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Managing payments for a health plan is not as simple as it was a few decades ago. Updated billing models, new compliance mandates, and complex provider networks can make it challenging for payers to align their processes and effectively manage payments.

In this blog, we unpack three common barriers to payment efficiency and what to look for in a payment integrity solution.

3 Key Barriers to Healthcare Payment Integrity

1. Disparate vendor network

To deal with complex healthcare payments, health plans often work with multiple vendors and disparate solutions. Often, each vendor focuses on one part of the process, like pricing, policies, or reviewing payments after they’ve been made. While this approach offers specialized support, it can lead to a tangled system where similar tasks are repeated by different partners. This setup makes it hard for health plans to make changes quickly or respond to new challenges.

2. Disconnected data sources

When each vendor keeps data within their own systems, information is siloed and hard for health plans to piece together in a meaningful way. In addition, any errors in the process are often handled on an individual basis, making it difficult to see bigger trends or identify recurring problems. This can lead to health plans taking action without a clear, unified view of the process.

3. Workflow inefficiency and payment errors

Most existing payment integrity systems work backwards: They try to find and recover funds from incorrect payments after the payment request is sent. This means health plans pay third-party vendors to track down mistakes that were made in-house – and likely could have been avoided. The payment recovery process can also be slow and expensive, leading to wasted resources and frustration.

A Unified Approach to Health Plan Payment Integrity

The team behind HealthEdge Source™ recognized that healthcare payers didn’t need another third-party editor or another pricing tool. Instead, health plans needed a way to integrate and streamline claims processing.

With the HealthEdge Source payment integrity solution, health plans have access to custom configuration, editing, and advanced analytics tools all in one place for greater visibility and catch errors before payments are sent.

4 Key Features of HealthEdge Source

• Easy Edit Building: HealthEdge Source includes a no-code edit builder, allowing users to create and update payment edits without special requests from engineering teams. An edit can be built and published in minutes.
• Automatic Updates: The platform automatically incorporates new rules based on regulatory changes from agencies, like the Centers for Medicare and Medicaid Services (CMS). New rules are built in every two weeks, with no manual work for your team.
• Test Before Going Live: A built-in Monitor Mode allows users to test new edits on real claims without affecting actual payments. This allows teams to see the impact of a new rule before fully implementing it.
• Clear Tracking and Analytics: Every claim is tracked with a detailed audit trail, and the system offers advanced analytics to help health plans spot trends, track performance, and make better decisions.

By uniting these tools in a single solution, HealthEdge Source helps turn payment accuracy from a guessing game into a straightforward, proactive process.

Innovations in Payment Integrity: Edit Management Enhancements

The HealthEdge Source team is always working on new solution enhancements based on user feedback and changes in the industry. Recently, we implemented two key improvements to make managing edits even more efficient.

1. Simplified Edit Configuration

Managing edits used to mean navigating multiple screens and manually updating rules for each provider type—a tedious and error-prone process. Now, HealthEdge Source offers a single, consolidated interface where all configurations happen in one place.

For example, if a health plan wants to require prior authorization for high-cost imaging services, this can be enabled with a single click for every relevant facility or provider group. If there’s a need for an exception, such as excluding emergency services, it takes only a few seconds to adjust.

This approach to configurations helps improve efficiency for policy management. Health plan teams can view, enable, adjust, or turn off edits for different provider types using simple checkboxes across the same dashboard, rather than tracking changes across separate screens. Centralizing these functions saves time while reducing the risk of manual errors and helps ensure updates are reflected in the proper places.

2. Global Edit Exceptions

With global edit exceptions, users can create exception rules in one central location, then apply them across as many edits as needed. If a particular provider, like a large hospital network, should be exempt from certain claim edits, a health plan only has to set up their tax ID or configuration details once. This rule can then be linked to every relevant edit, instead of repeating the same exclusion logic each time. This centralized approach reduces duplicate work and makes it easier to standardize processes across the organization.

When a contract changes or another provider needs a similar exception, users simply update the global exception in the central library, and the change automatically applies to the connected edits. This helps reduce the risk of missing updates or implementing inconsistent rules across a single system. For example, if a health plan wants to adjust exclusion criteria for a set of specialty providers, those updates can be handled quickly and accurately by revising a single rule, rather than searching for and editing each instance individually.

Ultimately, this approach helps deliver a stable, scalable foundation for managing edits, empowering health plans to manage regulatory shifts and network changes as a controlled process.

Watch our on-demand webinar, “Edit Smarter Not Harder with HealthEdge Source™” to get an inside look at how connected, automated payment integrity can work day to day.

AI is reshaping how software gets built—enabling faster delivery, real-time iteration, and deeper collaboration between technical and business teams. At HealthEdge^®, we’re exploring how AI-driven tools can streamline development while maintaining the precision required for healthcare technology. During a recent internal bootcamp, we put this concept to the test, and the results were game-changing.

For decades, product development has followed the same playbook: write extensive product requirement documents (PRDs), create detailed technical specifications, and document requirements. Teams invest weeks in upfront planning but still miss requirements and experience defects. The uncomfortable truth is that more documentation doesn’t necessarily lead to better outcomes.

Our recent AI bootcamp revealed a different path forward. In only four hours, paired teams of developers and executive leadership built fully functional applications that would normally take 1-2 weeks. But the real breakthrough wasn’t speed. It was what happened to the traditional process. When you can build working software in hours instead of weeks, the whole dynamic changes:

• Requirements stop being documents and become conversations.
• Stakeholders see what they’re getting while there’s still time to course-correct cheaply.
• Engineers and business leaders iterate together on actual, interactive software, figuring out what to build by building it rather than trying to specify it perfectly up front.

AI accelerates the implementation work, but the critical decisions about domain logic, compliance requirements, and business rules still require human expertise. The tools handle the coding, and developers can focus on the judgment calls that actually matter.

Why We Needed to Experience It, Not Just Discuss It

Our executive team had heard about AI’s potential to transform workflows. Developers knew these tools could accelerate development. Yet the gap between theoretical understanding and realized value remained wide. We needed to demonstrate the spec-driven development experience firsthand to show, not tell, how AI tools fundamentally change what’s possible.

The bootcamp was designed as a competition. We paired developers with executive leaders, assigned team members to simulated business roles, gave them 4 hours to build, and then presented keynote demonstrations of their solutions to judges.

Building a Customer Sentiment Navigator in Record Time

My team tackled a genuine business need: a navigator that aggregates customer sentiment across call transcripts, emails, and support tickets. The requirements included time-series visualizations to show emotional trends per customer, actionable item tracking with status management, and integration hooks for care management workflows. Conservatively, this would take 1-2 weeks. We had four hours.

Figure 1: The customer sentiment navigator showing active alerts and trend visualization

As part of HealthEdge’s partnership with AWS, we received early access to Kiro, a new integrated development environment (IDE), that flips the traditional coding paradigm. Unlike copilot-style tools that suggest code line-by-line, Kiro emphasizes requirements refinement and architectural design first. I fed our product requirements document into Kiro, and it generated comprehensive requirements and design documentation. Following my edits and approval, Kiro transformed the documentation into a granular task breakdown.

Figure 2: Kiro’s workflow – transforming PRD into requirements, design, and task list

Once the task breakdown was ready, Kiro went to work. It moved methodically through each task, implementing features one at a time. You could watch it work: build the data models, wire up the API endpoints, create the UI components. Within 30 minutes, we had a working application with LLM-powered sentiment analysis, dashboard visualizations, and core workflow functionality.

The Parallel Productivity Advantage

The parallel productivity unlocked here defines spec-driven development. While Kiro refined the application autonomously—fixing performance bottlenecks and correcting visualization bugs—I could context-switch completely to support teammates with their other tasks across their assigned personas.

When I noticed issues, conversational debugging replaced traditional reproduction steps and stack traces. “Sentiment analysis is running on app startup and slowing everything down.” Kiro understood the implication, refactored to asynchronous processing, and validated the fix. The feedback loop became describe-resolve-validate instead of write-test-debug-fix.

With time remaining, we added automatic JIRA ticket content generation for critical sentiment indicators—a feature that would normally trigger sprint planning. I described the requirement, and Kiro generated properly formatted ticket content using an LLM. This crystallized something important: spec-driven development doesn’t just compress timelines—it fundamentally expands what you can achieve within fixed constraints.

Figure 4: AI-generated actionable insights from sentiment data

When Experience Transforms Understanding

Four hours later, our team had built a production-quality customer sentiment navigator with LLM-powered analysis, interactive dashboards, actionable item tracking, and automated JIRA ticket content generation. We prepared our keynote and finalized deliverables for each persona, then demonstrated them to judges.

The reaction wasn’t just excitement about the output. It was recognition that something fundamental had changed. Executive leaders who stepped outside their comfort zones saw how AI could transform workflows across functions. Financial modeling, requirement refinement, design iteration, and content creation—all accelerated through AI assistance. Everyone left understanding this wasn’t an incremental improvement. This was a new operating model.

For HealthEdge’s comprehensive healthcare technology platform, the implications ripple outward. Developers can redirect energy from boilerplate implementation toward genuine complexity: core administrative processing logic, care management workflows, payment integrity algorithms, and the intricate integrations connecting health plans, providers, and patients. The spec-driven development experience accelerates the tedious while preserving space for intellectually demanding work.

From Prototype to Production

The bootcamp demonstrated spec-coding’s sweet spot: bringing ideas to life rapidly for customer demos, gathering feedback, or adding quick value to existing workflows. The path from prototype to production is straightforward—continue prompting the LLM to integrate features into larger codebases, connect to production infrastructure, and harden security. This makes spec-driven development particularly valuable for customer engagement: need to show a prospective client how their workflow could improve? Build it in an afternoon with real data and clickable interfaces.

The Boundaries and the Future

Spec-driven development is powerful precisely because it’s human-directed development. Throughout the bootcamp, I remained responsible for architectural decisions, requirement validation, and output quality.

In healthcare technology specifically, this oversight is non-negotiable. AI tools don’t inherently understand HIPAA compliance, clinical workflow requirements, or regulatory complexity. The AI-driven development experience accelerates implementation, but domain expertise and compliance obligations remain firmly in human hands.

This bootcamp validated that spec-driven development represents a clear competitive advantage for healthcare technology companies. As HealthEdge evaluates broader adoption of tools like Kiro, we’re exploring how to build capacity to deliver customer value at unprecedented speed.

The core insight from this evaluation is clear: spec-driven development isn’t a novelty or a shortcut. It’s the new baseline for what effective software development looks like in healthcare technology.

And once you’ve experienced it, there’s no going back to the old way.

 

Health plan leaders have dozens of digital solutions to choose from—so many that it can feel like real partnership is rare. Too often, vendors deliver software and walk away, leaving health plans navigating complex systems, shifting regulations, and employee upskilling alone while staff tackle day-to-day responsibilities. As a result, technology that looks good on paper fails to enable real change.

Why? Real transformation starts when technology comes with a partner, not just a platform.

HealthEdge Wellframe™ brings the human touch back to digital health. As a comprehensive care management and member engagement platform, Wellframe helps health plans combine adaptable technology with hands-on partnership to improve outcomes and create better member experiences. Our platform extends the reach of care teams through mobile-first engagement, two-way communication, and data-driven insights that bring the right support to members at the right time.

And we know technology alone isn’t enough. That’s why we pair every solution with hands-on partnership—guiding health plans through change management staff training, and continuous optimization. Because solving healthcare’s toughest challenges always requires people behind the technology who are deeply committed to progress.

Partnership That Starts Before Day One

Collaboration between HealthEdge and our Wellframe customers begins long before contracts are signed. While many vendors show up after the ink is dry, our engagement starts in the earliest stages of discovery.

During the sales process, subject matter experts sit shoulder-to-shoulder with potential clients to assess readiness—not only a health plan’s technology ecosystem, but organization and culture. Our implementation team looks closely at leadership alignment, care management capacity, and digital fluency across the workforce to help build a foundation that supports lasting transformation. When an organization is aligned from day one, digital solutions can take root, scale, and evolve along with the people who use them.

This early collaboration also helps ensure that by the time implementation begins, every stakeholder—from executive sponsor to care manager—understands not only what they’re implementing, but why. That clarity is what turns a deployment into a shared mission.

A Foundation Rooted in Flexibility

The Wellframe platform isn’t a one-size-fits-all solution. It’s a toolkit of digital resources designed to adapt to the unique needs, priorities, and maturity level of every health plan. This means some health plan customers begin their digital journey by implementing the HIPAA-compliant two-way chat, while others roll out comprehensive digital care programs to increase care capacity and member engagement.

Wellframe’s flexible design means clients can move at their own pace, scaling thoughtfully as their digital capabilities change. Whether a payer’s goal is to streamline communication, expand care management reach, improve member satisfaction, or strengthen competitive positioning, Wellframe helps provide the foundation to achieve it.

After Go-Live: Enter the Real Work

Many technology vendors fade into the background once implementation is complete. At HealthEdge, we recognize that digital transformation isn’t a destination—it’s a continuing evolution.

After implementation is complete, our team supports every client via a dedicated customer success manager, customer partner, and digital adoption expert. These teams remain embedded throughout the client’s lifecycle, offering consulting, coaching, and troubleshooting as payer goals shift and new challenges emerge. This commitment goes beyond technical support to deliver an enduring relationship rooted in shared accountability and long-term outcomes.

Guiding Change from Within

One of the greatest challenges in digital transformation isn’t the technology—it’s the people. Health plan staff that are accustomed to phone-based workflows often need support to transition to digital channels that feel less defined but more continuous. Recognizing this, Wellframe invests heavily in change management and upskilling resources tailored to every level of client organizations.

Our Digital Adoption and Clinical Enablement teams provide managers and clinicians with structured training on the how and why of digital care management. This includes practical coaching materials, leadership communication templates, and persona-based guides that address common barriers like hesitancy and administrative fatigue.

We also help health plans identify and cultivate internal champions who can advocate for digital transformation, helping make sure momentum doesn’t stall after implementation. This thoughtful, human-centered approach helps customers move beyond adoption to integration, where digital engagement becomes part of the organization’s internal structure.

Transforming Capacity and Care Delivery

For many payers, partnering with Wellframe unlocks a level of previously impossible scalability. Care teams that once supported a limited number of members by phone can now engage twice as many through scalable digital channels. Programs that were once resource-constrained—like maternal health, chronic condition management, or care transitions—also become more easily scalable through automation and asynchronous communication.

By empowering non-clinical staff to take on supportive digital roles and freeing clinicians from repetitive outreach, Wellframe empowers health plans to serve more members without increasing headcount – ultimately helping improve operational efficiency and supporting greater member satisfaction. In short, our technology amplifies the human touch rather than replacing it.

Continued Collaboration

Wellframe’s partnerships are built for longevity, meaning check-ins often evolve into strategic discussions about growth, optimization, and innovation. When clients want to expand to new populations or experiment with new workflows, Wellframe experts bring best practices, benchmarking insights, and lessons learned from our network.

Because every health plan ecosystem is different, our team tailors recommendations accordingly. Some clients need intensive support following leadership changes or internal restructuring. Others seek quick advice to troubleshoot engagement metrics or improve conversion rates. Whatever the need, our goal is to help clients evolve confidently with the platform.

Connection Across the HealthEdge Ecosystem

As part of the integrated HealthEdge ecosystem, Wellframe extends the value of partnership through deep integration with HealthEdge GuidingCare®, a unified care management solution that brings care teams, data, and workflows together to better support member care journeys. The Care-Wellframe integration allows health plans to seamlessly combine member-reported data with clinical and operational insights, creating a more complete picture of each member’s health journey.

This ultimately allows care teams to act faster by eliminating redundant workflows and reducing “phone-tag” inefficiencies. By putting actionable insights directly in the hands of care managers, health plans can deliver more coordinated, personalized care.

The Human Difference

What truly sets the Wellframe team apart is the culture of empathy, collaboration, and curiosity that drives every engagement. Our teams don’t simply implement software; they build relationships grounded in trust and mutual success.

That commitment—to learn alongside our partners, to iterate together, and to always keep the member relationship at the center—is what makes Wellframe more than a product. It’s what makes us a true transformation partner through HealthEdge.

See how Wellframe is helping health plans nationwide address population health through whole-person care. Download our eBook, “Advancing Population Health: Strategies for Health Plans Navigating Change, Compliance and Innovation.”

Better outcomes, lower costs: Why health plans are turning to HealthEdge® Wellframe

Across the healthcare industry, many health plans grapple with vendor sprawl—a web of disparate systems and point solutions for care management, member engagement, reporting, and compliance. While these tools were often adopted in piecemeal fashion to meet specific needs, they now create data silos, operational inefficiencies, and rising administrative costs.

The 2025 HealthEdge Annual Payer Market Planning Report highlights that 54% of payer leaders cite cost management as their top challenge, while 52% are focused on care management improvements and digital transformation initiatives. A key strategy to address these challenges is vendor consolidation, but many plans struggle to identify solutions robust enough to replace multiple disconnected systems.

Vendor Sprawl: The High Price Tag 

Multiple vendors mean multiple contracts, systems, and workflows. The result?

• Fragmented data: Care teams can spend significant time piecing together member information across platforms, limiting their ability to deliver coordinated care.
• Duplicative costs: Overlapping licenses and maintenance fees can eat into already-tight budgets.
• Staff inefficiency: Teams must learn and support several systems, which contributes to burnout and frustration, increases confusion, and ultimately slows care delivery.
• Compliance risks: Inconsistent data and reporting processes increase the risk of regulatory non-compliance.
• Poor member experience: Just like care teams, members can face confusing, disconnected digital touchpoints rather than a seamless journey rooted in customer experience (CX) best practices.

As one health plan leader shared, “We were always looking for these point solutions and then trying to stitch them together; it consumed time and resources. So, we looked for a best-in-class platform and found it with HealthEdge.”

Why Consolidation Matters  

Healthcare organizations face increasing pressures: rising care costs, evolving regulations, and heightened member expectations for digital-first experiences. According to the same HealthEdge survey indicated above, 62% of health plan leaders view modern, integrated technology as the number one way to achieve organizational goals.

Simplifying vendor complexity through consolidation offers health plans the ability to:

• Reduce costs by eliminating redundant vendors and streamlining technology contracts.
• Simplify compliance with centralized reporting and automated workflows.
• Improve member outcomes through unified data and AI-driven insights.
• Enhance provider collaboration with consistent, real-time information sharing.
• Build agility to scale and adapt to new regulations and market demands.

How HealthEdge Wellframe™ Simplifies Complexity and Drives Consolidation 

For many health plans, vendor sprawl creates roadblocks at every turn—from disconnected member experiences to staff inefficiencies. The HealthEdge Wellframe solution, a digital platform that helps health plans engage members and coordinate care, provides a single, integrated solution that eliminates those barriers and brings everything under one roof.

Unifying care management and engagement: Instead of juggling multiple apps and systems, the HealthEdge® Care-Wellframe integration combines the GuidingCare® care management solution with Wellframe to create one cohesive for care coordination and delivery platform. With this integrated solution, care teams gain a comprehensive view of each member and a set of guided workflows to enable faster decision-making.

Breaking down data silos: Real-time, API-driven integrations connect Wellframe to the broader HealthEdge ecosystem. This seamless flow of information eliminates manual processes and ensures teams have accurate, up-to-date insights for both operational and clinical decisions.

Scaling without adding staff: Wellframe’s AI-driven triage logic, dynamic decision support, and automated care programs allow care managers to handle larger caseloads, freeing up time to focus on high-value interactions.

Delivering a seamless member experience: Members engage through a single, user-friendly app or web portal for health education, two-way communication, and resources—removing the confusion of multiple logins or fragmented tools.

Simplifying vendor management: By consolidating disparate tools into one trusted solution, Wellframe reduces IT overhead and simplifies vendor oversight. This streamlining saves time, lowers costs, and strengthens relationships with both members and providers.

Real-World Impact: Better Outcomes, Lower Costs

Health plans using Wellframe have achieved measurable results, including:

• 6X increase in member interactions across risk levels
• 200% increase in active caseload size on average, enabling teams to support more members without sacrificing quality
• $1,923 in annual cost savings per engaged member, along with a 9% reduction in ER visits and 17% fewer inpatient admissions
• Improved quality ratings, including an 8% boost in HEDIS maternity care outcomes for one plan

One Blues plan care manager summed it up perfectly:

“I can manage a larger number of members with less time spent over the phone. Wellframe has streamlined the entire process for me to focus on what members truly need.”

Vendor Consolidation in Action

A regional health plan serving nearly 500,000 members partnered with HealthEdge to replace its patchwork of legacy systems with a member-centric digital ecosystem. By leveraging the Care-Wellframe integration alongside HealthRules® Payer, the plan gained near real-time visibility into authorizations and member interactions, improving both operational efficiency and member outcomes.

Another plan migrated 500,000 Medicaid and D-SNP members to the GuidingCare solution, cutting licensing costs by nearly $500,000 annually and simplifying compliance reporting across all populations.

The Future of Connected Care 

Vendor consolidation is more than a cost-saving initiative—it’s a strategic move to help future-proof health plans. By unifying workflows and data under one ecosystem, organizations can deliver the seamless, digital-first experience members expect while driving operational and financial efficiency.

Wellframe gives health plans the power to:

• Eliminate data silos and streamline vendor portfolios.
• Enhance care management with scalable digital tools.
• Improve engagement, outcomes, and satisfaction for members and providers alike.

As healthcare organizations face mounting pressures, the time to simplify and consolidate is now. With Wellframe, health plans can replace fragmentation with focus—and build a foundation for better care, lower costs, and lasting growth.

Discover how GuidingCare enables interoperability and regulatory compliance for healthcare payers. Download our guide, “Future-Proof Your Health Plan with HealthEdge GuidingCare®: FHIR-Driven Solutions Enable Compliance.”