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The One Big Beautiful Bill Act (OBBBA) is reshaping healthcare, especially for Medicaid and Medicare plans. With tighter budgets, closer oversight, and an emphasis on population health in rural communities, care management is entering a new era. For health plans, the message is clear: adapt quickly or risk falling behind.

The New Reality for Care Management

OBBBA is bringing big changes that demand smarter, more flexible strategies. Medicaid cuts mean plans must deliver more with fewer resources, making efficiency and measurable outcomes essential. Regulators are also raising the bar. The Centers for Medicare and Medicaid Services (CMS) and state audits are increasing, especially around risk adjustment and overpayments, so accurate documentation and strong data practices are more important than ever.

At the same time, $50 billion in new funding for rural health creates opportunities to expand digital care and engagement strategies that close long-standing gaps in access.

How Health Plans Can Prepare

To succeed under OBBBA, health plans will need to rethink how they connect with members, strengthen operations, and adapt to ongoing change. Health plans now must focus on reimagining member engagement, improving population health, leveraging AI, and remaining agile to comply with new regulations.

Reimagine Member Engagement Through Digital Tools

Members increasingly expect to connect digitally with their health plan. A recent HealthEdge survey found that 78% of all health plan members and 81% of Medicaid members are open to, or already using, their plan’s mobile app. User-friendly channels improve accessibility and health literacy, giving members the support they need anytime and anywhere.

When healthcare experiences are personalized and intuitive, members are more likely to feel satisfied, stay engaged, and remain loyal over time. For underserved groups in particular, digital-first outreach can be the difference between receiving the care they need and going without it. Digital-first solutions are more than convenient, they extend care team capacity, reduce administrative burden, and make it easier to engage and retain hard-to-reach populations, particularly in rural areas.

Focus on Population Health Outcomes

The focus on “health equity” may have shifted back to “population health” but the goal is the same: address nonmedical drivers of health while meeting regulatory expectations. Doing so not only helps members, but it also controls costs and improves quality scores.

Health plans should look to advanced risk assessment tools and care gap analytics to help identify rising-risk members earlier, so they can intervene before problems escalate. Flexibility is also key, as integrating both built-in and external tools allows plans to tailor strategies to their populations. Done well, these approaches support better outcomes across measures like Medical Loss Ratio, Star Ratings, HEDIS, and quality improvement programs.

Leverage AI Tools and Optimize IT Resources

AI-driven tools have become essential for modern care management. These AI tools streamline workflows, surface actionable insights, and help care teams make faster, better decisions. Beyond efficiency, AI provides intelligence that makes it easier for care managers to quickly understand a member’s history, coordinate care, and take timely action. This can result in lower costs and a more personalized, connected experience for members.

There is also an IT efficiency opportunity for health plans. Many health plans juggle disparate tools that do not work well together, creating internal data silos and inefficiencies. Consolidating these into an integrated digital ecosystem reduces complexity, improves data sharing, and makes scaling easier. When care teams have seamless systems, they spend less time troubleshooting and more time supporting members. This kind of IT optimization not only strengthens operations but also ensures digital transformation delivers real results.

Stay Agile with Regulatory Changes

OBBBA is set to adjust regulations on a rolling basis and differ by state, so health plans need to be nimble. Running “what-if” scenarios and adjusting benefits or eligibility structures on the fly is now table stakes.

Plans that can adapt quickly will avoid compliance headaches while staying ahead of the curve as regulations continue to evolve. Agility is a competitive advantage now more than ever.

Using the OBBA as a Catalyst for Change

The One Big Beautiful Bill is not just another piece of legislation—it is a catalyst for health plan transformation. Health plans that embrace digital-first engagement, focus on outcomes, harness AI, optimize IT ecosystems, and remain nimble with regulations will be best positioned to succeed. It goes beyond compliance to delivering better outcomes for members while controlling costs.

Solutions like HealthEdge GuidingCare®, HealthEdge Wellframe™, and the broader HealthEdge solution suite tackle these care management challenges head on to give health plans a competitive advantage. By consolidating technology, streamlining care management, and enabling smarter engagement, these platforms provide the foundation for meeting today’s challenges while preparing for what comes next.

Want to learn more about how HealthEdge solutions can help payers consolidate and enhance care management? Read the case study, “How a Regional Health Plan Unified Care Management with HealthEdge.”

Healthcare payers are under increasing pressure to integrate and unify digital solutions so they can streamline workflows and improve operational efficiency. With the passing of the Interoperability and Prior Authorization Final Rule (CMS-0057-F) from The Centers for Medicare and Medicaid Services (CMS) in 2024, modernizing prior authorization practices became an area of strategic focus for many health plans.

Enhancing prior authorization better enables payers to deliver timely, evidence-based care while reducing administrative burdens. Many health plans have already announced their efforts to “streamline, simplify and reduce prior authorization” in favor of accelerated decision-making, improved transparency, and expanded access to affordable care.

Why Modernizing Prior Authorization Matters to Health Plans

Modernizing prior authorization processes is essential to maintaining high-quality and effective care delivery without unexpected costs to payers, providers, or members. Traditional processes often lead to delays, inefficiencies, and frustration for both patients and providers.

Adopting an advanced and integrated prior authorization workflow can enable your health plan to:

• Deliver More Timely, Relevant Care: Patients need timely access to diagnostics, treatments, and non-clinical services. Streamlined prior authorization processes can reduce delays so members can get the care they need when they need it and avoid complications down the line.
• Reduce Administrative Burdens: Providers spend countless hours navigating manual prior authorization workflows, detracting from time spent on patient care. Automating routine authorizations can help significantly reduce this burden.
• Enhance Pricing Transparency: Modernized prior authorization processes can provide the clear, consistent information patients and providers need to make more informed decisions about care access and delivery.
• Improve Member Outcomes: Advanced digital solutions can analyze member information and flag high-risk members for intervention, helping improve clinical outcomes.

How HealthEdge GuidingCare® Supports Payers in Modernizing Prior Authorizations

At HealthEdge®, we’re proud to support health plans in transforming their prior authorization processes. HealthEdge GuidingCare® is a comprehensive care management workflow solution designed to give payers the insights they need to accelerate approvals and increase provider satisfaction.

By leveraging the Utilization Management module within the GuidingCare solution, health plans can achieve goals such as:

• Seamless Automation: GuidingCare automates prior authorization workflows, reducing manual data entry and streamlining approvals. This allows providers to focus on delivering care rather than navigating administrative hurdles.
• Real-Time Decision-Making: With advanced AI-driven and FHIR®-native APIs, GuidingCare enables real-time data sharing and faster decision-making, helping ensure patients receive necessary care without unnecessary delays.
• Regulatory Compliance: With robust data security measures and compliance with CMS and NCQA standards, GuidingCare helps health plans meet regulatory requirements with confidence.
• Enhanced Communication: The platform provides clear, actionable insights into prior authorization determinations, making the process more transparent and easier to navigate for payers and providers.
• Continuity of Care: GuidingCare facilitates seamless transitions for members by maintaining prior authorization records and supporting uninterrupted care.

GuidingCare®: Your Partner in Prior Authorization Transformation

At HealthEdge, we’re dedicated to helping health plans navigate the complexities of prior authorization and care management. GuidingCare is more than a platform—it’s a strategic partner that empowers health plans to achieve their goals and deliver better outcomes for their members.

“We now have the data that shows us by service how many prior authorizations are coming in, how many are we approving, how many are we denying, and what they cost,” said the Vice President of Care and Utilization Management at Priority Health. “We can make educated decisions on the value of asking for that prior authorization, and if there’s no value in it, then why are we asking physicians to jump through them?”

Read the full case study to discover how Priority Health worked with GuidingCare to achieve a preauthorization rate of 80%.

 

Increasing rates of claims denials cause operational bottlenecks and financial consequences across the healthcare system.

In 2024, the initial claims denial rate rose to nearly 12%. Denied claims cost hospitals about $260 billion every year, limiting cash flow and hindering their abilities to provide comprehensive care. High rates of claims denials can also impact members’ ability to access timely care.  Claims management and processing is complex, and there is no one-size-fits-all solution.

So why do claims denials continue to rise, and what are the ripple effects? In this blog, we discuss four key areas that are impacted most by claims denials and how advanced payment integrity can help.

4 Areas Impacted Most by Claims Denials

At a time when healthcare innovation improves outcomes and expands access, an increase in claim denials feels like a step backward. These denials often result from coding errors, insufficient documentation, policy discrepancies, or pre-authorization failures. While these measures may be intended to control costs, they frequently lead to unintended consequences that can create significant challenges for health plans, providers, and members.

1.    Financial and Operational Challenges

The Advisory Board highlights that nearly 90% of improper claim denials are preventable, and often caused by common administrative errors like incomplete documentation, coding mistakes, or missing prior authorizations. These errors are exacerbated by the complexity of the coding and billing system, which includes thousands of updates to diagnostic and procedural codes each year.

Furthermore, health plans must devote significant resources to reviewing and resolving denials, which leads to delays and operational inefficiencies. Taking a reactive approach to denials increases administrative costs for health plans and adds unnecessary strain, without delivering significant savings. This emphasizes the urgent need to invest in denial prevention strategies to streamline operations and minimize waste.

2.    Reputational Impacts

Claims denials don’t just hit a payer’s bottom line—they also chip away at members’ and providers’ trust.

For members, claim denials feel personal. Repeated denials, especially for time-sensitive care, can erode trust in their health plans. Recent public scrutiny only amplifies the reputational risks for health plans, exposing them to advocacy pushes, regulatory intervention, and legal challenges.

For providers, frequent or inaccurate denials increase frustration and undermine collaboration, making health plans appear as obstacles rather than partners in care. This misalignment can jeopardize network agreements and reduce the health plan’s credibility within the provider community.

3.    Poor Clinical Outcomes

High-utilization patients, like those managing chronic illnesses, usually face the steepest challenges. A 2023 study from the Kaiser Family Foundation found that 27% of people with frequent doctor visits had their insurance claims denied, compared to 14% of those with fewer visits.

4.    Reduced Provider Capacity

Healthcare providers face significant challenges from claim denials, spending an average of $43.84 per appeal. These costs add up to billions annually for hospitals and health systems, straining budgets and forcing organizations to divert resources from essential services.

Managing claim denials takes valuable time away from patient care and strategic improvements. Administrative staff responsible for complicated claims rework and appeals processes often face heavy workloads, leading to health worker burnout.

This problem hits smaller hospitals especially hard, as they typically have smaller administrative teams and fewer resources to handle the volume of denials. As a result, these facilities are forced to make tough decisions between paying to appeal claims denials or funding patient care efforts.

Enhance Claims Management with Prospective Payment Integrity

Reducing preventable claim denials requires a shift toward transparency, collaboration, and innovation in healthcare. For health plans, this means taking a proactive approach. Instead of treating claim denials as isolated mistakes to fix after submission, focusing on identifying patterns and addressing root causes can eliminate claims discrepancies at the source.

Payment integrity solutions like HealthEdge Source™ use advanced technology to improve claims management and efficiency.

With HealthEdge Source, the entire claims process—from pre-adjudication to post-pay—is managed through one streamlined, integrated platform. For health plans, this means fewer handoffs, faster resolutions, and significant time and resource savings. This all-in-one approach simplifies operations and gives health plans greater control over managing diverse lines of business.

Robust Reimbursement Content Libraries

HealthEdge Source offers a comprehensive reimbursement content library that is constantly updated to meet the latest payer and regulatory requirements. This helps health plans stay compliant and up-to-date as rules change.

A dedicated internal content team manages these updates, sourcing changes directly from the Centers for Medicare and Medicaid Services (CMS), state Medicaid programs, and other regulators. The team maintains Medicare and Medicaid edits, pricing rules, and rate schedules, delivering automatic updates every two weeks. This seamless process ensures health plans always have access to the most current information, keeping claims aligned with the latest standards and reducing denials caused by outdated information.

Advanced Claims Editing

HealthEdge Source makes claims management easier with advanced editing tools. Unlike traditional systems, the solution allows payment rules to be customized to fit unique health plan reimbursement policies, provider agreements, and regulatory requirements. Based on custom edits, it can flag discrepancies in real time, reducing denial rates and improving first-pass accuracy.

The editing process uses a dual-layer approach for added precision. First-pass edits catch errors upfront, while second-pass edits apply payer-specific rules before finalizing payments. This process helps identify issues such as duplicate claims, mismatched levels of care, or frequency limit violations, cutting down on post-payment corrections or recovery efforts.

The “Monitor Mode” feature adds another layer of control by allowing health plans to test potential edits in a sandbox environment before rolling them out. By modeling financial and operational outcomes ahead of time, plans can make informed decisions and avoid disruptions.

Real-Time Data and Reporting

HealthEdge Source offers clear insights and analytics through customizable dashboards that track key metrics like impacted claims, triggered edits, and financial outcomes. These tools make it easier to refine claims processes and meet regulatory reporting requirements. Root cause analysis adds another layer of support by identifying why denials happen—whether from coding mistakes, unclear policies, or missing documents.

The platform ensures fair and consistent decisions, reduces provider disputes, and promotes better collaboration by combining real-time feedback with history-based logic. Integrating real-time error detection allows health plans to proactively resolve claims issues before adjudication, which helps minimize costly post-payment recoveries.

AI Platform Enhancements

The partnership between HealthEdge Source and Gynisus enables dynamic analysis of claims data in real time to identify issues like coding errors and clinical documentation misalignments that frequently result in denials. This self-checking AI model adapts to the nuances of healthcare data, supports medical necessity validation, and delivers consistent outputs to meet stringent payer requirements. This combination of adaptability and automation reduces review times by more than 50% and empowers clinicians to focus on more complex cases that require specialized expertise.

In addition, leveraging HealthEdge Source in conjunction with Codoxo’s AI-driven Unified Cost Containment Platform can enhance end-to-end payment integrity processes. This partnership combines advanced prospective payment integrity capabilities with AI to address key challenges like fraud, waste, abuse (FWA), and inaccurate claims processing. By consolidating claims workflows and embedding AI directly into the adjudication lifecycle, this collaboration equips health plans with unprecedented transparency, faster time-to-value, and reductions in vendor reliance.

Together, these partnerships make HealthEdge Source an industry leader in proactive claims management, merging cutting-edge AI technology with a deep understanding of payment integrity. By reducing administrative overhead, streamlining error detection, and improving collaboration between payers and providers, these collaborations set a new benchmark for accuracy and operational excellence in healthcare.

Claims Processing Built for Today and Tomorrow

HealthEdge Source redefines payment integrity by addressing the complexity and fragmentation of today’s healthcare system with precision and agility. By combining editing, pricing, and analytics in one easy-to-use cloud platform, it streamlines payment processes and boosts efficiency.

With automation at its core, it reduces manual effort, enhances compliance, and delivers measurable cost savings, ensuring health plans operate at peak performance without the overhead of outdated systems.

Ready to transform inefficient and costly claims processes? Download our eBook, “Path to Payment Integrity: A Story of Innovation and Impact.”

Health plans are grappling with the challenge of reducing operating costs without sacrificing clinical outcomes. At the heart of this challenge lies the core administrative processing system (CAPS), responsible for claims processing, care coordination, and operational workflows.

Unfortunately, many health plans still rely on legacy CAPS solutions that are rigid, siloed, and incapable of scaling with modern business needs. Modern CAPS solutions, like HealthEdge HealthRules® Payer, are designed to scale alongside payers—helping improve margins, enhance efficiency, and drive innovation.

In this blog, we highlight 7 ways an integrated CAPS is a must-have for health plans aiming to stay competitive in a crowded and ever-changing healthcare landscape.

Limitations of Legacy CAPS Solutions

Legacy administrative systems often come with their own sets of challenges and inefficiencies that can cost payers valuable time and money:

• Reliance on Manual Workflows: Heavy reliance on manual review slows down claims processing and increases the risk of errors.
• Internal Data Silos: Disparate technology systems can fragment critical data, making it difficult to access holistic insights and facilitate coordinated care.
• Scalability Challenges: Adapting legacy systems to meet new demands, such as value-based care models or expanding Medicare & Medicaid lines of business, can require costly and time-consuming updates.
• Compliance Shortfalls: When using legacy CAPS, frequent regulatory changes require time-intensive manual updates and customizations.

Switching to an updated and integrated CAPS can help payers automate manual tasks, scale to meet the needs of new member populations, and stay prepared for changes to regulatory and reporting requirements.

Facilitate Health Plan Growth with a Modern CAPS Solution

Modern CAPS solutions like HealthRules Payer help address the pain points of legacy systems by leveraging cutting-edge technology and workflow automation.

1. Resilience and Enhanced Scalability

Integrated CAPS platforms are designed for adaptation and customization, making it easier for your health plan to stay on top of industry changes. Whether payers are responding to regulatory updates, launching new lines of business, or navigating large-scale population health issues, next-generation CAPS can enable health plans to remain resilient.

Real-World Impact:

• Amid the COVID-19 pandemic, Presbyterian Health Plan leveraged HealthRules Payer to configure new benefit plans within weeks (not months), ensuring members received uninterrupted service.

2. Superior Automation for Increased Efficiency

Automation is a hallmark of modern CAPS. From claims adjudication to retroactive reprocessing, advanced platforms automate repetitive tasks, reducing human error and administrative bottlenecks.

Key Metrics:

• 90%+ Auto-Adjudication Rates: HealthRules Payer uses auto-adjudication to streamline claims processing to achieve up to 99% claims accuracy, drastically cutting down on claim backlogs and administrative costs.
• 800% Increase in Claims Automation: Health plans like Medica reported significant gains in operational efficiency by automating previously manual processes.

3. Faster Time to Market

Launching new products and benefits no longer takes months and excessive IT resources to configure. HealthRules Payer allows business analysts to configure and update benefit plans, provider contracts, and member databases with intuitive, no-code tools.

Benefits:

• Health plans can quickly roll out value-based care models, Medicare & Medicaid expansion programs, and innovative consumer engagement initiatives.

4. Actionable Insights with Real-Time Analytics

Real-time data integration is a game-changer for health plans, facilitating claims processing, member engagement, and care coordination. Modern systems like HealthRules Payer consolidate operational data into one integrated accessible platform, allowing health plans to leverage up-to-date analytics to gain more actionable insights.

Capabilities Include:

• HealthRules Connector: Integrates HealthRules Payer seamlessly with other systems, partner networks and exchanges, to create a digital ecosystem.
• Machine Readable Files:  A cloud-based add-on that improves health plans’ processes for publishing Machine-Readable Files, making meeting regulatory requirements easier, faster, and more accurate than ever.

5. Operational Efficiency That Improves Margins

Efficiency is paramount in improving margins for health plans. By automating processes, eliminating data handoffs, and reducing IT resource dependencies, next-generation CAPS drastically lower operational costs. 

Measurable Outcomes:

• $1.2 Million Savings in the First Year: Medica achieved notable savings by implementing HealthRules Payer, thanks to reduced manual intervention and higher claims accuracy.
• Reduced customer service calls through accurate billing and faster claims resolutions.

6. Enhanced Member and Provider Experiences

With HealthRules Payer, health plans can offer members and providers a more transparent, responsive, and efficient experience.

Industry-Leading Features:

• Transparency Tools: HealthRules Answers provides access to operational data for reporting and analytical dashboards. Users can see and share metrics with stakeholders immediately to enable informed decisions at the point of care.
• Configuration: HealthRules Promote makes it easier for health plans to configure new benefits plans faster to meet the shifting needs of member populations.

7. Regulatory Compliance Without Complexity

Complying with evolving state and federal regulations is often a costly endeavor for health plans using legacy systems. Modern CAPS platforms like HealthRules Payer help ensure compliance through automated updates and flexible configuration tools.

Example:

• HealthRules Payer customers with Medicare and Medicaid lines rely on its built-in compliance functionality to update policy changes rapidly without disrupting operations.

Future-Proof Your Health Plan with HealthRules Payer 

Adopting a modern CAPS is no longer optional for health plans striving to: 

• Drive operational efficiency.
• Improve profit margins.
• Enhance member and provider experiences.
• Scale with agility in competitive markets.

The healthcare industry is evolving rapidly, but your technology doesn’t have to hold you back. Platforms like HealthRules Payer empower health plans to reimagine what’s possible by overcoming the challenges of legacy systems and unlocking future-ready capabilities.

By investing in a next-generation Core Administrative Processing System, you’re preparing your health plan to not just survive, but thrive in an increasingly competitive environment.

Read the brochure to discover how HealthRules Payer can improve resiliency to change, support new business models, enable integrations, and more.

As artificial intelligence (AI) rapidly transforms healthcare, many leaders are asking what it really means to go all in. For HealthEdge®, it means embedding practical, responsible, and transparent AI capabilities directly into the tools teams use every day—without compromising trust, quality, or compliance.

In a recent Q&A, Bobby Sherwood, Vice President of Product Management for the HealthEdge GuidingCare® care management solution, shared his perspective on:

-Common AI technology myths in healthcare

-What the future of automation in care management entails

-How HealthEdge is using AI to help customers unlock time savings, strengthen care coordination, and deliver more meaningful member experiences

“We’re all in. We believe AI is going to impact every corner of healthcare—and we’re embracing that head-on.”

Q: What are the biggest AI-related concerns or misconceptions you’re hearing from healthcare organizations today?

Sherwood: The two extremes I hear most often are, “AI is going to replace me” and “AI can’t be trusted.” Neither is true. We’re nowhere near a place where AI can—or should—replace everything a nurse does. But it can enhance them. Using AI to automate reviews and processes can free up teams to focus on more meaningful projects.

I often tell customers that you can use AI for what it does best and pair that with what you do best to improve how you work day-to-day and how you engage with members. That’s the real value: letting AI handle the heavily administrative and low-complexity tasks so care teams can focus on meaningful, human-centered interactions.

Security is the other big concern—and it’s valid. That’s why we spend a lot of time working with customers’ compliance, legal, and security teams to walk them through exactly how our solutions work. We’re very transparent about what we’re building and how it functions.

“That means we’re designing our tools to be transparent, traceable, and auditable from day one. Customers always have control over what’s enabled and when.”

Q: What’s different about the GuidingCare approach to AI compared to other healthcare organizations?

We’re all in. We believe AI is going to impact every corner of healthcare—and we’re embracing that head-on. We’re investing internally, hiring for the right skill sets, and accelerating our time to market. Whether it’s building solutions or forming smart partnerships, we’re prioritizing speed and adaptability. That lets us solve problems faster for our customers and helps them stay ahead, too.

Q: How does GuidingCare’s AI strategy support long-term compliance, ethical use, and internal governance?

Our team is adding AI features with future guidelines and regulations in mind. That means we’re designing our tools to be transparent, traceable, and auditable from day one. Customers always have control over what’s enabled and when. AI-generated content is clearly marked with visual cues, and nothing is auto-deployed without customer agreement. That level of openness is key to earning and keeping their trust.

We’ve also established a dedicated AI Governance Committee at HealthEdge. It includes leaders from product, engineering, compliance, and security, who are all focused on developing AI responsibly and in line with emerging frameworks, like the Cybersecurity Framework from the National Institute of Standards and Technology (NIST). It’s all about protecting our customers and their members.

Q: What questions should healthcare leaders be asking before adopting AI tools?

Start with security, compliance, and transparency—if a tool can’t pass those checks, it shouldn’t be implemented. But beyond that, leaders should ask: How does this align with our business goals? Does it actually support the people doing the work?

Take nurses, for example. The goal isn’t to replace their expertise, it’s to give them more time back—time to truly understand each patient’s unique history, needs, and circumstances. AI can help by surfacing the right information faster, reducing the time spent digging through records or typing notes during appointments. In short, it should take the technology out of the way—not get in the way—so nurses can focus on the human connection that matters most.

Q: Can you give us an example of that in action?

Our Care Management Note Summarizer for care management is a great example. It drastically cuts the time it takes for a care manager to review historical notes and prepare for a call. Instead of spending an hour digging through a record, a care manager can quickly see a high-level summary and focus on the member. That’s huge.

We’re also working with vendor partners on documentation tools that transcribe and summarize conversations in real time—so care managers can focus on listening and supporting, not typing.

[Video embed: https://learn.healthedge.com/healthedge-ai/healthedge-our-ai-vision ]

Q: Beyond care teams, how is HealthEdge thinking about AI from a member perspective?

There’s a big opportunity here, especially with younger generations. Many people don’t want to make a phone call or dig through a digital portal. We’re exploring how to make information like benefit coverage more accessible and personalized by using AI to surface the right content in the right channel at the right time.

We’ve even experimented with AI-generated podcasts from written materials—so someone could listen to smoking cessation tips in a conversational format instead of reading a PDF. It’s really about meeting members where they are.

Q: What does the future of AI look like across the broader HealthEdge ecosystem?

In addition to GuidingCare, we’re applying automation-first strategies across our operations solutions. One example is automating prior authorizations, making the workflow as seamless and accurate as claims processing. We want to reduce manual touches wherever we can and only route exceptions to staff. That means higher efficiency and faster turnaround for everyone involved.

Q: Bobby, do you have any final thoughts about developing AI tools?

We’re not building AI just for the sake of it. We’re building tools that solve real problems—tools that people can trust, that save time, and that make healthcare feel a little more human. That’s always the goal.

Learn more about HealthEdge’s enterprise approach to responsible, impactful AI. Read the data sheet.

Maintaining efficient claims processing workflows can become an overwhelming task for many health plans. Claims teams have to process every claim accurately and on time, keep up with changing rules, and meet the expectations of both providers and members.

Doing all this work with internal teams alone can leave health plans juggling multiple systems, relying on manual processes, and constantly creating new configurations. With shifting regulations and workloads piling up, it’s easy for mistakes, delays, and frustration to creep in.

The challenges only magnify for large-scale operations. Health plans that manage millions of claims each year will find that even a 1% error rate in claims processing can result in millions lost to overpayments, with added costs to correct mistakes, respond to audits, and restore the trust of members and providers.

4 Common Challenges in Claims Operations

Managing complex workflows, constant regulatory changes, and a flood of incoming claims isn’t easy. Mistakes and bottlenecks are bound to happen. Keeping everything running smoothly requires consistent attention. Here are 4 of the top claims processing challenges that can impact performance, drive up costs, and create friction across many health plans:

• Escalating administrative costs

In 2023, a report from Council for Affordable Quality Healthcare (CAQH) found that the medical industry spends $83 billion annually on administrative tasks—like verifying eligibility, coordinating benefits, submitting claims, compliance reporting, and fixing errors. These rising costs take a big toll on health plans, shrinking financial margins and funding available for member care, which can adversely affect medical loss ratio (MLR). As manual processes and inefficiencies persist, health plans face real challenges in staying compliant, adaptable, and cost-effective.

• Inaccurate payments and overpayments

Across the healthcare industry, it’s estimated that 3% to 7% of claims contain errors, though some health plans report inaccuracies exceeding 10%. In 2024, 16 federal agencies reported $162 billions in improper payments, with over $135 billion attributed to overpayments. These payment errors lead to labor-intensive audits, repeated provider outreach, and potential reputational damage.

• Keeping pace with regulatory changes

The Centers for Medicare & Medicaid Services (CMS) issues new rules and updates every year—sometimes several times a year—on both a fiscal and calendar schedule. For health plans, this means constantly adjusting to new requirements, reporting changes, and payment system updates. These ongoing changes add additional complexity to claims processes and stretch internal teams as they try to interpret, implement, and keep pace with each update. It’s easy to fall behind, and even a small oversight can disrupt daily operations or risk compliance. As the pace of regulatory changes picks up and expectations grow, maintaining compliance becomes a constant, high-stakes challenge for health plans.

• Resource strain and workforce fatigue

With medical costs projected to rise by 8% year-over-year, health plan teams are under growing pressure to manage expenses while also responding to escalating demands from members, providers, and other key stakeholders. At the same time, healthcare staff face widespread burnout and fatigue, driven by high work intensity and long hours. As requirements multiply and resources remain limited, the risk of missed deadlines, errors in compliance, and staff turnover grows. These intertwined challenges make it increasingly difficult for health plans to keep teams effective while adapting to an environment defined by relentless change and rising expectations.

Simplify Claims Processing with HealthEdge Source™ Professional Services

HealthEdge Source Professional Services make it easier for payers to manage the increasing demands on internal teams and digital solutions. The HealthEdge Source Professional Services team works directly with health plan users to address specific organizational challenges—whether it’s managing heavier workloads, navigating complex regulations, or supporting overwhelmed teams.

At HealthEdge®, we don’t just implement the technology and walk away. We provide hands-on support and practical solutions to alleviate pressure where it’s needed most. Our goal is to simplify daily tasks, help maintain compliance, and give your team time to focus on meaningful work instead of small, repetitive tasks. With Professional Services, health plans receive expert support so they can adapt and move forward, even with ever-growing demands.

Claims Solution Implementation & Configuration

Every health plan has its own way of working, so our team meets payers where they are. We start by reviewing workflows, identifying how existing systems connect, and outlining a plan that fits specific organizational goals. Working side by side with the health plan team, we customize system settings, business rules, and workflows to fit each team’s needs. This hands-on, data-informed process ensures the final setup aligns with a health plan’s operational goals and regulatory standards.

In addition, our team sets up automated processes that take care of repetitive tasks like claims validation and contract updates. With this approach, health plans have seen up to 50% faster configuration times and as much as a 90% reduction in managed configuration. Our goal is to get claims teams up and running with fewer disruptions to increase benefits from smoother processes, fewer errors, and more time for high-value work from day one.

Providing Ongoing Support

Support doesn’t stop at launch. We provide regular system updates and monitor performance to keep systems running smoothly. Our team works alongside payers to adjust workflows and settings as regulations and business needs shift. With proactive steps like quarterly regulatory briefings and hands-on training for new rules, we have seen up to 30% faster turnaround time for updates and adoption of changes.

Frequent check-ins and direct user access to our technical experts mean issues get caught early and audit findings are kept to a minimum, so operations stay on track. This ongoing support helps health plans respond quickly to industry changes, maintain compliance, and ensure consistent day-to-day performance.

Enhancing Payment Integrity

We use advanced analytics and data studies to help health plans identify the root causes of payment errors, like inconsistent contract terms or misapplied policy rules. By analyzing claim patterns and operational data, we create targeted edits and corrective actions to fix these recurring issues. Health plans we’ve worked with have seen up to 50% faster savings realization from edits compared to traditional methods.

We work closely with health plans to validate improvements and monitor results, making sure payment accuracy is achieved and maintained over time. By creating a feedback loop between analytics, operations, and system configurations, we help payers improve financial performance, maintain compliance, and adapt to industry changes.

How A Regional Health Plan Streamlined Maintenance & Helped Ensure Claims Accuracy

One large regional health plan, supporting commercial, Medicaid, and Medicare members, ran into daily problems with contract consistency and managing the volume of contract updates. Duplicate records and missing information kept popping up as they tried to keep everything current across their systems. Plus, the constant flow of policy updates meant their teams were always working to avoid falling behind on compliance.

HealthEdge Source stepped in with a hands-on support model designed to address these ongoing issues. Our subject matter experts worked closely with the plan to streamline contract maintenance and ensure accuracy. We provided dedicated support through bi-weekly release note walkthroughs, summary matrices, and actionable recommendations, making it easier for the plan to adapt to regulatory changes and integrate updates efficiently. A dedicated support analyst was assigned to guide the team through new requirements and enhance readiness for upcoming changes, allowing the plan to focus on strategic priorities.

As a result of partnering with HealthEdge Source, the health plan was able to:

• Eliminate duplicate contract records and improve overall reliability
• Realize significant reduction in manual contract maintenance efforts through consistent, expert-led support
• Maintain compliance with evolving regulations
• Improve workflow efficiency, freeing up staff to focus on advancing core objectives
• Strengthen operational readiness to respond quickly without disrupting daily operations

What’s Ahead for Payment Integrity?

Health plans deal with complex challenges every day—handling them alone often leads to more risk and higher costs. The HealthEdge Source team offers the expertise and support health plans need to keep operations accurate, accountable, and efficient.

Set your organization up to handle whatever comes next with confidence. Check out our resources to learn more about Professional Services offerings from HealthEdge Source.