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Health plans are under increasing pressure to modernize operations while managing rising costs, regulatory complexity, and evolving member expectations. Many have adopted tech-enabled services to address specific pain points—like claims processing, enrollment, customer service—but these are disparate services that often operate in silos, increasing the risk of fragmentation and inefficiency.

The next evolution is here: tech-enabled solutions. Business Process as a Service (BPaaS) represents a unified, scalable model that integrates technology, operations, and accountability into a single framework. It’s not just about outsourcing tasks—it’s about transforming how health plans operate.

The Problem: Fragmentation in a Digital World

Despite widespread adoption of digital tools, many health plans still struggle with:

• Disparate systems and vendors
• Manual interventions and data silos
• Limited scalability and oversight
• Rising administrative costs

These challenges are compounded by cybersecurity risks, the demands of value-based care, and the need for real-time responsiveness.

The Shift: From Services to Solutions

Tech-enabled services solve isolated problems. Tech-enabled solutions solve systemic ones.

BPaaS is the embodiment of this shift. It consolidates platform, operations, and vendor accountability into a single, outcome-driven solution. This model enables health plans to move beyond tactical fixes and embrace strategic transformation.

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What truly distinguishes BPaaS is its unwavering focus on agility and outcomes.

BPaaS Platform: The Engine of Agility

At the heart of BPaaS is a modular, cloud-based platform that supports automation, interoperability, and real-time execution. Whether through systems of record or engagement, it delivers stable run rates, built-in maintenance, and flexible pricing models.

Operations: Expertise Embedded in Technology

BPaaS integrates business processes with application workflows, embedding healthcare-specific knowledge into every layer. This ensures compliance, drives efficiency, and aligns operations with industry best practices.

Unified Contractual Framework

A single contract governs both technology and services, streamlining vendor management and ensuring accountability—even when third-party tools are involved. This simplifies oversight and enhances transparency.

Strategic Advantages of BPaaS for Health Plans

Simplified Oversight

With one vendor managing the full ecosystem, health plans gain centralized visibility and control. This reduces operational risk and accelerates decision-making.

Cost Efficiency

BPaaS eliminates the overhead of managing multiple vendors and systems. Fewer manual processes mean lower operating costs and reduced total cost of ownership.

Agility in a Changing Landscape

BPaaS enables rapid adaptation to regulatory updates, member needs, and market shifts. This agility is a strategic advantage in a dynamic healthcare environment.

Member-Centric Outcomes

Streamlined processes lead to faster claims, smoother enrollment, and better service. The efficiency gains can be reinvested into member-focused initiatives, improving satisfaction and loyalty.

From Tactical to Transformational

Tech-enabled services were a step forward. Tech-enabled solutions are a leap. BPaaS empowers health plans to move beyond fragmented fixes and embrace a unified, strategic operating model. It’s not just about doing things better—it’s about doing better things.

At HealthEdge®, we help health plans assess their needs and chart a path forward. We would love to hear more about your organization’s goals and challenges.

Learn more about the power of tech-enabled solutions in the case study: “Fixing the Foundation”.

At HealthEdge, AI is becoming a foundational capability that’s changing how we operate from the inside out.

In this fireside chat, I had the opportunity to sit down with @Andrew Witkowski, who leads our AI Team, to discuss what it truly means to become an AI-first enterprise. We explored how this shift goes beyond tooling to change the shape of work, the speed of innovation, and the experience of every team member and customer.

Rob: Let’s start with the big picture. What does it mean for HealthEdge to become an AI-first company?

Andrew: For us, AI-first means rethinking work at every level, not just layering automation onto existing processes. We’re using AI to fundamentally redesign how teams operate, where time is spent, and how decisions get made. It’s not about replacing people. It’s about empowering them. If AI can handle repetitive or manual work, our teams can spend more time solving complex problems, collaborating, and delivering value to customers faster.

We’re treating AI with the same seriousness we applied to our cloud transformation, which is full governance, intentional design, and alignment with our business strategy.

Rob: You’ve built a new program to support this transformation called the Workforce Transformation Lab. What does that team do, and how does it work?

Andrew: Think of the Lab as a hands-on innovation partner. We embed ourselves with teams across the company, from engineering and customer support to product and finance, to help them rethink their workflows. We partner with teams in one week long intensive Idea-to-Impact sprint, in which we systematically evaluate all the work they’re doing and prototype an AI solution that addresses their repeated, routine work. We ask: What should be done entirely by humans? What can be accelerated by AI? And what can be fully replaced? These experiments let us validate before we scale.

This isn’t just about efficiency. It’s about enabling team members to focus on higher-value tasks while building the literacy necessary for broader success.

We use a framework we call the “4 Rs”:

• Retain work where human judgment is critical
• Reassign work to more strategic roles
• Refactor processes to make them more AI-compatible
• Replace work entirely where AI can do it faster, with clear SLAs and fallback options

Refactoring, in particular, is where we see the biggest opportunity. This is where AI delivers the most value, not by removing humans from the loop, but by redesigning workflows so people stay in control while AI handles the repetitive heavy lifting. In healthcare technology, this balance is critical. And it fundamentally changes how people approach their work, freeing them to focus on judgment calls and edge cases while maintaining the oversight our industry demands.

Rob: How has this shift changed the way we develop software?

Andrew: The difference is night and day. We’re building what we call an “agentic factory,” a development environment where AI agents assist throughout the lifecycle: requirements gathering, test generation, documentation, and even deployment validation.

Where Agile was about delivering in two-week increments, AI enables us to prototype, test, and refine in hours or even minutes. It’s a shift in the constraint from execution to creativity and quality of judgment.

And it helps resolve one of developers’ biggest frustrations: blockers. AI reduces wait time for everything, including access, reviews, and approvals. That frees people up to focus on the creative and satisfying parts of the job.

Rob: What does this mean for HealthEdge customers?

Andrew: A lot. Our internal transformation directly benefits the plans we serve. Faster release cycles, smarter product features, and more aligned solutions across HealthRules® Payer, GuidingCare®, and HealthEdge Source™. The same AI-powered tools that help us internally are showing up in our products, with things like natural language understanding, enhanced analytics, and adaptive workflows.

It’s more than an efficiency play. It’s about creating solutions that are more intelligent, more responsive, and more tailored to how health plans actually operate.

Rob: AI can sometimes feel like it’s all about the tech. But you’ve emphasized the people side of this transformation. Can you talk more about that?

Andrew: Cultural transformation is one of the hardest parts of AI adoption. Our early success came from creating a space of psychological safety where people felt free to question the status quo and experiment.

We’re hiring people who can collaborate with AI, and we’re ensuring teams use AI before opening new roles. We’re also evolving our development standards and using AI support at every stage: testing, code reviews, and documentation.

At the role level, we’re seeing developers become AI-enabled problem solvers. QA professionals are becoming quality strategists. AI is changing how we work, and we’re helping people define their next chapter.

That can be scary for some, especially if you’re comfortable and confident in a particular workflow. That’s why transparency and trust are essential. We want people to feel supported, not sidelined. We’re making big investments in upskilling and development to ensure every employee becomes an AI-augmented contributor.

Rob: What’s next on the horizon?

Andrew: We’re focused on three things for the second half of 2025:

1. Scaling pilot success. We’ve seen great results, and now we’re formalizing strategy across the business.
2. Launching our internal AI platform. This suite of tools will integrate with the toolkits employees already use, meeting them where they are.
3. Embedding AI into our customer products. We’re actively running workshops with customers to understand what they want from AI. There’s a lot of excitement, and we want to deliver real value in the HealthEdge portfolio.

Closing Thoughts

Spending time with Andrew reinforces what makes HealthEdge different: a deep commitment to innovation, paired with a people-first mindset. We’re not chasing AI for hype. We’re building it into the way we work, which is thoughtfully, pragmatically, and in service of better outcomes for our customers and their members.

Operational efficiency isn’t just another key performance indicator—it’s the base that enables health plans to scale based on industry demands. As payers face mounting pressure to reduce administrative costs, meet regulatory demands, and deliver better member experiences, many turn to outsourced solutions. But not all outsourcing models are created equally.

Business Process Outsourcing (BPO) and Business Process as a Service (BPaaS) can both offer relief, but serve fundamentally different purposes: One adds capacity, the other supports acceleration.

When it comes to BPO models, payers contract with third-party vendors for distinct point solutions, like administration or claims processing. While BPO has the potential to enhance workflows for payers, it still relies on manual work rather than automation.

Meanwhile, BPaaS solutions are based in the cloud, allowing for enhanced automation and optimization for health plan business processes. BPaaS leverages advanced analytics, machine learning, and artificial intelligence (AI) technologies to simplify vital areas like claims processing, policy administration, and member enrollment.

BPO: The High-Control, High-Cost Path

BPO attracts health plans with its promise of immediate cost savings with lower labor costs.

Key Benefits:

• Immediate cost savings through lower-cost labor
• Automation of specific business processes
• Prioritization expertise through legacy knowledge and specialized skills

However, this deceptively simple solution often reveals significant challenges over time. While BPO providers focus on automating specific business processes, they frequently struggle with broader operational effectiveness.

Critical Challenges:

• Limited understanding of macro-level healthcare processes
• Insufficient investment in modern technology
• Reliance on outdated Core Administrative Processing Systems (CAPS)
• Struggle to adapt to evolving industry needs

The real cost challenge emerges as health plans scale. What begins as an attractive financial solution often becomes increasingly expensive through change orders and service delivery adjustments. These tools, frequently used to cover service delivery overruns during periods of fluctuating demand, gradually erode initial cost savings while making operations more rigid.

Technology Implications:

• Legacy systems struggle to adapt to business changes
• Limited investment in modern platforms
• Outdated data systems
• Growing cybersecurity risks
• Reduced operational flexibility

Instead of focusing on innovation and improving member experiences, leadership often becomes entangled in managing complex vendor relationships. Meanwhile, competitors who embrace more strategic partnership models gain significant advantages in the market.

BPaaS: Transforming Your Business

BPaaS goes beyond staffing—it reimagines how organizations can work. By combining cloud-based platforms, AI, and automation, BPaaS replaces manual workflows with intelligent systems that adapt, learn, and scale.

The healthcare industry is witnessing a transformative shift with the emergence of BPaaS partnerships. This innovative model fundamentally reimagines how health plans can operate, combining the cost efficiencies of traditional approaches with the strategic flexibility demanded by modern healthcare organizations. Unlike conventional operating models, BPaaS represents a sophisticated, connected ecosystem that extends far beyond the common misconception of being merely “BPO + Platform.” At its core, BPaaS delivers a comprehensive operational framework built on four essential pillars:

1. Pre-defined, configurable services that adapt to organizational needs
2. A scalable infrastructure that supports sustainable growth
3. Refined, standardized processes to help ensure operational excellence
4. Cost-efficient ownership model to maintain financial sustainability

What truly distinguishes BPaaS is its unwavering focus on agility and outcomes. Each health plan benefits from dedicated infrastructure specifically designed to support its unique operational and strategic goals. This tailored approach ensures organizations can maintain their competitive edge while advancing their long-term objectives.

The model delivers value through its:

• Seamless integration of emerging technologies
• Rapid response capability for regulatory changes
• Enhanced operational transparency
• Streamlined transition to value-based care models

In practice, BPaaS partnerships transform how health plans operate by creating a dynamic, collaborative environment. Organizations retain strategic control while gaining access to specialized expertise and advanced technological capabilities. This balanced approach enables health plans to focus on their core mission—improving member outcomes and driving innovation—while maintaining operational excellence

BPaaS isn’t about outsourcing tasks—it’s about upgrading your operating model.

Choosing the Right Model for Your Health Plan

If your goal is to extend the capacity of your team and maintain current workflows, BPO may be an option. But if you’re ready to modernize operations, reduce risk, and unlock long-term value, BPaaS offers a future-ready solution.

At HealthEdge®, we help health plans assess their needs and implement the right model. We would love to hear more about your organization’s goals and challenges. Let’s connect.

Read more about operating models and BPaaS in the whitepaper: Finding the Right Operational Model.

By Alice Zhan, AI team

Part 2: Technical Implementation

This is part two of a two-part blog series on HealthEdge’s AI Summarizer feature; this post focuses specifically on the feature’s technical implementation. Read Part One here for an overview of the business challenges and operational benefits.

Addressing Information Overload in Care Management

Healthcare organizations face a growing challenge as healthcare professionals struggle with information overload from extensive documentation. Our AI team recently developed the AI Summarizer feature for our GuidingCare care management platform to address this problem. This feature simplifies a care manager’s workflows by analyzing care management notes to generate a concise summary and a list of key action items.

The AI Summarization functionality can reduce care manager review time, translating conversational content from notes into specific tasks and insights.

A Platform-First Architecture

HealthEdge’s approach to AI implementation centers on building reusable platform capabilities rather than one-off solutions. Our AI team created a summarizer API within our broader GenAI platform, which manages the complex technical details that would otherwise burden individual product teams. These include decisions around model choice and temperature settings, as well as comprehensive logging, observability, and security protocols.

The platform also collects user feedback establishing a foundation for continuous improvement and future model evaluation.

This centralized infrastructure management allows product teams like GuidingCare to focus on what matters most for their specific use cases. Each use case defines its own summarizer configuration, including the input data schema, custom prompts, and desired output formats. This division of responsibilities enables each team to implement AI features as needed without creating bottlenecks. The result is faster deployment cycles and more targeted solutions that address specific business needs.

Embedding AI into GuidingCare Workflows

For GuidingCare, we embedded the AI summarization functionality directly into existing care management workflows through a simple “Summarize” button in the Member Notes interface. The technical architecture follows a secure data flow between components, including the GuidingCare UI, the GuidingCare Cloud API, the WSO2 gateway that connects GuidingCare to external services, and the AI Summarizer. Each layer manages specific responsibilities for data processing and security.

Behind the scenes, the summarization API follows a streamlined processing pipeline that ensures both reliability and traceability. When a summarization request is received, the system first loads and validates the configuration. The prompt template is then dynamically formatted using runtime parameters, the user-defined input data schema, and any optional prompt addenda before invoking the OpenAI chat API. Each operation generates comprehensive logs that capture both the formatted prompt and the resulting output, providing full audit traceability before returning the processed response to the requesting application.

One of the most impactful parts of this project was working closely with our business stakeholders to craft a carefully engineered prompt template. Through direct feedback from clinical teams, we learned that care managers primarily read extensive notes to identify their next actions. This insight drove the design of the prompt to not just summarize notes, but specifically extract actionable follow-ups, a distinction that makes the difference between a generic summary tool and one that directly addresses workflow pain points.

The prompt template uses a structured approach, instructing the AI to analyze clinical notes in JSON format and produce summaries that highlight key diagnoses, reasons for visits, and follow-ups or recommendations, along with a separate, clear list of actionable items. The system processes notes using a schema that includes note type, health notes content, care staff information, and timestamps. To balance comprehensiveness with performance, the summarization feature uses notes from the last 90 days of history. The 90-day lookback limit was established based on both performance and clinical factors—limiting the number of notes improved system efficiency while simplifying the summarization process for the model, reducing the risk of overlooking critical information or producing inaccurate content.

AI Safety and Quality Assurance

As with all AI systems, the inherent risks of inaccurate, incomplete, or unsafe outputs required careful consideration. Our implementation addresses these concerns through multiple layers of protection. The system architecture ensures that AI-generated content is exclusively derived from existing notes within the system, guaranteeing that the outputs are as reliable and secure as the input data. This design principle prevents the AI from introducing external information or making claims beyond the information in the clinical record.

The platform provides comprehensive logging and audit trails for each summarization, enabling ongoing evaluation, monitoring, and debugging. The feature incorporates responsible AI protocols, including explicit AI-generated content disclaimers and human validation, ensuring clinical judgment remains central to care decisions. We also subjected the system to rigorous testing that included both expected inputs and adversarial scenarios, helping to ensure reliability across various input conditions that might occur in real-world healthcare environments.

Security and Compliance

The implementation maintains enterprise-grade security through multiple layers of protection. Data transmission utilizes secure APIs with HIPAA compliance throughout the data flow, while authentication relies on OAuth 2.0 for secure API access. The underlying LLM services are hosted through Azure, leveraging Microsoft’s enterprise security infrastructure and compliance certifications, with all data remaining within HealthEdge’s controlled infrastructure.

Role-based access controls limit functionality to authorized users through a layered permission system that requires both appropriate role permissions and access to the underlying clinical data. This controlled rollout approach ensures proper governance while the feature undergoes early adoption validation.

What’s Next for AI in Care Management?

With intentional platform design, strategic prompt engineering, and robust risk mitigation, we have demonstrated how healthcare technology teams can effectively integrate AI to enhance clinical workflows—and this is just the beginning. Next, we are expanding the summarizer’s capabilities to include interactive features that will allow care managers to ask follow-up questions and engage in a conversational dialogue about member information. This evolution will transform the summarizer from a one-time analysis tool into a dynamic, intelligent assistant that provides deeper insights and even greater operational benefits.

To explore how HealthEdge is shaping the future of care with responsible, practical AI, visit Artificial Intelligence | HealthEdge.