In today’s evolving healthcare landscape, understanding what members want and need is more important than ever. To uncover those insights, HealthEdge conducted its 2025 Healthcare Consumer Study, collecting feedback from more than 4,500 healthcare consumers nationwide.
This summary focuses on a crucial subset of that group: the 2,210 respondents enrolled in Medicare, Medicaid, or those who are Dual Eligible. These populations face more complex health challenges and greater systemic barriers, making their experiences critical for health plans aiming to improve satisfaction, loyalty, and retention.
Why Being a Partner in Care Matters for Health Plans
Health plans that go beyond paying claims and act as partners in care to their members are rewarded with stronger member relationships.
Survey data shows that:
60% of Dual Eligible,
54% of Medicaid, and
53% of Medicare members already see their plan as a care partner, not just a payer.
This shift delivers measurable business benefits:
52% of partner-oriented members say they’re unlikely to switch plans (vs. 40% of payer-oriented members).
75% would recommend their plan to others (vs. 58%).
4 Common Member Pain Points and Barriers to Care
Despite growing digital engagement, members still face persistent challenges with cost and access to care.
High Costs – 17% of Medicare and Medicare Advantage members cite insurance premiums and out-of-pocket costs as a primary concern.
Limited provider choice – 15% of Medicaid and 13% of Dual Eligible members are frustrated by narrow provider networks, which can make it harder to access timely care.
Surprise billing – Unexpected medical bills are a significant issue for 31% of Medicaid members, leading to confusion and financial stress.
Access delays – 43% of Medicaid members say they “never” or only “sometimes” receive timely healthcare, compared to 31% of the general member population, putting them at greater risk of complications later in life.
What Members Want Most from their Health Plan Experience
When asked which innovations would most improve their experience, members ranked the following offerings as their top choices:
24/7 access to knowledgeable support reps
Greater focus on preventive care and wellness
Proactive, transparent communication about available resources
Digital tools and AI-driven solutions play a growing role in meeting member expectations for more accessible and personalized healthcare conversations.
Mobile app usage is rising across member populations: 81% of Medicaid, 77% of Dual Eligible, and 68% of Medicare members say they already use or are open to using mobile apps for managing benefits and care. While AI adoption is still emerging among these populations (25% Medicaid, 21% Duals, 16% Medicare), members show strong interest in AI-powered assistants that offer tailored support and insights.
Better Serve High-Risk Members with AI-Powered Insights
To better serve and retain Medicare, Medicaid, and Dual Eligible members, health plans must shift from being seen as just a payer of claims to a true partner in care. Health plans that deliver personalized support, clear communication, and timely access to care earn more trust and loyalty.
By combining integrated data, AI-driven insights, and a human-centered approach, health plans can improve care coordination and scale outreach that drives member satisfaction and long-term retention. This is not just a member experience strategy; it’s a growth strategy.
To explore the full findings and actionable insights from the 2025 HealthEdge Consumer Study, watch an on-demand recording of the Association of Community Affiliated Plans (ACAP) webinar, From Payers of Claims to Partners in Care.
Discover how the HealthEdge® Customer Operations team makes it easier for HealthRules® Payer customers to meet their business goals.
Health plans across the U.S. depend on the HealthEdge HealthRules® Payer solution every day for streamlined and integrated core administrative processing. The HealthEdge Customer Operations team is focused on ensuring the platform runs as seamlessly as possible, so our customers can worry less about accessing the tools they need and spend more time serving their members.
How the HealthEdge Customer Operations Team Supports Health Plans
Internally, HealthEdge teams make a commitment to being “customer obsessed,” and team members consistently strive to learn more about our customers—from the ways they work to their key operational goals—to provide a personalized experience.
As part of our commitment to customer excellence, our team leaders work to humanize the healthcare technology experience for our end users. We go beyond solving technical problems to make sure that key functions happen seamlessly—like eligibility files going through correctly so that a mother can get the medication for her sick child, or a grandmother can get the medical procedure she needs to experience the joys of playing with her grandchild.
These scenarios remind the HealthRules Payer Customer Operations team members of their purpose: to improve platform quality and access for our customers so their teams can do what is best for their members.
“Our team’s deep industry knowledge allowed us to make informed decisions with confidence, while HealthEdge experts guided us through configurations, troubleshooting, and ongoing refinements.”
-Chief of Staff to the CTO, Health Plan
Our 4-Prong Approach to Customer Operations
The Customer Operations team is comprised of four different groups that work cohesively together to ensure customers have the best possible experience:
The Infrastructure Operations team ensures the company’s private cloud, networks, and operational spaces are secure and available.
The Technical Support Services team manages the response to all inbound customer product inquiries and support tickets by coordinating with customers and product team members to facilitate fast responses and resolutions to any issues that may arise.
The Customer Success team is ultimately responsible for understanding the current and future needs of HealthRules Payer customers and prioritizing the work for the rest of the organization. They are the customer “captains” who understand each customer end-to-end from an operations perspective.
The Business Intelligence team works with the data to allow the rest of the team and customers to gain actionable insights so they can proactively address opportunities for improvement.
Although much of this work sounds technical, the “north star” for this group of hard-working, seasoned professionals is all about helping HealthEdge customers give their members access to the healthcare benefits and services they need when they need them.
“Overall, the migrations away from our legacy system to HealthRules Payer went very well. As with any large project, there is an initial learning and adjustment period, but the HealthEdge team of experts was with us every step of the way.”
-VP of Claims Operations, Health Plan
The Future of Customer Operations
As the HealthEdge customer community continues to expand, the Customer Operations leadership team is looking to improve our team’s own experiences. By establishing more standardized processes and proactively addressing the demand for unplanned work items, they are giving employees more time to discover innovative ways to support the growing customer base – all for the betterment of HealthEdge customers.
In addition, the team is working toward more standardized processes and a more integrated experience for customers of multiple HealthEdge solutions, including HealthEdge Source™ for payment integrity, HealthEdge® Provider Data Management for managing provider networks, GuidingCare® for care management, and Wellframe™ for digital member engagement. As more integration points across these solutions become available, customers will have a more seamless experience working with HealthEdge.
“I was extremely impressed with the HealthEdge team’s depth of knowledge and blown away with the ideas that they already had in preliminary meetings”
-Director, Eligibility and Operational Support, Shared Services Organization
Finally, as the organization encourages and enables health plans to become digital payers, HealthEdge is adopting more digital-centric capabilities that automate manual tasks and improve productivity. Modern technologies that proactively monitor and adjust server capacity are also being implemented to benefit team members and customers alike.
The HealthEdge Customer Operations team is more than just a group of engineers and technical resources who support clients. They are members of a dedicated group focused on making a difference in people’s lives by enabling high-quality healthcare at the right time and the right place.
To learn more about optimizing your experience using HealthRules Payer, visit our data sheet: Optimization Assessment forHealthRules Payer Customers.
Care managers enter the healthcare field to support patients—not drown in paperwork. Yet for many, that’s the daily reality: hours spent sorting through handwritten notes, summarizing past encounters, and piecing together a member’s story before the next touchpoint. It’s time-consuming, mentally exhausting, and pulls focus from what matters most—delivering meaningful, one-on-one care.
The increasingly heavy documentation burden is one of the leading causes of burnout in care management. According to a recent study, nearly 75% of health workers say documentation impedes patient care. Each member interaction can generate pages of notes—some structured, some freeform, captured through chats, assessments, or phone calls. Without a tool to bring it all together, care managers are left to manually sift through scattered information just to surface key facts and decide what to do next. It’s not just inefficient—it’s unsustainable.
This generative AI-powered feature, embedded within the GuidingCare platform, transforms how care managers work by summarizing lengthy, complex notes in a matter of seconds. Instead of spending 30 minutes manually reviewing past documentation, care managers can quickly understand what information matters most, freeing up time and mental bandwidth for more personalized, effective care.
The summarizer pulls in everything from historical care manager notes to chat transcripts and distills it into a clear, actionable summary. It’s not just a passive reporting tool; it actively identifies gaps, flags new opportunities, and suggests additional goals or interventions that can be added to a member’s care plan. It even surfaces personal context—like a member mentioning their pet was sick—to allow care managers to personalize interactions, build rapport, and strengthen trust.
This isn’t a one-size-fits-all solution. The Care Management Note Summarizer is purpose-built for the data environments and workflows that exist within GuidingCare. It’s also been specifically trained to understand how clinical information is documented and how that documentation translates into care decisions. That means it delivers more relevant, targeted insights than generic AI tools—insights that align with both compliance needs and care quality goals.
The Hidden Costs of Administrative Work
Without this feature, hidden costs of administrative work can pile up quickly. Care managers must spend excessive time digging through notes, which delays care, strains team capacity, and increases the likelihood of missed information. In the worst cases, members may have to remind their care managers about prior conversations, eroding trust and confidence.
Early users are already seeing a difference. Initial feedback from care managers using the Care Management Note Summarizer points to meaningful time savings and a noticeable improvement in the quality of member interactions. Care managers also report feeling more prepared going into encounters—and less overwhelmed by documentation afterward.
Responsible AI Innovation at HealthEdge®
As with any AI innovation, responsible development is critical. HealthEdge has established a robust internal AI Governance Committee that includes leaders from product, engineering, compliance, and security. This team ensures that every AI use case meets evolving industry standards for ethics, transparency, and fairness. They also actively monitor external frameworks—such as guidance from the NIST AI Risk Management Framework and the latest discussions from the NIST AI Healthcare Council—to align internal practices with leading regulatory and ethical standards in the healthcare space.
This transparency and accountability are key to adoption and ongoing evolution. HealthEdge understands that organizations can’t just tack on an AI solution—they need confidence in how it’s designed, deployed, and maintained. That’s why every implementation is guided by best practices and clear communication with customers.
The current summarization capability is just the first step. HealthEdge is already working on expanded functionality, including digital assistants that can fetch and present information on command, conversational interfaces, and AI-driven automations that draft messages or update care plans directly.
These tools aren’t replacing care managers—they’re amplifying their capacity. By lightening the administrative load, AI gives care managers more time to do what they do best: support, guide, and build lasting relationships with members.
The Care Management Note Summarizer is a step forward in modernizing care management. And it’s only the beginning of what’s possible with AI-powered innovation from HealthEdge.
Healthcare consumers are raising the bar for what they expect from their health plans. Members want experiences that are personalized, convenient, and responsive. Meeting these expectations across large, diverse member populations is a growing challenge for health plans. That’s where artificial intelligence (AI) can make a meaningful impact.
By using AI to scale member engagement and streamline interactions, health plans have the opportunity to deliver more relevant, proactive, and efficient experiences, without adding administrative burden. Yet according to the 2025 Healthcare Consumer Study from HealthEdge®, only 21% of healthcare consumers say they’ve used—or even know they have access to—AI-powered tools from their health plan.
These survey findings show a big opportunity for health plans. Consumers are ready to embrace AI assistance—but health plans must make it accessible, trustworthy, and demonstrate its value. Below, we explore what the data tells us, the strategies health plans can use to meet rising expectations, and why HealthEdge is uniquely positioned to help with solutions like GuidingCare® and AI-powered workflow tools.
Survey reveals strong interest in AI, despite low user adoption
The 2025 Healthcare Consumer Study highlights a clear disconnect between interest and usage. Only 1 in 5 members have already used an AI tool offered by their health plan—but 64% say they’re open to it.
The members interested in these tools place particular value on AI features like:
Chatbots, virtual assistants, and coaches (94%)
Personalized health education and resource suggestions (92%)
Cost-saving benefit tools and provider recommendations (90%)
Tracking health goals and progress (86%)
So why is adoption of AI tools still so low?
The answer lies in how health plans have historically implemented AI. To date, most AI investment has focused on supporting backend operations, such as improving claims processing, ensuring payment accuracy, and detecting fraud. While these applications are important, they’re often invisible to members.
Even when health plans do use member-facing AI-driven tools, they may not provide information on the technologies behind AI or machine learning (ML) tools. As a result, healthcare consumers are largely unaware of how AI is currently being used across the industry and what value it brings—or could bring—to their experience.
To bridge this gap, health plans need to shift more of their AI focus to member-facing tools that directly enhance engagement, education, and care navigation—which impact health plan costs and operational savings.
Consumer skepticism remains a barrier to AI adoption
Despite their openness to using AI, many healthcare consumers still have reservations. The survey uncovered several key concerns:
26% worry about the quality and accuracy of AI-generated health information
20% are concerned about data privacy
20% cite data security as a barrier to using AI tools from their health plan
To overcome this skepticism, healthcare consumers said health plans could earn their trust by increasing transparency on how and when AI tools are being used, as well as providing data privacy certifications and explanations on how personal data is used and protected.
Ultimately, health plans that take a thoughtful, transparent approach can turn AI from a point of hesitation into a driver of member confidence.
Why now is the right time for AI-powered member engagement
There are several industry trends converging to make AI a strategic priority. Consumer expectations have shifted—they want self-service tools, quick answers, and proactive engagement. At the same time, health plans face rising cost pressures and administrative complexity. AI-driven tools can help summarize and surface key member information to help providers prioritize member outreach.
Evolving healthcare regulations aim to encourage payers to streamline workflows, improve data transparency, and enhance proactive care coordination and delivery. AI-powered solutions can help reduce administrative burden while giving payers more effective ways to engage and retain members.
By deploying AI thoughtfully, health plans can meet members’ expectations and operational needs at the same time.
HealthEdge solutions for AI-driven engagement
HealthEdge is leading the way in delivering AI-powered tools that help health plans transform care and services, while keeping member needs at the center.
Enterprise AI strategy for health plans
At HealthEdge, our comprehensive approach to AI focuses on using these tools responsibly, building trust, and layering capabilities incrementally. This ensures health plans don’t treat AI as a bolt-on feature, but as a core capability embedded across care and operations.
GuidingCare leverages AI for care coordination
GuidingCare uses AI to simplify complex care pathways: triaging cases, identifying care gaps, and summarizing key clinical data. This allows care teams to focus on high-impact interactions while AI handles routine administrative details. It drives both efficiency and personalization in member outreach.
Wellframe’s AI-driven member engagement
Wellframe leverages AI to transform member engagement, creating concise, actionable summaries of member data. This empowers care teams to deliver personalized, timely support, focus on high-impact interactions, and drive greater efficiency and improved member outcomes.
Transforming operations with HealthRules® Payer
Within HealthRules Payer, our core administrative processing system (CAPS), AI helps payers streamline and accelerate workflows, reduce administrative costs, and modernize member experiences.
AI-powered workflow in HealthEdge Source™
HealthEdge Source integrates machine learning to improve payment integrity and claims processing. AI-driven analytics detect patterns, highlight high-risk claims, and enable faster, more accurate reviews, improving the overall member experience.
Intelligently merge data with AI-powered Provider Data Management
The HealthEdge® Provider Data Management solution leverages advanced AI that enables payers to develop a single source of truth for provider data. AI-driven data ingestion and matching help ensure accuracy, consistency, and complete data lineage across all health plan operations.
Dig deeper on the benefits of AI-powered tools
The 2025 Healthcare Consumer Survey shows that healthcare consumers are ready for more intuitive, digital-first engagement powered by AI, but they also want reassurance, clarity, and trust.
HealthEdge leads the way, embedding AI into core platforms like HealthRules Payer, HealthEdge Source, HealthEdge Provider Data Management, GuidingCare, and Wellframe to empower health plans to modernize operations and meet rising expectations. By focusing on transparency, accuracy, and member value, health plans can build confidence while scaling their impact.
To explore these insights and more, download the full 2025 Healthcare Consumer Survey report here.
AI is changing business operations across industries. See how HealthEdge® is integrating AI to automate workflows & improve business outcomes.
Artificial intelligence (AI) is reshaping how industries operate. It’s not just a transformational opportunity for health plans – it’s an urgent one. Rising costs, labor shortages, increased compliance requirements, and administrative complexity are pushing plans to rethink how work gets done, and AI offers a way forward. We sat down recently with Rob Duffy, Chief Technology Officer at HealthEdge®, to explore what becoming an AI-native enterprise means for health plans and the partners who support them.
Rob shares his vision for reimagining the structure of work with AI, his approach to responsible AI adoption, and why the most significant breakthroughs in healthcare will come not from front-end tools but from transforming the everyday processes that quietly power the system.
Generative AI is currently a catalyst for innovation in many industries. What do you see as its most transformative applications for health plans over the next few years?
Rob Duffy: People often jump straight to front-end applications or member-facing tools when talking about AI. And those are important. But the most transformative potential lies in how we refactor work itself.
Across the healthcare industry, many processes still rely on long, manual sequences— read this, look that up, log into three systems, extract five data points, and re-enter them somewhere else. A single task can require 20 separate steps that take up time and create bottlenecks. Agentic AI refers to AI systems and models that can act proactively and autonomously to achieve goals. Agentic AI can take a meaningful subset of those steps off your plate.
Imagine not having to check multiple systems to verify one claim or read 30 pages of documentation to find the two sentences that matter. AI can summarize, extract, auto-complete and present the information you need when you need it. The result? If you’re a care manager, you have more time for members. If you’re in operations, you can resolve backlogs faster and more accurately.
Ultimately, this kind of transformation frees up human capacity for higher-order work and drives better digital experiences. But step one is about reducing friction. We need to start by eliminating 40 to 50 percent of the redundant steps people are still performing across the enterprise. From there, the real innovation can begin.
HealthEdge is on a mission to become an AI-native enterprise. Can you give us a high-level overview of what this transformation entails?
Duffy: Think about the cloud migrations we’ve all gone through over the past decade. Those efforts had structure. We created centers of excellence, developed frameworks, categorized workloads using frameworks like the 6 Rs: rehost, refactor, rearchitect, rebuild, retire, and replace. And we used those for every workload to say, “How will we treat this workload in the cloud?”
That kind of framework doesn’t exist yet for AI. What most organizations are doing now is experimenting. They’re handing people tools like ChatGPT or Copilot and saying, “Try it out.” That can be useful in the short term, but it won’t drive systemic transformation.
At HealthEdge, we’re flipping that approach. We treat AI transformation like a major migration effort. We’ve created an Agentic Center of Excellence and developed our own model for identifying, mapping, and migrating work. We then move work through our version of a factory, just as we would with infrastructure. This time, however, the work we’re mapping encompasses human activities rather than technical systems – tasks, decisions, interactions, clicks, and manual reviews are all in the hands of people.
We ask: Can this be eliminated? Can this be automated? Can we augment the human in the loop instead of replacing them outright? Once we evaluate it, we push it into what we’re calling the “agentic factory,” a structured, repeatable way to move work from human execution to AI systems.
But agentic AI isn’t about replacing people – it’s about partnering with them and augmenting how they work. We need to give people a model that helps them see what AI is doing, why it’s helping, and how they’re still in control.
That’s why HealthEdge is being intentional. We’re not just putting technology out there, but building governance, guidance, and adoption models that help teams know how to use it, when it’s appropriate, and how to build trust.
As our transformation progresses, HealthEdge is focused not only on internal enablement but also on establishing a blueprint that others in healthcare can follow. By leading with process discipline and repeatable models, the company is making it easier for health plans to adapt and scale responsibly.
The industry doesn’t need more experimentation. It needs scalable progress. We are focused on achieving real business outcomes, reducing friction in high-effort workflows, and improving the delivery of care. That means embedding AI directly into our core digital healthcare platforms, not layering it on top. When we do that, we can streamline operations, improve the member experience, and drive real value for our customers.
That’s the kind of impact we aim for: not just a smarter tool, but a smarter system. That’s what HealthEdge is building.
Can you tell us about your agentic AI vision for HealthEdge?
Duffy: My vision is simple: stop doing proofs of concept and start doing real work. We’ve reached a point where experimentation alone isn’t enough. If the only AI in your life is a robot vacuum that sweeps the kitchen floor, you’re not tapping into the full potential of agentic systems.
Our goal is to identify the repetitive, low-value tasks no one wants to do and automate them with intelligence, not just with scripts or bots, but with systems that can reason, respond and learn.
For us, this isn’t about one use case or one solution. It’s about building the infrastructure and processes to apply AI across the board, with governance and accountability built in from the start. That’s how we get to scale, and that’s how we deliver real results for health plans, providers, and members.
Healthcare is a notoriously complex and risk-averse industry. How is HealthEdge balancing innovation and accountability to ensure trust, security and fairness in its AI initiatives?
Duffy: Innovation only works when it’s trusted. To that end, we’re taking a measured and structured approach. First, we’ve developed an internal AI adoption policy and enterprise risk governance model. It draws on frameworks like the NIST AI Risk Management Framework and is guided by principles of fairness, transparency, safety and regulatory compliance.
Second, every candidate technology goes through a structured evaluation process. We don’t deploy a tool just because it’s available. We assess its performance, examine its risk profile, and determine whether it aligns with our internal standards and our customers’ values.
Third, we have a governance council to oversee this work and provide input on direction and oversight. Internally, we want to become excellent at managing innovation responsibly so that externally, we can lead with confidence and transparency.
Our goal is not just to innovate, but to do so in a way that earns and maintains trust. If we get that balance right, the rewards for our customers will be enormous.
For other organizations in healthcare looking to adopt AI, what strategic advice would you offer to help them achieve impactful outcomes while avoiding common pitfalls?
Duffy: Treat AI adoption like a transformation project, not a side experiment. Too often, organizations pursue whiz-bang use cases because they’re flashy or popular. But those don’t always translate into meaningful impact.
I recommend starting with a work inventory. Map what your teams are doing. Look for places where tasks are repetitive, rules-based, or require high cognitive load but low judgment. Then, apply the same rigor you would to a cloud migration. Build a repeatable model. Plan it. Staff it. Execute in waves.
If you do this right, you’ll find that 15 to 20 percent of your people’s work today could be streamlined, automated or augmented. That’s not a hypothetical number. That’s an actual opportunity. It’s not about replacing people. It’s about giving them better tools and freeing them to focus on higher-value work.
What excites you the most about the future of AI in healthcare?
Duffy: There’s a quote I love from Michio Kaku: “When a technology becomes sufficiently advanced, it becomes both everywhere and nowhere.” He used electricity as the example. It’s in everything we do, but we never really notice it. We just expect it to work.
That’s what I want for AI. I want it to become so embedded in our systems, so well-integrated into the experience of delivering and receiving care, that it fades into the background. That’s when you know you’ve really made it.
Imagine a world where care managers don’t have to dig through files to understand a member’s history, claims are processed instantly with no manual review, and members receive proactive outreach because AI knows when they need support. That world is coming, and we’re building toward it now.
Ready to transform your health plan with enterprise AI?
The healthcare industry is at an intersection of technology, artificial intelligence (AI), and operational efficiency. For payers, ensuring provider data integrity is fundamental to scaling business operations and thriving in a competitive environment.
Provider data serves as the foundation for nearly every health plan operation, yet many organizations struggle with disparate systems. Gathering data from multiple sources, verifying, and uploading to a single database can create costly inefficiencies.
PEHP’s experience with managing provider information illustrates the magnitude of these challenges can reach: before implementing a comprehensive provider data management solution, the payer managed 65,000 practitioners across multiple disparate systems and contended with significant data quality issues.
“We had 7,000 data issues with our practitioners, 1,500 duplicate locations, and practitioners listed multiple times for each location they practiced at,” said Lance Toms, Operations Management Director at PEHP. “We were exponentially increasing our claims backlog.”
These data quality problems created a cascade of operational issues, requiring five full-time employees dedicated solely to manual data entry and processing. The organization relied on paper applications and multiple fillable PDFs, with manual data entry processes taking up to two weeks to complete. These practices led to payment delays, provider abrasion, and increased administrative costs.
Address Critical Data Management Pain Points with an Integrated Solution
With ongoing advancements in digital technologies, AI, and machine learning, payers have access to a modern, comprehensive approach to provider data management. Traditional systems and processes often lack the continuity and sophistication needed to handle the dynamic nature of provider information, which includes frequent changes in credentialing status, network affiliations, and practice locations.
“Provider data is no longer a back-office data set,” said Parvathy Sashidhar, Senior Director of Product Management at HealthEdge. “It’s front and center when it comes to your AI transformation, technology shifts, or any major initiatives within your organization.”
Modern provider data management platforms address these challenges through key capabilities like:
Automated Data Integration and Cleansing
AI-powered provider data management platforms can process both structured and unstructured data formats, utilizing generative AI frameworks to transform disparate data sources into standardized formats. This eliminates the manual processing that previously consumed significant staff resources.
Real-Time Validation and Enrichment
Modern systems can perform over 300 built-in quality checks, including real-time NPPES validations and address standardizations. This proactive approach prevents inaccuracies from impacting downstream systems.
Intelligent Duplicate Prevention
Advanced trust hierarchies and validation logic address duplicate records at their source, eliminating one of the most persistent challenges in provider data management.
Quantifiable Results Drive Operational Excellence
PEHP’s implementation of HealthEdge Provider Data Management delivered measurable improvements across multiple operational areas. The data migration process achieved a 99.96% success rate and was completed in just 3.5 hours, addressing years of accumulated data quality issues and delivering immediate efficiency gains in less than one full business day.
The automation capabilities allowed PEHP to reallocate resources previously dedicated to manual data processing.
“We’ve been able to reduce between two and five FTEs just for data exchange alone and allocate their time differently,” Toms noted. This resource optimization enabled staff to focus on higher-value activities that directly support business objectives.
At the same time, PEHP enhanced claims processing efficiency, achieving a 13% to 15% increase in auto-adjudication rates immediately following implementation. This improvement reduced claims backlogs and accelerated payment processing for providers.
Finally, the solution’s dashboard capabilities provide comprehensive visibility into critical data like provider networks, organizations, and practitioner roles. This enhanced visibility enables data analytics teams to focus on performance analysis rather than data reconciliation, supporting more strategic decision-making.
3 Strategic Advantages of a Modern Provider Data Management Solution
Beyond immediate operational improvements, modern provider data management platforms can position health plans for future growth and innovation. The foundation of accurate, accessible provider data enables advanced analytics, AI-driven insights, and automated workflows that drive competitive advantage.
1. Compliance Support and Risk Management
Regulatory requirements, including the No Surprises Act and various state mandates, demand accurate, up-to-date provider directory information. Automated compliance support ensures timely updates and reduces the risk of penalties associated with inaccurate provider data.
2. Member Experience Enhancement
Accurate provider directories directly impact member satisfaction by ensuring members can locate in-network providers and access care without unexpected costs. This reduces member service calls and improves the overall member experience.
3. Future-Ready Architecture
Cloud-native platforms built on modern architectures support scalability and integration with emerging technologies. This flexibility enables health plans to adapt to changing regulatory requirements and market conditions without significant system overhauls.
Implementation Considerations for Provider Data Management Solutions
As with any new technology adoption, successful provider data management implementation requires careful planning and execution. Key change management considerations include factors like integration capabilities, custom configurations, and the availability of staff adoption training.
An effective provider data management tool should offer both native integration with existing core administrative processing systems (CAPS) and the flexibility to connect with external systems through configurable APIs. This ensures seamless data flow across the entire technology ecosystem.
Business rules and validation processes should also be configurable to accommodate a health plan’s unique organizational requirements. Low-code, no-code frameworks, like the ones HealthEdge Provider Data Management uses, enable rapid customization without extensive technical expertise.
But to get full value from advanced provider data management solutions, staff need to know how to use them. Offering staff training, sharing regular implementation updates, and embracing feedback about process adaptation are critical for success.
Positioning Your Health Plan for Future Success
The healthcare industry continues to evolve, with increasing emphasis on value-based care, population health management, and regulatory compliance. Provider data management serves as a critical foundation for these initiatives, enabling health plans to operate efficiently while delivering superior member and provider experiences.
“We’re really excited about putting this platform in place that allows us to do the things we’ve been trying to do for so many years,” said Toms. “We now have the tools to do so.”
Organizations that invest in modern provider data management capabilities today position themselves for success in an increasingly complex healthcare environment. The combination of operational efficiency, regulatory compliance, and enhanced member satisfaction creates a sustainable competitive advantage that drives long-term organizational success.
Learn more about how the HealthEdge Provider Data Management solution can help your health plan ensure provider data accuracy to stay ahead of the shifting regulatory landscape. Read the data sheet.
