are constantly shifting, and providers frequently move to different practices, making it difficult for payers to maintain accurate provider directories. However, member frustration often stems from outdated or inaccurate information listed on provider directories. Incorrect data about provider locations or network status can lead to delayed care, out-of-network visits, and delays in claims processing.

HealthEdge Provider Data Management helps ensure accurate and validated provider information by:

• Implementing 300+ built-in quality checks.
• Leveraging third-party validations, like National Plan and Provider Enumeration System (NPPES) and address standardization.
• Automating real-time updates through APIs and event-based distribution.

2. Simplify Provider Access

Accessible and accurate provider directories are crucial for members looking for timely, in-network care. The HealthEdge Provider Data Management solution supports members in their search, empowering them to confidently schedule appointments and avoid unnecessary hurdles and unexpected bills. By housing provider data within a unified source of truth, the solution helps ensure members find the right provider on the first try.

3. Accelerate Claims Processing

Claims errors due to inaccurate provider data are costly and time-consuming, impacting both members and health plan operations. HealthEdge Provider Data Management automates workflows to eliminate the causes of manual review at their source, helping health plans:

• Avoid claims delays and denials caused by duplicate or incomplete provider records.
• Automate claims-related workflows to enhance payment accuracy.
• Strengthen payment integrity, especially in compliance with regulations like the No Surprises Act.

4. Automate Data Validation 

Instead of spending hours reconciling inaccurate or duplicate provider records, health plan employees can focus on delivering higher-value member-centric services. Streamlining data integration and validation with HealthEdge Provider Data Management allows health plans to reallocate staff resources toward personalized member support, boosting satisfaction and outcomes.

5. Maintain Regulatory Compliance and Transparency

Members and businesses alike value health plans that remain compliant with evolving healthcare regulations. With a robust infrastructure for managing regulatory data requirements, HealthEdge Provider Data Management helps payers achieve:

• Provider directory compliance to prevent regulatory penalties.
• Alignment with transparency-focused mandates, fostering member trust.
• A proactive approach to adapting to new legislative requirements, avoiding disruptions to member services.

A Case Study in Efficiency and Satisfaction with PEHP

Public Employees Health Program (PEHP) serves as a compelling example of the impact HealthEdge Provider Data Management can have. The health program achieved an initial 99.96% success rate in data migration after implementation, allowing them to update large volumes of provider records in near real-time and achieve faster time to value. This also allowed PEHP to reallocate the work of five full-time employees to higher-value assignments.

As a result, PEHP saw an increase in member satisfaction as well as significant cost savings and enhancing operational efficiency. To learn more, read the full case study.

Why Invest in Next-Generation Provider Data Management?

Advanced Provider Data Management is no longer just an operational upgrade; it’s a strategic necessity. Unified and accurate provider data ensures:

• Streamlined operations: Reduced administrative overhead thanks to fewer manual interventions.
• Improved member satisfaction: Better access to accurate and timely care.
• Regulatory readiness: An automated approach to compliance.

These elements collectively position health plans to thrive in an increasingly complex and competitive healthcare landscape.

Get Started with HealthEdge Provider Data Management

Unlock efficiencies, elevate your member satisfaction scores, and align with regulatory standards using HealthEdge Provider Data Management. Contact us to see how we can partner with your organization.

Table of Contents 

• Top 5 Challenges in Managing Medicaid Programs 

• The Consequences of Falling Behind in Medicaid Offerings

• Solve Key Medicaid Challenges with Advanced Payment Integrity

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.