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In our December IMPACT customer event, we introduced a few key areas of investment at the platform level, and I have some exciting updates to share with you on customer experience, integrations and interoperability, artificial intelligence and automation, and early access Professional Services opportunities.

Customer Experience at HealthEdge®

Quality Center of Excellence

Over the last six months, we’ve been doubling down on quality. For us, that means increasing the levels of automation, deploying a consistent quality platform, enhancing product quality, and reducing the number of bugs making their way into user acceptance testing (UAT) and production environments.

Our Quality Center of Excellence has been focused on:

• Enhanced product quality
• Stable release processes
• Reducing effort spent on UAT
• Defect free user experiences

What we have done:

• Launched an operational platform
• Selected a Test Data Management solution (TDM)
• Established a consistent automated testing framework & process

Our wins:

• HealthRules® Payer: 38% bug reduction year-over-year
• HealthEdge Source™: 30% bug reduction year-over-year
• HealthEdge® Provider Data Management: 100% test automation
• Wellframe™: 60% automation across web & mobile platforms
• GuidingCare®: Quality Assurance (QA) sanity tests caught 14 critical bugs

What’s next:

• Roll out the TDM process for tests with real-world and synthetic data
• Unify our performance testing infrastructure and framework
• 80% test automation across the board
• 80% reduction in defect escape by the end of 2025

HealthEdge User Experience Platform

Our vision is to create something like Microsoft Office – where you go from Excel to PowerPoint to Word – but it still feels like a unified experience, with a comfortable familiarity between the products. We have brought on a new user experience (UX) leader who has been driving the enhancement of the user experience platform.

This platform is enabling us to create a consistent, high-performance, accessible, and modern user experience across products, leading to:

• Increased usability
• Enhanced productivity
• Faster time-to-market

What we’ve done:

• Created a design system to modernize and unify our products
• Published components for the design system in React
• Rebuilt an internal application with these components

Our wins:

• Identified six projects as candidates to adopt our design system in Q2-Q3
• Set up a Continuous Integration/Continuous Deployment (CI/CD) pipeline to automate testing and publishing of new versions of the components

What’s next:

• Consistent and adaptable customer experiences and accelerated time-to-market

Integrations & Interoperability

API & Integration Platform

We have been investing heavily in our new API & Integration Platform. We brought on a new leader and have standardized all our integration work into one workstream. This platform is extending our current integration tooling into a highly secure, scalable, and comprehensive solution for cross product and partner integration.

We have been focusing on providing a world-class API & Integration platform, driven by the following:

• Secure and scalable integrations
• Compliance and governance
• Future-proof real-time architecture

What we’ve done:

• Developed centralized API management and messaging components, with real-time, dynamic messaging
• Built a data integration platform to support data ingestion needs
• Built the streaming platform
• Created FHIR Converter to support electronic prior authorization workflow

Our Wins:

• Real-time messaging platform: Live with integration between HealthRules Payer and Provider Data Management solutions, on track to be live with integration between HealthRules Payer and GuidingCare solutions in April
• Centralized API management platform live with integration between HealthRules Payer and HealthEdge Source
• Live with Salesforce integration for HealthRules Payer customers

What’s next:

• Creating a “marketplace” of point and click integrations
• Standardizing solutions for all data ingestion and extraction needs
• Enhancing FHIR support
• Building enterprise services like identity and tenant management

Infrastructure Center of Excellence

For the past six months we’ve been working on a plan to move our applications to the public cloud. To do so, we have created an Infrastructure Center of Excellence, which is focused on standardizing our infrastructure, DevOps, and Site Reliability Engineering (SRE) to provide you with high application availability, security, performance, and scalability. Our vision is that when we move to the cloud, we have one enterprise way of doing things and it’s a best-in-class enterprise platform, ensuring our long-term scalability and performance.

We’re focused on:

• Enhanced scalability
• Stable releases
• Less effort spent releasing

What we have done:

• Established standards for scalability, security, stability, and monitoring
• Automated routine operations
• Selected enterprise tools for all cloud operations

Our wins:

• Started migrating to an enterprise-wide tool for CI/CD to enable stable releases and processes
• Established enterprise-wide SRE operations for cloud-based products

What’s next:

• Ensuring long-term scalability, performance, and adaptability

Artificial Intelligence & Automation

AI and automation have been another key investment area. We’re working toward a unified generative AI and foundational model platform that will efficiently and safely deliver AI-powered workflows and tools across our products. We have an exciting roadmap of AI advancements planned.

We’re thinking about AI and using AI tools and agentic infrastructure to automate the last part of the manual work during claims processing. We’re working on leveraging enterprise AI and automation internally to improve our efficiency and in our products to improve your efficiency.

Our AI and automation guiding principles are:

• Secure, compliant, safe
• Cross platform opportunities
• Enhanced support, documentation, and training

What we’ve done:

• Launched operational platform
• Prioritized project list for 2025
• Consistent approach to deliver AI driven solutions

Our Wins:

• GuidingCare Member AI Summarizer released in April 2025
• AI Optical Character Recognition (OCR) Fax ingestion solution by July 2025
• Multiple other projects under design and development

What’s next:

• Scale AI and drive innovation across products
• Leverage agentic AI architecture to streamline user workflows for efficiency, accuracy, and speed

Looking Ahead

Data, Business Intelligence, and Reporting

I spoke with a lot of our customers, including CIOs, CTOs, VPs, and technical users. One key theme emerged – data and business reporting are critical, but with so many different systems and pieces of data, consolidating data and getting an enterprise view is difficult.

To help address that, we’re heavily investing in an enterprise-wide data platform to enable business intelligence, analytics, and AI with data aggregated from all products. This will include features like:

• Pricing contract data from HealthRules Payer & HealthEdge Source in July 2025
• History, Audit and Monitor mode data from HealthEdge Source available by August 2025
• Claims history for performance metrics from HealthRules Payer available by Q4 2025
• GuidingCare and Wellframe reporting data in design phase

Driving to 100% test automation

We are making progress on our goal of 100% test automation, increasing the quality within our platform, and getting to a place where we have zero defect escapes across all our products. This year we intend to achieve 80% test automation. Important updates include:

• Quality initiatives focused on test automation prioritized across the enterprise
• Engaged third-party automation specialists to achieve 80% automation goal by the end of 2025
• All products actively working on automating manual test cases with a focus on commonly used features first
• TDM will enable running automated tests against de-identified real-world data and synthetic data further enhancing the effectiveness of automated testing

Our Vision for AI Across HealthEdge

Another key area is Artificial Intelligence. Our vision for AI is to accelerate AI-powered innovation in healthcare, ushering in a future that improves cost and care outcomes while enabling members to live their best lives.

We have been investing in agentic platforms, partnered with a third party for their expertise, and have working proofs of concept for how the agentic workflow is going to help us ingest data, move it through the AI-powered workflow, and provide rules or configurations at the other end. Our focus areas include:

• Intelligent Claims Operations
• Automate every aspect of claims adjudication with AI, including contract management, adjudication, fraud detection, and improved financial accuracy
• Proactive & Integrated Care
• Improving care and cost outcomes while driving care team quality and efficiency through predictive insights, automation and tailored care support
• Elevated Member & Provider Experience
• Enabling personalized experiences at scale to meet member and provider needs across intelligent content, workflows and data

Early Access to 3 Professional Services Offerings in 2025

Want to meet with us and work on this together? We’re looking for partners in the following areas to work with our Global Professional Services team:

1. Reporting Data Lake

If you’re a HealthEdge customer and you’re thinking about your data strategy and how you’re going to get reporting and business intelligence across products, we would love to partner with you. Come spend half a day with us to run a design sprint so that we can understand your data landscape and how we might design our data lake to mirror that. It includes:

• Multiple new and existing report options across HealthRules Payer, HealthEdge Source, HealthEdge Provider Data Management, GuidingCare, and Wellframe
• Customized report options
• Consultation on report options
• Best practice recommendations
• Run a Design Sprint—half-day to one-day workshop to understand current, necessary, and recommended reporting requirements

2. Test Automation as a Service

Client-side testing is essential for us to ensure the success of our implementations. The current method is inefficient and costly. But there’s a better way – with HealthEdge’s new test automation platform, which leads to better speed, efficiency, quality, and value. By working together, we can substantially and meaningfully improve the amount of automation and testing we have within your environments, and we can do it on our platform with our knowledge and expertise. It includes:

• User Acceptance Testing and integration from domain experts
• Faster, reduced risk, and added capacity for other org priorities
• IP that can be capitalized
• Run like Design Sprint—half-day to one-day workshop to understand what your team is doing now, current team size, types of testing, and testing of current processes
• Proposal with testing automation experts and quality assurance

3. Agentic AI Services

Agentic AI is the next generation of robotic process automation. We’d like to work with you to figure out how we can design a system that closes that gap in automation. For example, with a HealthRules Payer claim, when it goes pending, there are a bunch of steps a human must do (open documents, read information, and gather data from multiple systems). We’d like to create an AI-based agentic workflow system that automates those manual tasks based on the information that’s available to it and build it into the product so that your users can do less manual work.

We’re looking for:

• 10 customers for Q2 visits
• Robotic optimization on top of HealthRules Payer, GuidingCare, or total health plan
• Manual tasks that you want to automate
• Turn these into a platform with agents
• Currently looking for design partners

These are three exciting offers we have. We’re bringing them to you early because we think they’re meaningful and because we’d like to design them with you to better understand how you can get leverage from them.

Contact your Customer Success Executive to learn more and join us in one of these early access opportunities.

 

Care managers are responsible for far more than delivering care. They coordinate member communication, update health records, navigate program changes, and play a crucial role in ensuring compliance—all in a dynamic environment. These are all tasks in which summarizing data is critical to providing the right care at the right time. In these multitasking, context-switching scenarios, care managers must understand each member’s latest conditions, care plans, and history every time they assist them to deliver informed, high-quality interactions.

Data available to care managers is meant to support and inform better care, engagement, and accountability, but culling and making sense of all of it often results in information overload, making it harder to focus and efficiently draw the insights needed for personalized member support. Manual prep is time-consuming and mentally taxing, hindering staff satisfaction and caseload efficiency.

Introducing the HealthEdge AI Summarizer

The AI Summarizer for HealthEdge Wellframe™ streamlines care managers’ preparation for member interactions by creating concise, actionable AI-generated summaries of the member’s data. With this capability, care managers can quickly understand critical details without sifting through long records. This is especially helpful for members with complex health histories. As a result, staff can deliver more personalized and timely responses, improving care outcomes and the overall member experience.

Use AI to Empower Health Plan Staff and Enhance Member Interactions

Health plans can significantly improve staff efficiency and member care quality using the AI Summarizer. Many care managers are expected to work on larger caseloads

that often include members with complex health issues. By generating concise summaries of member data, care managers can quickly understand essential information and action items without reviewing the full history and detailed notes. This time-saving feature is also highly beneficial when co-managing members or covering for other staff, helping ensure continuity of care and consistent support for members.

With the AI Summarizer, care teams are able to:

• Reach More Members — With reduced time spent on data review, care managers can engage with a larger number of members effectively, ensuring broader coverage and support across their assigned population.
• Reduce Cognitive Load — The AI Summarizer distills complex member histories into easily digestible summaries, significantly decreasing the mental strain on care management staff. This reduction in cognitive load leads to improved focus and decision-making throughout the day, as well as improved satisfaction.
• Practice at the “Top of License” — By automating time-consuming data synthesis, the AI Summarizer frees care managers to utilize their expertise where it matters most. They can focus more on complex case analysis, strategic care planning, and direct member interactions.

Improve the Quality of Member Interactions

The HealthEdge AI Summarizer doesn’t just help expand the breadth of care delivery—it also enhances the quality of interactions between care managers and members. The AI Summarizer overview empowers care teams by delivering:

• Comprehensive Understanding — Care managers begin each interaction with a holistic view of the member’s health journey and potential areas of concern. This comprehensive understanding allows for more personalized and relevant discussions.
• Increased Preparation Time — With less time spent on data review, care managers have more time to prepare for each interaction, developing targeted questions and tailored care strategies focused on the future.
• Improved Engagement — Using AI-powered insights, care managers can engage members in more meaningful conversations without searching for information during a conversation or simply proceeding without essential details. This leaves time to address specific health concerns and check on progress points that might have been overlooked.
• Timely Interventions — The AI Summarizer helps highlight potential issues or changes in a member’s health status, enabling care managers to provide interventions and support at the right time for the member.

By leveraging AI Summarizer, health plans can significantly enhance care management operations. This leads to more efficient staff performance and, ultimately, improved health outcomes for members.

Transform Member Engagement with AI Summarizer

AI Summarizer represents a significant step forward in our mission to drive digital transformation in healthcare. As we continue to innovate and push the boundaries of what’s possible with AI in healthcare, one thing remains constant: our commitment to providing health plans with the tools they need to deliver exceptional care in an increasingly complex healthcare environment.

Advancing an Enterprise AI Strategy for Health Plans

AI Summarizer is one example of how HealthEdge applies AI to enhance health plan performance and improve member outcomes as part of our broader Enterprise AI strategy. We’re advancing AI across the healthcare journey by targeting three strategic areas:

• Intelligent claims operations – Leverage AI to adopt advanced automation for every aspect of claims processing, including contract management, auto-adjudication, fraud detection, and improved financial accuracy.
• Proactive and integrated care – Improve clinical and cost outcomes while driving care team quality and efficiency through predictive insights, automation and tailored care support.
• Elevated member experiences – Enable personalized experiences at scale to meet member and provider needs across intelligent content, workflows and data.

The AI Summarizer fits directly into the second pillar—proactive and integrated care—by helping care managers quickly understand a member’s full health journey and act on the most relevant information.

To ensure that innovations like these are deployed responsibly, HealthEdge follows a robust Enterprise AI framework built on four foundational pillars:

1. Healthcare AI Principles – We align with emerging healthcare industry healthcare AI principles, coalitions, and frameworks such as the published Healthcare AI Commitments and the CHAI™ guidelines to build safe, equitable, and transparent AI solutions.
2. Responsible AI – Our dedicated enterprise AI risk governance incorporates frameworks such as the NIST AI RMF 1.0.
3. Collaboration & Partnership – We foster strong partnerships with customers, end users, and industry stakeholders to develop innovative AI-enabled solutions aligned to the evolving needs of our customers.
4. Operational Value – We are committed to developing AI-enabled features that generate meaningful outcomes for health plans, empowering them to adapt and evolve with dynamic market changes and demands.

HealthEdge is actively integrating AI across its product suite, including HealthRules® Payer for claims automation, GuidingCare® for care management, and HealthEdge Source™ for payment integrity.

To learn more about how HealthEdge is enabling health plans to transform operations and care delivery using AI, read the data sheet.

As regulatory guidelines evolve and the emphasis on improving healthcare access and outcomes intensifies, health plans that serve Medicaid and D-SNP populations face an urgent mandate to improve access, deliver whole-person care, and meet new compliance standards. And they must achieve this without increasing their administrative burden.

To assist plans in navigating the changing regulations, the Association for Community Affiliated Plans (ACAP) and HealthEdge® partnered to host a webinar: “Advancing Health Equity: Strategies for Health Plans Navigating Change, Compliance, and Innovation.” The panel included Nai Kasick, Principal at Health Management Associates; Dr. Sandhya Gardner, Chief Medical Officer and General Manager of Care Solutions at HealthEdge; Jennifer Vicknair, Senior Director of Regulatory Compliance at HealthEdge; and Jennie Giuliany, Senior Director of Clinical Solutions at HealthEdge.

Together, they shared regulatory updates, market insights, and practical strategies for promoting equitable care and easing the burden of compliance.

What’s Changed: New Medicaid and D-SNP Requirements

Regulatory and policy changes are redefining how Medicaid and Dual-Eligible Special Needs Plans (D-SNPs) operate, emphasizing care coordination, accountability, and support for members’ broader health-related needs. Nai Kasick outlined the shifts accelerating the urgency for action among health plans:

• Medicaid 1115 waivers are reshaping reimbursement by allowing states to fund non-clinical services, such as housing, food, and other holistic assistance, through community-based organizations (CBOs). These CBOs are becoming key partners in whole-person healthcare delivery.
• D-SNP integration requirements are accelerating. By 2026, states like California will require full alignment between Medicaid and Medicare services for dual-eligible members. Plans must prepare for tighter oversight and more complex benefit coordination.
• NCQA and CMS health equity standards are now in force. Plans must collect and report on Social Drivers of Health (SDOH) and Health-Related Social Needs (HRSNs), close the loop on referrals, and demonstrate measurable progress in access, quality, and outcomes.

“Behind every policy is a person,” said Kasick. “Our work must reflect that by aligning systems to meet the real-world needs of members [who, for example, are] navigating pregnancy, grief, and housing instability all at once.” 

Three Goals for Health Plans: Aligning Strategy with Regulatory Reality

As regulatory expectations rise and operational complexity increases, health plans require a clear roadmap for adapting their models, systems, and partnerships. Jennifer Vicknair presented a practical framework based on three strategic goals:

• Advance health equity through whole-person care. Plans must go beyond traditional clinical care to address the behavioral, environmental, and social factors that shape health outcomes. Models like Enhanced Care Management (ECM) and Population Health Management (PHM) offer proven strategies to identify and address care gaps, support populations with high rates of chronic illness, and fulfill emerging mandates designed to improve access to care.
• Ensure compliance with evolving regulations. Oversight from NCQA, CMS, and state agencies is intensifying. Health plans are now required to demonstrate transparent, measurable improvements in care access, outcomes, and coordination, especially for populations who traditionally face barriers. California’s Managed Care Accountability Sets are one example of how performance expectations are being made public and tied to contracts.
• Reduce administrative burden through technology. As data requirements multiply, manual workflows are becoming unsustainable. Automation, artificial intelligence (AI), and advanced analytics can streamline critical tasks like risk stratification, referral tracking, and regulatory reporting. These tools can free care teams to focus on directly supporting members.

“This is about more than checking boxes,” Vicknair emphasized. “It’s about building an infrastructure that supports the kind of care we all believe in.”

Key Takeaways: Real-World Strategies That Work

The panel discussion explored how health plans operationalize equity and compliance in real-world settings. From member engagement to technology infrastructure, panelists shared the tactics and mindsets helping organizations manage change.

• Member engagement drives outcomes. Plans that engage members consistently through digital tools like HealthEdge Wellframe™ see higher satisfaction, better adherence to care plans, and improved retention. “Digital engagement helps us reach members where they are—not just during a crisis,” Dr. Gardner said.
• AI and automation are essential for scale and compliance. Innovative health plans use AIto identify high-risk members, recommend personalized next steps for their care, and automate compliance reporting. “The real power of AI is just beginning,” said Dr. Gardner. “It’s going to reshape how we deliver equitable care.”
• Partnerships with CBOs must be intentional. As community-based organizations take on more responsibility for delivering reimbursable services, plans must support them with training, infrastructure, and collaborative contracting. “CBOs often aren’t familiar with coding, reimbursement, or healthcare processes,” said Vicknair. “We need to meet them where they are.”
• Interoperability is non-negotiable. Integrated platforms that enable seamless data sharing across care teams, health plans, and social service providers are now essential for effective coordination and compliance “Without interoperability, we’ll never fully utilize the SDOH and HRSN data we’re collecting,” Vicknair said.
• Vendor partnerships must go beyond technology. Health plans need partners who understand the realities of compliance and operations. “Look for NCQA-recognized solutions and vendors who collaborate closely to help you meet your goals,” Dr. Gardner advised.
• Cross-functional alignment is critical. The most successful plans are breaking down silos internally. Compliance, IT, and care management teams must work together to design systems and strategies that support equity and efficiency.

The Time to Act Is Now

The panel closed with a clear call to action: the pace of change isn’t slowing, and health plans that delay digital transformation, community partnerships, or compliance readiness will fall behind in efforts to advance health equity and whole-person care.

“Whole-person care isn’t a trend; it’s the direction the industry is headed,” said Giuliany. “And the health plans that invest now will be the ones that thrive.”

To explore the full discussion and gain more insights, watch the webinar on-demand.

Visit HealthEdge.com to learn more about how HealthEdge can help your health plan with digital transformation, compliance, and advancing health equity.

Health plans serving dual-eligible populations face significant regulatory changes from the Centers for Medicare & Medicaid Services (CMS). The 2027 D-SNP requirements introduce significant changes affecting Highly Integrated Dual-Eligible Special Needs Plans (HIDE SNPs) and Fully Integrated Dual-Eligible Special Needs Plans (FIDE SNPs).

While the full rule doesn’t take effect until 2027, certain critical compliance requirements begin as early as 2025, necessitating immediate action. Gaining insight into these changes and preparing now will enable health plans to adapt and strengthen their position with dual-eligible populations.

Key Changes to CMS Requirements  

New regulatory requirements from CMS aim to enhance the integration of Medicare and Medicaid to simplify administration and improve care for dual-eligible beneficiaries. The changes that are in effect in 2025, and the more significant adjustments that health plans need to prepare for in 2027, include:

For 2025, health plans must implement exclusively aligned enrollment (EAE) for FIDE SNPs, ensuring members are simultaneously enrolled in both the Medicare SNP and the affiliated Medicaid managed care plan. They must also establish capitated contracts for HIDE SNPs that cover their entire Medicare service area, including behavioral health or long-term services and supports (LTSS). Plans should have already adjusted their enrollment processes, systems, and state Medicaid contracts.

By 2027, CMS requires all Dual-Eligible Special Needs Plans (D-SNPs) affiliated with Medicaid Managed Care Organizations to operate with exclusively aligned enrollment. Non-aligned SNP enrollments will no longer be allowed, which necessitates operational restructuring. Health plans must proactively prepare by assessing enrollment alignment and communicating effectively with members.

Why CMS is Making These Changes and Why Health Plans Must Act Now

With its latest guidance, CMS addresses historical issues related to fragmented and disconnected care for dual-eligible beneficiaries who previously navigated two separate healthcare systems (Medicare and Medicaid). This led to duplicative processes, multiple insurance cards, conflicting information, care delays, and significant frustration among members and caregivers.

New CMS regulations aim to:

• Ensure integrated, coordinated care across Medicare and Medicaid programs.
• Simplify administrative processes to improve the member experience
• Strengthen accountability and collaboration between Medicare and Medicaid to enhance healthcare outcomes and efficiency.

The transition to integrated Medicare and Medicaid for dual-eligible members is underway, and health plans should seek immediate action due to the operational complexity of this endeavor. Implementing exclusively aligned enrollment and service area adjustments requires significant changes across internal systems, processes, and training.

Additionally, health plans should engage early in state Medicaid negotiations and approvals, which can be a lengthy process. Early compliance with 2027 mandates and beyond mitigates risk and enhances health plans’ competitive positioning.

Immediate Steps Health Plans Should Take for HIDE & FIDE Compliance

The 2027 CMS integration requirements for HIDE SNPs, FIDE SNPs, and D-SNPs raise the stakes for health plans. At a minimum, to effectively prepare for CMS’s upcoming regulatory changes, health plans must assess their current enrollment structures to comply with exclusive enrollment requirements. Proactively engaging with state Medicaid agencies is crucial to secure compliant, capitated contracts that cover necessary service areas and benefits. Clear communication, both internally among teams and externally with members, will also facilitate a smooth transition.

However, investing in advanced technology infrastructure is equally critical. Without a modern care management solution, health plans risk non-compliance, which can lead to CMS penalties. Missteps can disrupt member care, inefficiencies can drain resources, and slow adopters will lose ground to more agile competitors. Modern care management technology is the essential element that helps health plans avoid these pitfalls. With a cutting-edge solution, health plans can optimize enrollment, simplify compliance oversight, and strengthen reporting capabilities This ensures health plans are well-equipped to provide exceptional, fully coordinated care while adhering to regulatory requirements.

How HealthEdge® Supports Health Plan Compliance

The HealthEdge GuidingCare® platform is designed to help health plans navigate regulatory compliance and integrated care delivery as CMS and state regulations continue to evolve. GuidingCare provides robust regulatory support and customizable workflows, enabling health plans to:

• Streamline Compliance. Automate enrollment and eligibility verification processes to reduce administrative complexity associated with CMS and state Medicaid requirements.
• Enhance Care Coordination. Integrate management of Medicare and Medicaid benefits, including behavioral health services and long-term supports (LTSS), to improve health outcomes for dual-eligible members.
• Improve Regulatory Reporting. Leverage comprehensive reporting capabilities for efficient compliance monitoring and auditing to meet CMS and state regulatory requirements.
• Support Operational Excellence. Utilize customizable workflows tailored to the unique needs of dual-eligible populations to facilitate proactive management of regulatory and operational changes.
• Ensure Scalability and Flexibility. Quickly adapt to changing regulations to seamlessly align operations in response to evolving compliance demands.

Investing in a care management platform such as GuidingCare strategically positions health plans for the future. The solution enables payers to meet immediate regulatory demands while establishing a strong foundation for long-term operational success, exceptional care management, and advanced member experiences.

Achieve Compliance and Operational Efficiency

By proactively addressing these new requirements related to dual-eligible populations, your health plan can meet compliance timelines, minimize disruption, and deliver superior member experiences. HealthEdge is committed to supporting health plans as they navigate these critical changes.

Contact us today to learn how GuidingCare can help your health plan stay ahead of evolving regulations.

Want to learn more about how solutions like GuidingCare empower health plans through compliance support? Read our blog, Adapt to CMS Standards and Improve Star Ratings with Digital Care Management .

 

Artificial Intelligence (AI) is transforming healthcare by helping payers streamline operations, reduce costs, and enhance experiences for staff, members, and providers. However, health plans must look beyond technology to fully realize AI’s potential. They must address the cultural shifts needed within their organizations to support adoption—like recognizing the benefits for all stakeholders, and building trust in the responsible, sustainable use of AI.

The Importance of AI in Healthcare

AI has the potential to revolutionize how health plans operate. It can increase automation, reduce training times, lower costs, and improve staff efficiency. Embracing AI is critical for health plans who want to stay competitive and meet the evolving needs of members and providers.

According to McKinsey & Company, health plans that embrace digital and AI transformation stand to achieve significant financial and operational gains — it could save health plans up to $1.2 billion and grow revenue by another $1.2 billion for every $10 billion in revenue. In addition, Gartner predicts AI will help reduce health plan administrative costs by up to 30% by 2027, and nearly all health plans are expected to adopt AI solutions by 2026.

Why Adopting Healthcare AI Is More Than Just the Technology

Adopting AI is not just about deploying new software or automating workflows. Implementing AI-powered solutions requires rethinking manual processes for staff and establishing trust in new experiences for members and providers. Health plans must cultivate a culture of innovation and adaptability to fully benefit from AI tools. This includes helping staff see AI not as a threat to their roles but as a tool to amplify their impact.

Understanding Cultural Resistance to Adopting AI Tools

AI adoption can encounter resistance rooted in organizational culture. Common challenges include:

• Skepticism about AI’s potential. Staff may question AI’s potential benefits and may resist its adoption due to concerns over its ability to improve productivity, solve complex problems, and enhance decision-making processes.
• Fear for job security. Many people fear that AI will result in job loss and are resistant to its adoption for this reason. It is important to address this concern by highlighting the potential for AI to create new jobs and improve existing ones.
• Reluctance to change workflows. Some people may resist AI adoption due to a reluctance to change established workflows and processes. It is important to provide ongoing training and support to help people adapt to new technologies and ways of working.

Acknowledging and proactively addressing these concerns is essential. Through our own experience accelerating AI innovation and close collaboration with health plans, HealthEdge® has identified change management best practices that every health plan should consider.

3 Best Practices to Accelerate AI Adoption at Health Plans  

1. Conducting Ongoing Workshops and Training Sessions

Education is one of the most effective ways to address resistance and increase engagement. Hosting AI workshops and training sessions can give staff clarity on the long-term plan for AI solutions, how the new technologies will benefit them, and the opportunity to explore use cases, see the technology in action, and ask questions.

Successful training sessions often include:

• Role-based walkthroughs of AI-driven workflows.
• Peer-to-peer Q&A.
• Clear guidance on how AI will enhance their daily responsibilities.
• Compelling communication and examples of how AI will benefit members and improve outcomes.

This engagement clarifies AI’s benefits and establishes a foundation of trust.

2. Sharing Success Stories Within the Organization

Sharing early success stories from champions and pilot projects reinforces the benefits of AI and makes the value feel more real.

For example, demonstrating how a care manager streamlined their workflow using AI-generated member summaries or how claims staff reduced turnaround time with automated validations provides peers with concrete examples of AI’s potential.

Peer validation is a powerful tool. When staff hear directly from colleagues about improvements in accuracy, efficiency, or member experience they are more likely to embrace the change.

3. Setting Clear and Achievable Goals

Setting clear, achievable AI goals helps focus teams and creates accountability.

The goals should be:

• Aligned with key priorities such as reducing claim rework, improving HEDIS scores, or boosting member satisfaction.
• Measurable and time-bound.
• Communicated frequently to reinforce purpose and progress.

A strong goal framework clarifies the AI strategy for staff and helps them feel part of the “why” to accelerate AI adoption and integration.

Realizing Operational Value: Communicating the Vision

Once a health plan establishes cultural readiness, it can focus on realizing its broader AI vision. For example, HealthEdge defines its AI vision as creating value for health plans in three key areas:

• Intelligent Claims Operations.  Automate every aspect of adjudication with AI, including contract management, adjudication, fraud detection, and improved financial accuracy.
• Proactive & Integrated Care. Improve care and cost outcomes while driving care team quality and efficiency through predictive insights, automation, and tailored care support.
• Elevated Member & Provider Experience. Enable personalized experiences at scale to meet member and provider needs across intelligent content, workflows, and data.

Each health plan should convey an outcome-focused vision that aligns with its organizational goals. This establishes a framework for clear communication that flows through new capabilities, reimagined workflows, and enhanced experiences. 

Key Takeaways for Health Plans: AI Readiness Checklist

Successful AI adoption requires more than next-generation, AI-powered capabilities. Based on HealthEdge’s journey with AI, we see that it requires:

• Cultural readiness and open communication
• Strong change management and leadership support
• Ongoing training and employee engagement
• Clear alignment between AI and business priorities and goals

When these elements are in place, health plans can confidently advance their AI strategy and deliver measurable improvements in healthcare and financial outcomes.

Innovate with a Partner That Understands Healthcare Digital Transformation

HealthEdge understands that adopting AI isn’t just about deploying new technology. It’s about enabling strategic, sustainable transformation centered on the needs of your organization, your teams, and the members you serve.

From identifying the highest-impact use cases to implementing AI responsibly and supporting long-term change management, we’re here to help health plans move forward confidently. Our approach combines deep healthcare expertise, proven technology, and a commitment to transparency and trust.

Contact us to discover how HealthEdge solutions leverage AI to help transform operations and outcomes for healthcare payers.

Not ready for a discussion? Discover how the HealthRules® Payer solution helped Medica health plan transform claims operations through strategic automation. Read the case study.

Gartner, Predicts 2025: AI Reshapes How U.S. Healthcare Payer CIOs Do Business, 16 January 2025

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Now more than ever before, health plans are recognizing the importance of holistic care delivery to improve outcomes and reduce costs. Social determinants of health (SDOH) such as food security, transportation, and housing stability significantly impact member health, making it crucial for payers to adopt solutions that integrate medical and community-based support.

Wellframe, a HealthEdge solution, is taking a major step forward in this effort by pursuing the National Committee for Quality Assurance (NCQA) Wellness and Health Promotion (WHP) Accreditation in 2025.

Why NCQA Accreditation Matters

NCQA is widely recognized for its commitment to quality measurement, transparency, and accountability in healthcare. For health plans, working with NCQA recognized vendors provides several advantages:

1. Trust and Reliability: NCQA recognized vendors are held to high standards, ensuring their solutions align with evidence-based best practices.
2. Regulatory Alignment: Recognition helps health plans stay ahead of regulatory requirements from CMS and state Medicaid programs, particularly as policies related to health equity and SDOH rapidly change.
3. Operational Efficiencies: Health plans partnering with NCQA recognized vendors may benefit from oversight relief and automatic credit in their own NCQA surveys, reducing administrative burdens.
4. Better Outcomes and Cost Savings: Studies show that coordinated care and strong member engagementlead to improved health outcomes and reduced healthcare costs.

By pursuing NCQA WHP Accreditation, Wellframe is reinforcing its commitment to alignment with NCQA standards. Delivering high-quality, evidence-based digital health management solutions empowers members to engage with their health plan care team and supports health plans in meeting their clinical quality and health equity initiatives.

How Wellframe Supports Person-Centered Community-Based Care

Wellframe is already playing a crucial role in addressing SDOH. The platform integrates digital health management with personalized coaching, helping health plans identify and support members’ social and clinical needs. Some key capabilities include:

• Health Coaching & Self-Management Tools: Wellframe provides evidence-based resources that can be used by the health plan’s care team during health coaching. Self-management tools are available to help individuals navigate their health journeys, including managing chronic conditions, mental health, and lifestyle changes.
• Comprehensive Health Appraisals: The platform facilitates health appraisals, which may also be known as health risk assessments, that include questions on social determinants of health, helping to identify members who may need additional support.
• Personalized Outreach & Engagement: Wellframe’s digital capabilities allow health plans to proactively reach members with tailored interventions, ensuring that populations with new or emerging risk receive the support they need.
• Community Resource Connections: Through partnerships with organizations such as Unite Us, Find Help, and 988 crisis services, Wellframe helps connect members with community-based organizations that address SDOH.
• Data Exchange & Integration: Wellframe facilitates data sharing between health plans, providers and members, enhancing care coordination and ensuring that data is meaningful and actionable.

These capabilities already position Wellframe as a powerful tool for addressing health inequities and enhancing member engagement. However, NCQA certification will take these benefits to the next level.

The Impact of NCQA Recognition on Wellframe’s Capabilities

With NCQA accreditation, Wellframe will be able to offer even greater value to health plans, particularly in the areas of quality measurement, engagement, and health equity. Here’s how:

• Enhanced Standardization & Quality Assurance: NCQA accreditation ensures that Wellframe’s wellness and health promotion programs meet rigorous nationally recognized standards, validating the effectiveness of its health assessments, self-management tools, and member engagement strategies.
• Improved Regulatory Standing for Health Plans: Wellframe’s WHP Accreditation will provide health plans with automatic credit during NCQA surveys for Population Health standards for Health Appraisals and Self-Management Tools, reducing administrative costs associated with maintaining their own Health Plan Accreditation (HPA).
• More Robust Measurement of Outcomes: NCQA requires WHP accredited vendors to continuously measure and improve their effectiveness. Wellframe will leverage these insights to refine processes, data collection, and educational content to help ensure greater impact on clinical outcomes
• Strengthened Member Trust & Adoption: NCQA’s standards are designed to encourage members to engage with their care team and promote a collaborative care model with industry-leading quality benchmarks. This will further boost the effectiveness of Wellframe’s digital engagement strategies.
• Greater Alignment with Value-Based Care Models: As the industry shifts toward value-based care and shared provider risk arrangements, NCQA accreditation will reinforce Wellframe’s role in helping health plans accurately measure quality and improve overall population health

Overcoming Challenges in Addressing Needs of a Population

While solutions like Wellframe are making strides in addressing specific needs of members, challenges remain. Health plans often face hurdles such as data integration complexities, regulatory uncertainties, and member engagement barriers. However, Wellframe’s approach, coupled with NCQA WHP accreditation, will help mitigate these challenges:

• Data Silos: Many health plans struggle with fragmented data systems that prevent a holistic view of member needs. Wellframe’s advanced interoperability capabilities improve data sharing across stakeholders.
• Regulatory Compliance: As Medicaid, Medicare, and commercial payers increasingly incorporate SDOH into quality metrics, NCQA accreditation helps ensure that Wellframe remains aligned with industry best practice and standardized metrics.
• Member Engagement & Digital Literacy: By leveraging mobile-first strategies and personalized care management, Wellframe helps bridge digital literacy gaps and deliver tailored health support to members.

Looking Ahead: The Future of Wellframe & NCQA Accreditation

As Wellframe progresses toward achieving NCQA accreditation in 2025, health plans can expect even stronger alignment with industry standards and clinical best practice metrics. The combination of Wellframe’s innovative technology, evidence-based content and NCQA-backed credibility will provide health plans with an unparalleled tool to advance population health and address social determinants of health.

Ultimately, Wellframe’s NCQA accreditation will not only enhance the quality and effectiveness of digital health engagement but also reinforce health plans’ ability to deliver holistic, person-centered care. By proactively addressing members’ unique needs, health plans can improve member outcomes, reduce costs, and drive long-term sustainability in an increasingly value-driven healthcare environment.

Wellframe’s pursuit of NCQA accreditation underscores the company’s dedication to improving clinical quality, health industry innovation, and equitable person-centered care.

Do you want to learn more about how your health plan can use digital care management solutions to meet care managers and members where they are? Watch our on-demand webinar.