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At a recent executive roundtable, HealthEdge® brought together health plan leaders from across the U.S. to share their experiences and see how other organizations are addressing key challenges. One recurring barrier? How to eliminate internal data siloes and leverage actionable insights.

In this article, we highlight key insights from a panel of payer executives who shared how their organizations are currently leveraging the HealthEdge ecosystem to improve data accuracy, transparency, and efficiency.

Why should payers focus on interoperability and data transparency?

Interoperability has been a major disruptor for the healthcare industry, forcing payers to address legacy technologies, siloed processes, and outdated systems. This shift has highlighted the undeniable need for digital innovation and vendor partnership.

By focusing on making data accessible and understandable, payers can streamline processes and move toward a more integrated, forward-thinking system that supports the future of interoperability.

“As we evaluated our operations, we recognized the need to take a data-centric approach to drive meaningful change,” said one panelist, the Enterprise Platform Strategy Leader at a regional health plan. “We applied the RACI model to our data, not just for identifying users and authors, but also focusing on data transformers, a critical yet often overlooked piece. Data is transformed through processes, and by understanding this, we could better align and optimize our operations to meet interoperability requirements.”

What are the practical advantages of leveraging a cloud-first, modern architecture to break down data silos?

Focusing on data as a corporate asset was key. For digital solutions like the HealthEdge ecosystem, the cloud isn’t just a storage site—it’s a foundation for everything from interoperability to analytics. For example, using the FHIR data standard in the cloud isn’t just for compliance. By making this information available in a universal format, health plans can easily repurpose it in areas like provider workflows, integrating data where it adds the most value and meeting requirements beyond regulatory mandates.

“We’ve been cloud-first for 10 of the 11 years I’ve been with the company,” said the Chief Information Officer at a New York-based health plan. “We’re as well-positioned as we could be. Because we organize our data according to FHIR, we’ve been able to use it to create endpoints that we’ve been able to integrate into provider workflows that has delivered value.”

How do health plans address the separation of “business” and “IT” to drive cross-functional collaboration?

“Separating business and IT is a false dichotomy,” said the Vice President of IT at a nationwide health plan. “In our role, we have a unique vantage point to see the silos and inefficiencies that exist across operational areas. It’s not enough to simply point these out; we need to understand the business deeply enough to propose and build meaningful use cases that deliver real value.”

Take “care-related” transactions as an example. Sometimes, the only way a provider knows a member has been discharged is through personal phone calls—a process that’s far too slow. By following the member’s journey and connecting all the data touchpoints, we can provide timely, actionable insights. For instance, tracking discharge data and delivering it to providers immediately can help prevent re-admissions and ensure better care. Our role is to connect the dots, drive accountability, and create solutions that enable business value and improve outcomes.

How can payers ensure new technologies improve efficiency instead of adding more complexity?

The process begins by evaluating what the legacy system actually does. Usually, the system is attempting to serve every need but failing to address core priorities effectively. Payer leaders must identify when a workflow faces bottlenecks, or when a cluttered system is more overwhelming than supportive.

“We really had to understand what our legacy platform did,” said the Enterprise Platform Strategy Leader. “Because we built it, it became all things to all people. But it can’t be everything to everyone, otherwise it’s nothing to nobody. Our legacy platform had more than 500 letters for member communications. By simplifying the logic and adopting a more efficient data model with HealthEdge GuidingCare®, we were able to reduce that to 17.”

With tools like GuidingCare Letters, member communications can be generated in real-time without manual effort, significantly cutting overhead and allowing care managers to focus on improving member outcomes.

With so much data available, how can payers determine what is actionable for improving care management?

Having a lot of data means nothing if you can’t trust it or act on it. The first step is to build a culture that trusts and validates available information so it can guide organizational action. It’s common for health plans to get different answers to the same question depending on where and when the data is pulled.

“I don’t think our core KPIs change, it’s the speed at which we understand the data in order to get those KPI changes materializing,” said the Vice President of IT.

Solutions like HealthEdge® Provider Data Management can automate data ingestion and validation to give payers a single source of truth, reducing workflow complexity and improving the member experience.

What are the most promising AI strategies you’re seeing in healthcare right now?

Artificial Intelligence (AI) is a hot topic, with use cases ranging from streamlining care management to enhancing customer experiences. Innovative uses include agentic AI for tasks like syncing provider data across platforms or performing ambient call center analytics.

“Trust is the fuel that goes in the rocket of AI,” said the Vice President of IT. “We’re exploring how to use AI to identify the right data, confirm its cleanliness, understand its governance and history, and then apply it effectively. The problem often isn’t the absence of data, but rather knowing which data is clean, what it means, and how to use it. By using AI to establish that foundation of trusted data, we can unlock its full potential.”

AI-driven tools can unlock new possibilities, but the costs often emerge before the economic benefits, requiring health plans to maintain careful oversight and budget management. The key to success is keeping humans in control—defining, containing, and curating the knowledge an AI agent can access while validating its outputs.

“I think it’s really important that humans have to stay in control,” said the Chief Information Officer, “We’re spending a lot more time investing in managing knowledge and making sure we’re in control of the knowledge we give AI access to.”

What are the key technology challenges and priorities for health plan executives?

A persistent roadblock for many payers is that demand for new projects consistently exceeds the available supply of resources. It’s easy to initiate technology adoption, but far more challenging to demonstrate tangible value and complete them. Promoting a culture of rapid iteration and testing is essential.

“A cultural thing we struggle with is embracing failing often enough, because we’re trying something so new—and embracing that at the engineer level is key,” said the Vice President of IT. “We’re seeing such an accelerated pace of change in technology that if we spend too much time trying to make one solution work that multiple competitive capabilities can come out in the meantime. It’s important to be able to fail, fail fast, be okay with it, and move on to new things.”

Another significant challenge is driving adoption and establishing trust among teams who may be skeptical of new technologies. It is common for users to demand explainable, compliant AI solutions before they are willing to fully integrate them into their workflows. Consequently, effective change management and complete transparency regarding the capabilities and limitations of these tools are essential for successful implementation.

Achieve Greater Value from your Digital Solutions

This panel discussion revealed that breaking down data silos is not just a technical challenge, but a strategic priority for healthcare organizations. By aligning technology with business objectives and implementing AI responsibly, health plans can leverage verified data to streamline operations and deliver superior member experiences.

Learn more about how your health plan can leverage technology to deliver an integrated and impactful member experience in the eBook, “Disjointed to Dynamic: How Nascentia Health Modernized Care with HealthEdge GuidingCare.”

HealthEdge Source™ earned the 2026 Best in KLAS Awards: Software and Services as the leader in “Pre-Payment Accuracy & Integrity Solutions (Payer)”—with an overall score 8% higher than its competitors. HealthEdge Source was also the only solution to earn a higher overall score in 2026 than the previous year. This achievement not only highlights the HealthEdge® commitment to excellence, but our customers’ recognition of the ongoing innovation and partnership we deliver. 

“The Best in KLAS awards recognize the vendors who consistently deliver excellence through partnership with healthcare organizations. Winning this award means customers trust you to help them succeed in our rapidly changing healthcare landscape.”
-Adam Gale, CEO, KLAS Research 

Across the healthcare industry, health plans are moving from traditional “pay-and-chase” models to making prospective payments. Solutions like HealthEdge Source help ensure payers are accurately processing claims the first time to improve cost avoidance and reduce downstream waste. 

What Does it Mean to Earn “Best in KLAS”?

KLAS is a trusted third-party research firm dedicated to improving healthcare by gathering, analyzing, and sharing insights based on direct feedback from thousands of healthcare professionals.  

Unlike other industry recognitions, the annual Best in KLAS reports are not based on marketing claims or theoretical performance. Instead, rankings are determined based on testimonials from anonymous, direct feedback from actual health plan customers. For payers, these rankings highlight vendor software solutions that excel in helping healthcare organizations ensure accurate payment and reimbursement.  

In the 2026 report, HealthEdge Source outperformed competitors across several critical categories: 

These scores reflect a platform that is not only robust in its technical capabilities but also passionate about empowering health plan operations by being a true partner. 

Why the Best in KLAS Designation Matters

For health plan leaders, selecting a payment integrity solution is a strategic decision with long-term financial and operational implications. The Best in KLAS designation offers validation that HealthEdge Source delivers on its promises to streamline payment integrity workflows, reduce rework, and process claims correctly the first time. 

One statistic from the report stands out above the rest: when asked if they would adopt HealthEdge Source again and include it in their long-term plans, 100% of customers said “yes”. 

This perfect loyalty score affirms the long-term commitment HealthEdge has made to helping payers optimize pre-payment integrity. It demonstrates that the platform is designed and supported by a team with the common goal to improve healthcare for everyone. 

Real Results Through a Unified Platform

Why do health plans choose to partner with HealthEdge Source? The answer lies in the shift from reactive, disjointed tools to a proactive, integrated ecosystem. While many traditional black-box payment integrity solutions offer limited visibility for health plans to address root-cause issues, HealthEdge Source provides an open book approach that empowers health plans to make edits in-house, proactively address errors, and reduce operational waste. 

The unique platform architecture provides health plans with control, transparency, and future-ready functionality, addressing the core challenges of modern claims processing. 

Configurable Edits and Rules

The platform does not force a “one-size-fits-all” approach. Instead, it offers advanced, configurable editing tools that can be tailored to each health plan’s specific reimbursement models and clinical policies. This helps ensure precision and compliance with internal and external standards. 

Integrated Payment Integrity

Efficiency demands connectivity. HealthEdge Source seamlessly connects with core administrative systems, pricing engines, and external data sources for a unified and transparent workflow. This approach redefines payment integrity by providing platform-level access rather than isolated point solutions. 

Actionable Intelligence

Data is only valuable when it drives informed decision-making. The platform provides intuitive dashboards and comprehensive audit trails, offering advanced analytics and radical transparency that support compliance and strategic decision-making. 

Keep Your Health Plan Up to Date

To help payers meet market needs, digital platforms need to operate with the latest intelligence and guidelines. HealthEdge Source delivers platform-wide updates on a 2-week cycle to help maintain accuracy and flexibility. Plus, the Retroactive Change Manager tool improves transparency throughout the claims management process by automatically flagging reconcilable claims, scheduling reviews, and reducing the need for manual intervention. 

Partner with the Market Leader in Payment Integrity

“Health plans need payment integrity that delivers accuracy, insight, and control at scale. Being named Best in KLAS validates HealthEdge Source as the modern standard for payment integrity—and we expect to continue raising the bar for the industry.” 
-Ryan Mooney, Chief Product Officer at HealthEdge 

When they choose HealthEdge Source, health plans gain a partner that is dedicated to delivering a transparent, accurate, and open-book approach to payment integrity. From being the first solution in the market to include pricing and editing in a single module to integrating AI-powered features, the solution helps payers operate more efficiently and support their members more effectively. 

To see a breakdown of the data and learn more about how HealthEdge Source can transform payment integrity, download the data sheet. 

Industry pressures like regulatory complexity and the shift toward value-based care demand that health plans take an integrated, strategic approach to care management. Whether payers are evaluating a new care management platform or seeking greater value from an existing solution, precision and a commitment to innovation are essential for success.

HealthEdge GuidingCare® offers an advanced, integrated care management solution that delivers measurable outcomes for care teams, administrators, and members. The GuidingCare platform delivers a robust foundation that enables health plans to maintain core care workflows while improving key areas such as Medical Loss Ratio (MLR) and holistic care delivery. By fully utilizing GuidingCare’s built-in modules, healthcare organizations can eliminate data silos, enhance member engagement, and unlock actionable insights on clinical and financial performance.

Unlock Efficiency by Combining Fragmented Solutions

Fragmented solutions can impede agility and elevate costs. When functions like utilization management and population health analytics exist in isolation, care teams are forced to reconcile disparate data sources, resulting in inefficiencies and delayed interventions. But platforms with built-in integration capabilities can provide a unified view of each member’s journey and enable more personalized outreach.

GuidingCare was built as a modular, fully interoperable digital ecosystem. Whether payers are considering the platform for the first time or expanding their current usage, there are opportunities to enable seamless data flow across care management, digital engagement, analytics, and compliance.

Translating Data into Action: GuidingSigns Analytics

For new adopters, GuidingSigns Analytics provides predictive power that goes beyond conventional reporting to transform retrospective claims data into forward-looking, risk-based intelligence. Existing users can drive even greater ROI by configuring customizable risk models and integrating Social Determinants of Health (SDOH) data to help prioritize member interventions.

GuidingCare gives care teams access to real-time, comprehensive member profiles that inform targeted outreach and move away from reactive risk mitigation to proactive cost avoidance. The platform’s flexibility supports rapid response to emerging risk and optimizes care team productivity, directly impacting key areas like MLR and member outcomes.

Closing the Engagement Gap with Digital Tools

Member engagement is foundational to any successful care management strategy. GuidingCare’s digital member engagement module supports HIPAA-compliant, streamlined, bidirectional communication between care teams and members. For health plans new to GuidingCare, this means integrated engagement from day one. For current customers, activating digital engagement enables real-time data sharing, symptom tracking, educational interventions, and feedback loops that inform clinical interventions, build member trust, and improve satisfaction.

Operational Agility and Regulatory Excellence

The move toward modular, integrated care management is not only about outcomes but achieving operational resilience and compliance at scale. GuidingCare’s Appeals & Grievances and Utilization Management modules are engineered for regulatory agility, automating complex processes and mitigating compliance risks without additional administrative overhead.

By consolidating disparate point solutions, health plans can benefit from streamlined data management, reduced IT burden, and enhanced agility to respond to market and regulatory change.

Real-World Member Journey: Bringing Whole-Person Care to Life

Imagine a member diagnosed with congestive heart failure who has recently been discharged from the hospital. Using GuidingCare, the care manager begins by accessing a unified, longitudinal member profile that aggregates clinical history, pharmacy data, SDOH factors, and recent hospital events.

The care manager leverages GuidingSigns Analytics to assess the member’s risk for readmission, identifying social or behavioral health barriers that might impact recovery. Through configurable business rules, the platform recommends an evidence-based, individualized care plan and initiates an automated transition-of-care workflow.

Leveraging the digital engagement module, the care manager quickly enrolls the member in daily symptom and medication adherence tracking. When the member logs new symptoms through the mobile app, this data is instantly available to the care manager, who receives a real-time alert. The care manager responds by adjusting the care plan, coordinating with primary care and specialists, and scheduling necessary virtual or home visits.

Throughout the journey, the Utilization Management module allows the coordination of authorizations and services while the Appeals & Grievances module ensures that member issues are documented and resolved with full transparency. The entire process—from risk assessment to multi-channel communication and regulatory compliance—is streamlined within the integrated platform, empowering the care manager to support better outcomes, reduce avoidable readmissions, and foster meaningful member engagement.

Your Partner for Transformation

Healthcare continues to evolve, driven by innovation, regulation, and member needs. HealthEdge® is committed to advancing care management through solutions that anticipate tomorrow’s challenges while delivering measurable ROI.

Whether you’re ready to embark on your care management transformation or seeking to amplify the impact of your existing platform, GuidingCare delivers a future-proof ecosystem for comprehensive, member-centric care.

Discover what GuidingCare can do for your organization. Read the 2025 IDC MarketScape: U.S. Value-Based Healthcare Analytics Vendor Assessment to see how our unified digital ecosystem delivers operational, clinical, and financial results.

Care teams, product managers, and operations leaders across healthcare live inside documents: contracts, benefit summaries, clinical policies, internal runbooks, and email threads. These artifacts carry critical business logic, yet they are largely unstructured and scattered across repositories. Finding a precise answer often means opening multiple PDFs, searching manually, and asking colleagues to “remember where that clause was.” It’s slow, brittle, and hard to scale.

To address this, our AI Platform team built a retrieval-augmented generation (RAG) layer that uses AI agents to reason over unstructured content at scale. Instead of treating each content type as a custom integration, we now empower customers to use a single platform that can ingest, enrich, index, and serve knowledge from contracts, product documentation, release notes, and more.

Healthcare Runs on Documents—But Finding Answers Is Often a Big Challenge

Our starting point was a simple but pervasive problem: “I know this answer exists somewhere in a document, but I can’t find it quickly.” We heard from our customers that this is one of the most common statements across all types of teams, including those responsible for contracts, pricing, implementations, and customer communication.

We wanted a solution that was:

1. Unstructured first – Worked across unstructured content without requiring any schema upfront.
2. Safe for healthcare – Could be safely used in regulated healthcare contexts.
3. Composable – Was reusable across multiple products and workflows rather than built as a one-off feature.

The first wave of use cases includes contract, policy, and product documentation question-and-answer resources for internal users.

A Healthcare-Ready AI Platform for Unstructured Content

Our new AI-powered RAG capability is designed as a platform service, not a single UI, and is part of a broader vision for modern, intelligent health plan technology. At its core, it provides a small, opinionated set of features that product teams can compose into their own experiences:

Natural language Q&A over documents

Users pick a corpus (for example, “Client X Contracts 2025” or “Product Release Notes”) and ask natural language questions. Responses are concise, grounded, and come with citations to the underlying pages or paragraphs.

Context-aware chat

A conversational interface keeps context across turns, allowing users to drill deeper (“Show me where you found that” or “Explain the contract terms to me”).

Traceability and safety controls

Every answer includes citations, and audit logs are stored. This makes it easier for users to validate responses and for teams to adopt the system in workflows that require human review.

Because the platform is API-driven, feature teams can embed these capabilities in different places: internal tools, client-facing portals, or operational dashboards—all backed by the same RAG layer.

Under the Hood: How HealthEdge’s RAG Platform Works

The architecture follows a classic RAG pattern designed for multi-tenant use.

Ingestion and enrichment: Content lands in our blob storage module, either through bulk loads or product-specific pipelines. An event-driven ingestion service listens for new or updated blobs and orchestrates:

• Extracting text from documents and scanned content.
• Chunking content into overlapping segments with a fixed character length, so long documents can be searched efficiently while keeping enough local context for the model to answer questions accurately.
• Enriching with metadata (tenant, application, document name).
• Generating vector embeddings for each chunk—numerical representations of the text that capture its meaning—so we can perform semantic search, not just keyword matching.

The enriched chunks and metadata are then pushed into AI search indexes—specialized data structures optimized for search, which store both full-text and vector representations. Per-tenant isolation is handled via index boundaries and metadata filters, ensuring that each client’s content remains logically and operationally separate.

Retrieval and generation: For each user query, the retrieval service:

• Resolves the tenant and corpus to the correct index scope.
• Returns a compact set of passages with metadata and citation handles.
• Invokes an AI agent with a prompt that includes the most relevant passages, conversation history, and system instructions focused on citation, faithfulness, and tone.

All calls travel through guardrails, including content safety and prompt injection checks, and are fully instrumented with logging and observability. Because product teams integrate with the RAG platform via a stable API, we can change models, tweak prompts, or introduce new retrieval strategies behind the scenes without affecting downstream consumers.

Early Wins: Faster Answers, Safer Decisions, and Shared Infrastructure

While still early in rollout, we are already seeing tangible benefits in pilot teams:

• Time-to-answer – Routine contract questions that previously took several minutes now typically get resolved in a single query and follow-up.
• Consistent, auditable responses – Citations and logs provide a clear trail from an answer back to specific clauses.
• Reusable building block – Instead of building bespoke Q&A for each project, product teams can plug into a single RAG service with configuration for their domain.

Equally important, teams are no longer building parallel, one-off RAG implementations. They can focus on product-specific UX while the platform team centrally evolves retrieval quality, observability, and guardrails.

Turning Institutional Knowledge into Actionable Answers

Unstructured documents are where much of our institutional knowledge lives, but they have historically been hard to search, compare, and operationalize. By building a RAG capability, we’ve created a common layer that can turn those documents into actionable, explainable answers.

As we expand, we’re focusing on making answers even more grounded and consistent, strengthening evaluation of retrieval and response quality, deeper integration into existing workflows, and support for additional content types. But the core idea remains simple: meet users where they already work.

To follow HealthEdge’s AI strategy in greater detail, visit the Resources section of our website, www.healthedge.com.

Contact HealthEdge to learn how our AI solutions can streamline your provider data management operations.