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Leverage Next-Generation CAPS to Drive Competitive Advantage and Adaptability

Posted on by HealthEdge

Health plans today are under increasing pressure to modernize their technology and processes to adapt to the complexities of modern healthcare and take advantage of market growth opportunities. They must meet the evolving needs of their members, comply with rapidly changing regulatory requirements, and resolve operational inefficiencies.

Legacy Core Administrative Processing Systems (CAPS) create a widening capability gap that leaves health plans struggling to integrate data, adapt to new payment models, and meet rising member expectations. To remain competitive, health plans must implement a next-generation CAPS that drives efficiency, enhances adaptability, and provides exceptional experiences for members and providers.

Adopting a next-generation CAPS, such as HealthRules® Payer, enables health plans to position themselves as leaders in today’s healthcare landscape. The market dynamics that drive urgency for modernization include:

Digital transformation is unstoppable. Health plans require systems that integrate data, create seamless workflows, and adapt to ongoing industry changes to allow them to remain competitive, meet member expectations, and strengthen provider relationships, now and in the future.

  • Modern automation delivers breakthrough efficiencies. Modern CAPS enhances claims accuracy, lowers operational costs, and boosts productivity by minimizing reliance on manual processes.
  • Member expectations continue to rise. Today’s members are increasingly digitally savvy and demand transparency, convenient interactions, and personalized experiences that enhance satisfaction and retention.
  • Real-time data is essential for success. Access to accurate, actionable data supports better decision-making, care coordination, and operational efficiency.
  • New business models require modern capabilities. Flexible systems such as HealthRules® Payer enable health plans to adopt value-based care models, efficiently launch new products, and ensure compliance with changing regulations.

5 Key Next-Generation CAPS Capabilities

Modern CAPS offer advanced capabilities that transform operations and member service. These capabilities deliver significant value to growing health plans of all sizes:

Hybrid Cloud Delivery:

Modern CAPS offer the flexibility of hybrid cloud delivery, providing health plans with the scalability needed to grow and adapt without the constraints of costly infrastructure. These systems combine cloud-based and optional on-premises capabilities, reducing infrastructure expenses and freeing resources for strategic initiatives. Data access from anywhere ensures faster, better-informed decision-making and seamless operational performance.

Business-Friendly Configuration:

Advanced systems empower business users to configure processes and policies, minimizing delays caused by reliance on IT teams. Rules can be created once and reused across multiple products for consistency and efficiency. System-wide adjustments propagate instantly to enable health plans to respond quickly to market demands and regulatory changes.

Adaptable Modern Architecture:

Next-generation CAPS offer the flexibility to quickly adapt products, benefits, and contracts to align with changing regulations and market demands. With seamless updates, these systems ensure uninterrupted access to the latest features, minimizing disruption and supporting long-term agility.

Ready for Value-Based Models:

CAPS built for today’s healthcare needs support diverse payment models, including bundled payments and capitation, so that health plans can align with value-based care. In addition, data sharing fosters improved provider collaboration and streamlines administrative processes. Built-in compliance tools ensure adherence to evolving regulations, enabling innovation without sacrificing accuracy or accountability.

Seamless Ecosystem Integration:

Modern CAPS integrate seamlessly with other systems, technologies, and services using preconfigured APIs and industry-standard protocols. These platforms reduce the complexity and costs of custom coding. They are also highly adaptable for integrating new systems, creating a unified ecosystem that is efficient and effective in supporting member populations.

The advanced capabilities available today not only resolve the inefficiencies of legacy systems but also unlock a wide range of measurable benefits.

Benefits of a Next-Generation CAPS solution

Modernizing CAPS empowers health plans to thrive in today’s increasingly complex and competitive healthcare environment. By improving processes, fostering stronger provider relationships, and delivering exceptional member experiences, these systems enable measurable gains across every aspect of your organization.

  • Stay Competitive: Adapt quickly to regulatory changes, implement new benefit designs, and respond to market demands with agility.
  • Improve Provider Relationships: Streamline communication and payments while building trust through robust data sharing and transparency.
  • Enhance Member Experience: Empower members with personalized, on-demand access to information and seamless, transparent communication.
  • Mitigate Costs: Reduce administrative expenses with automation and improve claims processing, compliance, and workflow efficiency.

The Time to Act Is Now

Modernizing CAPS is more than a technology upgrade—it’s a transformative step to adapt and grow in a competitive and evolving healthcare environment. With next-generation CAPS, health plans overcome the limitations of legacy systems and drive efficiency, enhance adaptability, and deliver personalized experiences that today’s market demands.

By adopting advanced solutions like HealthRules® Payer, health plans can streamline operations, improve outcomes, and position themselves as leaders in the industry. Now is the time to bridge the gap between outdated processes and future-ready innovation.

Learn more about how the HealthRules Payer solution enabled one health plan to achieve ther digital transformation goals. View the infographic.

Improve Data Security & Compliance with a Prospective Payment Integrity System

Posted on by Diana Nguyen

The healthcare industry has long been a primary target for cyberattacks due to the vast amount of sensitive data it handles. The increasing prevalence of cyber incidents, combined with ever-evolving regulatory frameworks, has made security and compliance top priorities for health plans.

According to the Annual Payer Market Planning Report 2025 by HealthEdge, which surveyed more than 450 health plan leaders, 46% of respondents indicated that security is their primary concern. This is followed closely by concerns about regulatory compliance, with many health plans struggling to keep pace with regulations from the Centers for Medicare and Medicaid Services (CMS) like the No Surprises Act and the Transparency in Coverage​.

The Growing Importance of Data Security in Healthcare

In general, the healthcare industry has witnessed a series of high-profile cyberattacks in recent years, highlighting the critical need for robust data security. In 2024, incidents like the February breach affecting Change Healthcare and the August data breach at National Public Data exposed vulnerabilities in the healthcare system.

As a result, data security in technology and data science has quickly become the top technology concerns for health plans.

Leaders are seeking ways to protect member data while ensuring compliance with HIPAA regulations and other data privacy standards​. HealthEdge Source™ (Source), HealthEdge’s prospective payment integrity platform, offers health plans a clear path to data security by incorporating security and scalability at the beginning and consistently throughout the software development process.

In fact, Source was recently recognized as a Sample Vendor in the 2024 Gartner® Hype Cycle™ for U.S. Healthcare Payers in two categories: Prospective Payment Integrity Solutions and AI-Enabled Fraud Detection. Source incorporates AI capabilities, allowing health plans to leverage AI-driven insights for improved security and compliance.

How HealthEdge Source™ Helps Automate Compliance  

Navigating the complex web of healthcare regulations is another major challenge for health plans. Non-compliance can lead to penalties, reputational damage, and potential legal issues. Health plans must continually monitor CMS changes, update their policies and procedures, and ensure that staff members are well-versed in the evolving regulations.

According to the Market Planning Report, managing CMS fee schedules and staying compliant with evolving regulations are among the most significant pain points for health plans. More specifically, the report outlines leaders’ top 3 biggest challenges when it comes to maintaining CMS compliance:

  • Managing Fee Schedules (55%)
  • Lack of technology partners to ensure regulatory compliance (54%)
  • Lack of staff/resources to make necessary changes (50%)

The Source solutions empower health plans to address these challenges in multiple ways.

Compliance Monitoring

The Source team of regulatory compliance experts monitor and maintain CMS fee and policy changes daily. They are dedicated and well-versed in tracking the changes and helping health plans interpret and implement the necessary changes to maintain compliance. The platform continuously monitors compliance with CMS fee schedules and policy changes and generates reports, enabling health plans to stay on top of their obligations and avoid penalties.

Automated Fee Schedule Management

Keeping up with CMS fee schedule updates can be daunting, but Source simplifies this by automatically uploading fee schedule updates every two weeks. This ensures that health plans always work with the latest data and remain compliant with CMS payment regulations.

Claims Auto-Adjudication

Compliance with CMS payment rules requires accurate and timely claims processing. Source’s auto-adjudication feature reduces the risk of human error, ensuring that claims are processed in accordance with the latest regulatory standards. This helps health plans meet the strict timelines required by CMS, such as the 7-day turnaround for prior authorization decisions.

Preparing for Future Regulatory Changes

Another key finding from the report addresses compliance readiness. The bottom line: Many health plans do not feel adequately prepared for upcoming regulatory changes, particularly regarding the Payer-to-Payer Data Exchange and Advanced Explanation of Benefits. Less than half of respondents report being ready for these regulations​.

HealthEdge Source helps health plans stay ahead of regulatory changes by offering:

  • Scalable Compliance Solutions: The platform is designed to scale with evolving regulations, ensuring that health plans can easily adapt to new requirements without needing significant system overhauls.
  • Regular Updates: Source continuously updates its platform to stay compliant with the latest CMS rules and regulatory guidelines, reducing the burden on health plans to manually track and implement changes.

HealthEdge Source™: Your Strategic Partner in Data Security and Compliance

As health plans navigate the complexities of data security, regulatory compliance, and technology modernization, it is clear that having the right technology platform is critical to success. Source addresses these challenges by offering a comprehensive, integrated payment integrity platform that enhances security, automates compliance, and drives long-term operational efficiency.

Learn more about how Source can help your organization not only stay compliant but also turn regulatory challenges into opportunities for innovation. Watch a demo of the Source solution.

The Hidden Costs of Legacy Core Administrative Processing Systems (CAPS) 

Posted on by HealthEdge

Many health plans continue to rely on legacy Core Administrative Processing Systems (CAPS) as the backbone for managing critical operations such as claims processing, benefit configuration, and member enrollment. However, these systems were not designed to meet the complexities of modern healthcare. As regulatory requirements grow more stringent, payment models evolve, and member expectations for transparency, personalization, and real-time interactions continue to rise, the limitations of these outdated systems have become increasingly limiting—and costly.

At the same time, innovation in healthcare technology is accelerating, widening the gap between the functionality of legacy CAPS and the strategic capabilities and user experience provided by next-generation systems. Health plans that fail to address this capability gap risk falling behind competitors that leverage modern solutions to enhance efficiency, improve member experiences, and adapt to emerging payment models like value-based care.

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The Challenges of Legacy CAPS

Legacy CAPS impede operational agility and the seamless integration required to thrive in today’s healthcare market. The following challenges leave health plans at a strategic disadvantage, unable to capitalize on opportunities or keep pace with industry demands.

1. Limited Adaptability

Legacy systems impede health plans’ capacity to innovate and swiftly respond to shifting market conditions and operational demands. Expanding into new markets and launching innovative products tailored to meet the diverse needs of members can encounter significant delays. This results in missed growth opportunities.

Modifying benefit designs, provider contracts, or claims rules requires substantial IT involvement. This reliance diverts resources from strategic initiatives and increases operational expenses, hindering progress and flexibility.

2. Rigid Architectures

Legacy CAPS rely on outdated technology, which impedes integration, scalability, and innovation for health plans. These rigid systems often struggle to connect with modern solutions like EHRs, care management, and member experience platforms, disrupting information flow. This limits the ability to offer personalized, member-centric services crucial for success. Essentially, CAPS play a central role in the health plan technology ecosystem, either hindering or enhancing surrounding capabilities.

Increased claim volumes and market expansion can lead to latency issues that slow processing. This results in errors, denied claims, and delayed payments, which frustrate members and providers and damage trust. To cope, health plans rely on manual workarounds that increase complexity and costs. This rigidity puts them at a disadvantage in a competitive market.

3. Fragmented Data

The inability of legacy CAPS to unify and share data creates significant obstacles to compliance, operational efficiency, and member engagement. Key capabilities such as enrollment, claims processing, and cost tracking often operate in silos, preventing a cohesive flow of information. This fragmentation undermines workflow efficiency, coordinated care efforts, and integrated member experiences.

Inconsistent or incomplete data within these isolated systems also poses compliance risks. Regulatory reporting becomes an error-prone, labor-intensive process. Fragmented data deprives health plans of the insights needed to identify trends, predict member needs, or optimize provider contracts. This lack of actionable intelligence limits decision-making, stifling innovation and efficiency.

4. Costly Maintenance

Maintaining outdated systems is a resource-intensive and financially draining process that restricts strategic progress. Legacy CAPS require frequent patches and updates to stay operational. As these systems age, the likelihood of breakdowns increases, resulting in costly IT projects and extended downtime that disrupts daily operations.

The IT teams maintaining these outdated platforms must dedicate substantial time to troubleshooting and upkeep. This leaves little room for innovation, such as exploring new technologies or enhancing member services. These opportunity costs further delay health plans from achieving long-term growth and competitiveness.

5. Falling Short of Member Expectations

Members now expect health plans to provide real-time access to information, personalized interactions, and transparent communication about benefits and claims. Legacy CAPS are ill-equipped to meet these demands, leading to frustration and diminished member satisfaction.

Without real-time capabilities, members are left waiting for updates on claims status, cost-sharing details, or eligibility inquiries. This delay jeopardizes growth as it undermines trust and satisfaction with members. Additionally, legacy systems deliver generic experiences.  The inability to personalize interactions results in disengaged members who may seek a more modern experience elsewhere.

The Costs of Legacy CAPS

The challenges of legacy CAPS create a cascade of inefficiencies, compliance risks, and missed opportunities. Health plans that delay modernization face:

  • Escalating Operational Costs — IT maintenance or customizations,  manual workflows, and system inefficiencies drive up costs without creating innovation. There’s a high cost to maintaining the status quo.
  • Regulatory Exposure — Disconnected data and outdated processes increase the risk of non-compliance with ever-evolving regulations.
  • Competitive Disadvantage — Health plans with legacy systems struggle to keep pace with competitors that leverage modern, integrated technology to deliver superior member and provider experiences.

Modernizing CAPS is essential for health plans looking to thrive in a competitive, complex, and rapidly changing healthcare landscape. Addressing the limitations of legacy systems is not just a technological challenge — it’s a strategic imperative.

To further explore this topic, download our infographic on this topic or learn more about the HealthRules® Payer next-generation CAPS platform.

Elevating Member Experience Through Digital Solutions: Insights from the HealthEdge Leadership Forum

Posted on by HealthEdge

At the HealthEdge Leadership Forum in October, health plan leaders shared their insights about adopting digital member experience solutions to improve engagement and operational efficiencies. Michelle Fullerton, Vice President of Care Management at Blue Cross Blue Shield of Michigan (BCBS of Michigan), and Dr. Josette Gordon-Simet, Chief Medical Officer at Blue Cross Blue Shield of Nebraska (BCBS of Nebraska), joined a conversation with HealthEdge’s Chief Medical Officer, Sandhya Gardner, MD, on how these two prominent health plans transformed care management.

Let’s review the key takeaways from this discussion on how digital member experience led to significant improvements in member interactions and improved the efficiency of care management.

Key Takeaways: Adopting Digital Member Experience

1. Digital Engagement Solutions Improve Member Experience

Both BCBS of Michigan and BCBS of Nebraska recognized that traditional telephonic-centric processes alone no longer met members’ expectations for convenience and personalization. With the rise of digital consumer experiences, members increasingly expected similar access and immediacy in healthcare.

BCBS of Michigan began its care management transformation by adopting the Wellframe™ member experience platform. This shift allowed for automated outreach and real-time communication with members, replacing labor-intensive phone calls as the primary method of engagement. The result was a sharp increase in interactions that enabled earlier interventions and better health outcomes.

“We needed another way… We went all-in with digital care management, and the engagement numbers speak for themselves. We’ve gone from four or five interventions per case to 20-40… and we’re answering questions in real-time.” – Michelle Fullerton

Similarly, BCBS of Nebraska adopted Wellframe to address the limitations of traditional outreach. Wellframe’s app allowed members to chat directly with care managers and access digital health resources when convenient.

With Wellframe, BCBS of Nebraska also implemented a model for continuity of care. When one care manager is out of the office, interactions can be effortlessly assigned to other staff who have easy access to all the patient data needed to take the next step.

“Our ‘One Nurse, One Source, One Connection’ model ensures continuity, and Wellframe allows us to provide a seamless experience for our members.” – Dr. Josette Gordon-Simet

With a digital member experience, these health plans report that members are better supported and connected to their care teams, which leads to better engagement and interventions across the board.

2. Digital Tools Save Time and Improve Focus for Care Teams

Adopting Wellframe’s digital tools has significantly lightened the cognitive load on care teams. Streamlined workflows allow care managers to practice at the top of their licenses. Two examples highlighted are the introduction of digital assessments and a new solution, Wellframe’s AI Summarizer, of which BCBS of Nebraska was an early adopter.

BCBS of Michigan rolled out digital assessments, allowing members to submit their health information online. This shift from phone-based assessments to a digital workflow has freed up time for care teams to focus on critical interventions and member engagement.

“We integrated digital assessments into our system… nurses love it, and members like the convenience of answering digitally.” – Michelle Fullerton

For BCBS of Nebraska, Wellframe’s new AI Summarizer significantly reduced care managers’ time preparing for patient interactions. By generating concise summaries of previous engagements, the solution allows managers to quickly understand a member’s history without reviewing extensive notes or asking patients to repeat themselves.

“The AI Summarizer has been fantastic for our nurses, cutting down on time spent reviewing previous notes and letting them focus on care delivery.” – Dr. Josette Gordon-Simet

These streamlined workflows demonstrate how care teams can dedicate more time to direct member care rather than being bogged down by administrative tasks.

3. Seamless Care Management Requires Systems Integration

For BCBS of Michigan and BCBS Nebraska, integrating Wellframe into their other systems was key to their digital strategy. These integrations ensure that data—such as member assessments, alerts, and real-time updates—automatically feeds into the broader documentation and workflows care teams use, allowing for more efficient and timely care planning.

Before implementing Wellframe, care teams at BCBS of Michigan and BCBS of Nebraska often had to manually input or track down critical member information across multiple systems, leading to inefficiencies and care coordination delays. With Wellframe, all relevant member data, including health assessments and real-time alerts, is directly integrated into the existing infrastructure.

This data centralization gives care teams a comprehensive view of the member’s health journey, allowing them to make more informed decisions and act quickly.

“We integrated Wellframe into our care management system, and now nurses get real-time alerts and automatically documented updates.” – Michelle Fullerton

BCBS of Nebraska has experienced similar benefits from integrating Wellframe with its systems, and it is currently implementing HealthEdge’s GuidingCare® digital care management solution. The integrated solution combines member experience with streamlined coordination across the care spectrum.

With GuidingCare, the health plan can seamlessly manage clinical and behavioral health needs, automate care planning, and target high-risk populations to provide whole-person care.

4. Digital Member Experience Establishes Competitive Advantage

By adopting a digital-first strategy, both health plans have positioned themselves as leaders in a market where exceptional member experience is essential to success. BCBS of Michigan has found that Wellframe has been instrumental in adding new members through its commercial line of business with employers:

“Customers tell us that our use of Wellframe sets us apart… It’s been a game changer in the RFP process… Wellframe has made a competitive difference for us in the market.” – Michelle Fullerton

BCBS of Nebraska has also experienced how Wellframe provides an advantage when competing for new business:

“Consumers are much more digitally savvy than they were five years ago, three years ago even. This suite of products really allows us to be…ahead of in many spaces.” – Dr. Josette Gordon-Simet

5. Digital Transformation Success Requires Change Management Strategies

Implementing digital tools like Wellframe is not just about technology—it’s about ensuring that an organization’s people and processes are ready to adapt to new workflows.

When BCBS of Michigan first introduced Wellframe, many nurses had spent years working in familiar systems. The shift to a digital-first approach required new skills and a change in mindset. To address this, BCBS of Michigan built a team of early adopters to influence the organization:

“You need a team of champions… Our early adopters helped guide their colleagues and supported those struggling to adapt to the new digital workflows.” – Michelle Fullerton

BCBS of Michigan prioritized regular feedback loops and continuous training to ensure a smooth transition. By listening to care teams, leadership addressed pain points, refined workflows, and adapted based on real-world usage. This fostered a culture of continuous improvement that empowered care teams to provide feedback and contribute to ongoing success.

BCBS of Nebraska employed a similar approach, ensuring their internal teams were engaged throughout implementation and understanding that adopting digital tools is an ongoing process that requires continuous refinement.

“By engaging our internal teams and making iterative improvements, we’ve created a better overall experience for both members and staff.” – Dr. Josette Gordon-Simet

By listening to their teams, learning from early challenges, and adapting their strategies, these organizations ensured that Wellframe helped them accomplish their goals.

The experiences of BCBS of Michigan and BCBS of Nebraska demonstrate that Wellframe’s member experience solution enhances member engagement and streamlines care workflows, driving meaningful improvements in health outcomes and operational efficiency.

Visit the HealthEdge website to learn how Wellframe can elevate your health plan’s member experience.

Expand Health Plan Product and Service Offerings with Advanced Healthcare CAPS

Posted on by Diana Nguyen

Health plans face continual pressures to modernize their services and provide personalized offerings to broader member populations—without breaking the budget. For 36% of health plan leaders, “business growth & competitive pressures” are among the most significant challenges facing their organizations. Staying competitive requires investment in new and existing technologies that can scale with your organization to meet industry demands without overextending your health plan’s resources.

Integrated Core Administrative Processing Systems (CAPS) can help expand health plan product and service offerings by helping facilitate data sharing and reduce manual intervention. In this blog, we identify the key CAPS capabilities that can give your health plan a competitive edge in meeting growing industry demands.

Expansion: Key health plan priorities

In our Annual Payer Market Planning Report 2025 from HealthEdge®, health plan leaders reported focusing on three key areas for expansion: [DN1]

1. Enhancing existing products and services (62%)

2. Digital transformation and technology upgrades (49%)

3. New product lines and service expansions (47%)

These priorities demonstrate payers’ commitment to developing and supplementing their current resources, instead of replacing them with new solutions. Enhancements are also likely to center around interoperability and integration capabilities that allow health plans to streamline their vendor relationships and better leverage key data.

Effective interoperability leads to seamless data sharing across systems, which helps reduce errors, improve internal collaboration, and encourage scalability. By reinvesting in an integrated CAPS, health plans can access the proprietary data and insights they need to develop solutions and offerings that stand out in the market.

Benefits of an Integrated Core Administrative Processing System (CAPS)

Healthcare CAPS are the backbone of many payer IT systems. By centralizing and automating administrative processes, modern integrated CAPS can provide an invaluable framework for achieving operational transformation.

According to one recent report , 50% of payers plan to invest in CAPS solutions by 2025 to stay ahead of future challenges. This trend is indicative of the growing reliance on interoperable healthcare solutions to continue scaling business operations.

A modern CAPS helps streamline and accelerate health plan workflows by automating key administrative tasks. These solutions also help reduce manual errors and ensure compliance, allowing staff to focus on more strategic priorities—like expanding service offerings. Plus, an integrated CAPS gives health plans more control over their data and processes, helping reduce reliance on third-party vendors and making it easier to leverage key insights.

Gain a competitive edge with advanced healthcare CAPS

Modern CAPS solutions offer a strategic advantage for health plans by enabling digital transformation and technology modernization. By prioritizing these advancements, payers can unlock a multitude of opportunities and benefits.

Enhanced Member Experiences

Health plan members increasingly prefer digital experiences and interactions over traditional channels like phone calls. By adopting integrated digital tools, health plans can deliver personalized interactions that meet members’ unique needs and improve the member experience.

Improved Data Security

Modernizing health plan technologies can help reduce data security risks by adopting the latest data privacy and security protocols. Integrated solutions also facilitate fast, secure data sharing, which helps limit sensitive data access to authorized parties.

Vendor Consolidation

Consolidating vendor solutions can help health plans achieve several goals. It fosters enterprise alignment and transparency by knocking down internal data siloes and reducing barriers to data sharing. Consolidation also helps control costs by minimizing the number of contracts and negotiations.

Scalability and Adaptability

Modern CAPS solutions can scale more easily than legacy solutions to meet evolving industry demands. These platforms provide an intuitive user experience and often allow for more widespread integration opportunities than legacy systems.

Enhance operational efficiency with HealthEdge CAPS

Next-generation CAPS solutions, like HealthRules® Payer from HealthEdge, come equipped with ecosystem-enabled features that improve performance while supporting accuracy and compliance. Integrated with HealthEdge Source™, the solution will automatically update Centers from Medicare and Medicaid Service (CMS) fee schedules every two weeks—so payers don’t have to manually research critical guidelines.

One health plan that adopted HealthRules Payer and Source significantly improved auto-adjudication rates and operational efficiency. The transition positioned them to expand their product offerings and better serve members. To learn more, read the full case study.

Health plans today face unprecedented demands, but they also have unparalleled opportunities to grow and thrive. By investing in innovative technologies, businesses can enhance operational efficiency, better serve members, and maintain a competitive advantage in a dynamic market.

Is your health plan ready to lead the charge toward a more efficient future? Don’t wait—download the HealthEdge Annual Payer Market Planning Report 2025 to learn how top health plan leaders are transforming their strategies to meet the demands of tomorrow. It’s time to take the next step in optimizing your health plan’s process.

 

Payer Market Planning Report: Key Regulations Impacting Health Plans in 2025

Posted on by HealthEdge

For healthcare payers, complying with shifting regulations can be a challenge. Increasingly, state and federal guidelines focus on improving cost transparency while improving patient data safety. Key regulations impacting health plans include the Health Insurance Portability and Accountability Act (HIPAA), the No Surprises Act, the Interoperability and Patient Access Rule, and the Affordable Care Act (ACA). Many payers are reinvesting in their technology ecosystems to increase regulatory compliance through workflow efficiency and streamlined data sharing.

In this article, we highlight four regulations impacting health plans and actionable strategies payers can use to ensure compliance, improve patient satisfaction, and remain competitive.

4 Regulations Impacting Health Plans

The healthcare regulatory landscape is growing more complex, with frequent updates and new laws requiring constant flexibility. Some changes, like the No Surprises Act and recent HIPAA amendments, urge health plans to make regular updates to their policies and procedures. The sheer volume and pace of these changes are unprecedented, underscoring health plans’ need for dedicated resources and specialized expertise to maintain compliance effectively.

The Health Insurance Portability and Accountability Act (HIPAA) Updates

HIPAA is undergoing significant revisions, particularly within the Privacy and Security Rules. By 2024, provisions will streamline patient access to Protected Health Information (PHI), reducing the maximum response time for requests from 30 days to 15 days. This update prioritizes administrative efficiency while maintaining robust privacy and security standards, improving care coordination and patient access to health information.

What it Means for Health Plans

  • Accelerated timelines require faster administrative processes.
  • Enhanced privacy and security frameworks are critical to safeguard patient information.
  • Investment in advanced data management systems like HealthRules® Payer can streamline compliance with these new requirements.

No Surprises Act

As of June 30, 2024, the Centers for Medicare & Medicaid Services (CMS) received over 16,000 complaints from payers related to the No Surprises Act. Many of the complaints highlighted difficulties payers had adhering to guidelines regarding billing transparency and surprise billing provisions. The issued complaints also demonstrate the challenges many payers face in improving organizational transparency and data sharing with their current workflows.

What it Means for Health Plans

  • Transparent cost-sharing policies must become a priority for healthcare payers.
  • Enhanced member education and digital tools are crucial for addressing transparency concerns.
  • Solutions like GuidingCare®, which help manage member engagement and care coordination, can assist in adhering to regulatory mandates.

Interoperability and Patient Access Rule

By 2027, health plans must implement Fast Healthcare Interoperability Resources (FHIR) APIs to facilitate seamless, secure sharing of health records. This rule aims to drive operational efficiency, reduce manual processes, and improve data accessibility for both providers and patients. For health plans, this means balancing short-term adjustments with long-term opportunities to innovate and drive operational improvements.

What it Means for Health Plans

  • Short-term adjustments are required to integrate FHIR-compliant APIs.
  • Long-term opportunities exist for innovation in member service delivery.
  • Updates to existing technology solutions can enhance interoperability while ensuring compliance.

Affordable Care Act (ACA)

Extended open enrollment periods and enhanced subsidies under the ACA have created new opportunities for member growth. However, success depends on payers reassessing their pricing structures and benefit designs to attract a variety of consumer groups. Diversifying plan options can help payers appeal to evolving member needs and stay competitive in a crowded market. It’s also valuable for health plans to communicate any changes in their offerings to members in a clear and timely way—and, ideally, across multiple channels to increase visibility.

What it Means for Health Plans

  • Clear communication of benefits through digital platforms is essential.
  • Personalized customer service and tailored plan options improve engagement and retention.
  • Strategic investments in member experience technologies can ensure competitiveness and improved outcomes.

3 Challenges in Regulatory Compliance

1. Agility and Market Responsiveness

Keeping up with regulatory changes demands agility and responsiveness from payers and their administrative solutions. Yet 55% of health plan executives identify managing fee schedules as a major challenge, according to the Annual Payer Market Planning Report from HealthEdge. Outdated and legacy systems often can’t handle the complexity, update frequency, and data sharing requirements of new regulations—increasing the risk of non-compliance.

2. Resource Shortages & Compliance Gaps

Health plans face pressing operational challenges, including a lack of in-house IT expertise to address regulatory requirements. According to the same Market Planning Report, 50% of health plan executives highlighted “insufficient staffing and resources” as barriers to regulatory compliance. This shortage can hinder a health plan’s ability to implement changes swiftly, leaving organizations vulnerable to penalties.

By leveraging the expertise and knowledge of vendor resources, like the HealthEdge Professional Services team, health plans can minimize disruption, maintain the integrity and efficiency of their contracts, and streamline business functions.

3. Cybersecurity Risks

With escalating cyber threats, protecting sensitive patient data has become a top priority for healthcare organizations. Compliance with HIPAA and other cybersecurity-focused regulations is essential to reduce the risk of breaches that could lead to financial and reputational damage. Many payer technologies lag behind in implementing modern data security features. HealthEdge solutions leverage artificial intelligence (AI) and other tools to help payers achieve enterprise cybersecurity transformation.

4 Strategies to Help Ensure Health Plan Regulatory Compliance 

To keep pace with these challenges, health plans can implement the following strategies:

1. Invest in Modern Technology

Modern Core Administrative Processing Systems (CAPS) solutions can empower health plans to adapt swiftly to regulatory changes without compromising operational efficiency. Platforms like HealthRules® Payer can help streamline administrative workflows, reduce manual errors, and enhance data access, ensuring compliance with minimal disruption.

2. Form Strategic Partnerships

Collaborating with technology vendors experienced in compliance and change management can lighten internal resource requirements and provide specialized expertise. These partnerships offer cutting-edge tools and insights to keep health plans ahead of regulatory shifts.

3. Conduct Regular Compliance Audits

Regular compliance audits are the safety net every health plan needs. They can identify compliance gaps, highlight areas for improvement, and help avoid costly penalties. Audits can also uncover billing inconsistencies, allowing time for corrections before regulators step in. Beyond risk mitigation, audits foster a culture of accountability and continuous improvement within health plans.

4. Engage Key Stakeholders

Effective compliance strategies extend beyond internal initiatives. Engaging stakeholders—including providers, members, and regulators—helps establish transparency and trust. Open communication about regulatory changes fosters collaboration and ensures compliance responsibilities are shared instead of siloed.

By integrating these strategies, health plans can build a resilient compliance framework that both meets current regulatory demand and allows for future growth. Investing in advanced technology solutions can empower health plans to scale their operations through seamless integrations, data sharing, and automation. HealthEdge’s suite of solutions, including HealthRules® Payer, HealthEdge Source™, GuidingCare®, and Wellframe, are designed to support health plans in navigating regulatory complexities and achieve success.

Want to dive deeper into these insights and discover strategies from top health plan executives? Download our HealthEdge Annual Payer Market Planning Report 2025 for an exclusive look at trends, challenges, and solutions shaping the industry. Get actionable strategies to strengthen compliance, improve patient satisfaction, and drive success.