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For health plans, payment errors and discrepancies aren’t just frustrating—they can be costly. Without access to updated pricing information, health plans face payment delays and inaccuracies that can negatively impact provider relationships, regulatory compliance, and administrative processes.

Many payers rely on a patchwork system of point solutions to address individual business needs. While disparate systems may work well for their specific niche, a network of disparate tools can lead to siloed data, cumbersome workflows, and a reliance on manual intervention. An integrated digital ecosystem can empower your health plan to respond faster to market demands and scale your offerings.

HealthEdge Source™ breaks the paradigm of disjointed point solutions by integrating the industry’s leading third-party payment integrity solutions directly into a unified ecosystem. This approach helps payers directly address inefficiencies while providing actionable insights and analytics.

3 Benefits of an Integrated Payment Integrity Solution

A third-party payment integrity ecosystem rewrites how payers approach payments and billing, creating clarity while enhancing operational outcomes. Here’s what the shift to an integrated solution can do for your organization.

1. Reduce Administrative Burdens

Every new vendor a payer adopts comes with its own learning curve—oversight responsibilities, system compatibilities, and manual review processes can take valuable time away from strategic action. It’s not uncommon for payers to find themselves juggling multiple vendor contracts, managing system redundancies, and comparing siloed data from disparate systems.

For example, HealthEdge Source delivers automated updates to help streamline workflows, ensuring your systems stay up to date without requiring manual intervention. The solution also automates fee schedule updates, allowing payers to reclaim critical hours and focus on achieving organizational goals.

Integrating third-party tools can be a game-changer. For one HealthEdge Source customer, the integrated solution led to a 30-40% reduction in resource-intensive contract maintenance processes. By embedding pricing, compliance, and editing solutions directly into the payment integrity ecosystem, payers can reduce their reliance on disconnected systems to streamline workflows and reduce administrative burden.

2. Driving Cost Savings

Efficiency and accuracy can help drive cost savings for healthcare payers. From minimizing vendor contracts to automating updates, the scalability of integrated payment integrity tools enables payers to capture immediate savings—and sustain those reductions over time.

By aligning teams around a unified third-party ecosystem, payers can reduce the hidden costs of operational silos. Whether it’s avoiding duplicated effort, cutting contract negotiation delays, or auto-adjudicating claims with high accuracy, streamlined functionalities create long-term financial advantages for payers.

For one health plan, leveraging the HealthEdge Source solution led to a 500% increase in savings. The integrated pricing and editing functions allowed the payer to achieve these significant saving by streamlining processes and reducing manual intervention.

3. Compliance Confidence

Keeping up with consistent regulatory updates (like the No Surprises Act and updates from the Centers for Medicare and Medicaid Services (CMS) is a never-ending task for health plans. Falling out of compliance isn’t simply an inconvenience—it can damage provider relationships, tarnish payer reputations, and lead to significant penalties.

Compliance with evolving regulations begins and ends with accurate, accessible information. HealthEdge Source helps simplify this process by embedding compliance updates within the ecosystem, ensuring you remain aligned with the latest mandates. For instance, automatic CMS fee schedule uploads every two weeks guarantee health plans operate with current policy information. Additionally, automated features—like real-time claims adjudication—help ensure accuracy.

With these safeguards in place, payers aren’t rushing to adjust systems or scrambling in response to regulatory shifts. Instead, they operate with confidence, delivering value to both providers and members.

Discover the Third-Party Ecosystem Built for Growth

HealthEdge Source transforms its integrated ecosystem into more than just a platform—it’s a strategic partner that evolves with you. By incorporating third-party payment integrity solutions into one centralized system, the solution eliminates unnecessary complexities while enabling smarter decision-making.

Key advantages of the HealthEdge Source solution include:

• One-Stop Access to Top Solutions: Industry-leading libraries like RJ Health and FAIR Health are embedded directly into the solution.
• Automated Updates: Continuous updates to the solution and available data reduce the workload for your team.
• Reduced IT Overhead: HealthEdge Source doesn’t require custom coding or high-maintenance integrations.
• Proactive Cost Savings: Innovations like auto-adjudication and customizable workflows deliver ongoing value.
• Future-Proof Compliance: Easily adapt to new regulations without system overhauls.

From the American Society of Anesthesiologists’ billing data to real-time fraud prevention tools from Codoxo, every element of the HealthEdge ecosystem is designed to enhance accuracy, elevate outcomes, and diminish inefficiencies across the board.

Healthcare leaders know that piecemeal solutions can’t keep pace with modern demands. HealthEdge Source weaves together the industry’s best third-party solutions into a unified ecosystem that’s built to scale and evolve. By integrating editing, pricing, and compliance solutions in one system, payers can achieve unprecedented levels of clarity and precision.

Leave the inefficiencies behind—learn more about how HealthEdge Source can help your health plan leverage integrated third-party payment solutions and make sure you’re prepared for the future of payment integrity.

Medicaid programs nationwide are increasingly requiring and incentivizing health plans to incorporate whole-person care and the social determinants of health (SDOH) into their service models. Recognizing SDOH’s significant influence on health outcomes and costs, Medicaid programs are encouraging payers to move beyond traditional clinical care and focus on holistic approaches that address the underlying social needs of vulnerable and high-risk populations.

Initiatives such as California’s CalAIM exemplify this shift, implementing high-touch member services and support for housing, food, and other physical, behavioral, and social needs. These efforts are especially important for high-risk populations.

Similarly, other state programs, including North Carolina’s Healthy Opportunities Pilot, Michigan’s Health Equity Project, and Arizona’s Whole Person Care Initiative, challenge payers to adopt integrated care strategies that meet members’ social needs alongside their medical needs. These programs set new care management standards, often requiring partnerships with community organizations to deliver services that can positively impact long-term health outcomes.

Integrating SDOH into Digital Care Management

Adapting to these new standards calls for a comprehensive approach to addressing SDOH. This is where technology platforms integrated with social care networks, such as Unite Us, become essential. The integrated GuidingCare and Unite Us solution provides health plans with the ability to seamlessly coordinate social services, creating a more efficient, impactful whole-person care model that aligns with evolving Medicaid requirements across the U.S.

By incorporating SDOH data into the GuidingCare platform, care managers can gain a 360-degree view of their members’ health, allowing for more personalized and effective care plans. This holistic approach addresses not just clinical care needs through GuidingCare but also provides referrals to services that improve social and environmental factors, which significantly impact health outcomes

What Is Unite Us?

Unite Us is a technology company that builds coordinated care networks of health and social service providers. Their platform offers health plans access to one of the nation’s largest networks of social service providers, enabling efficient referrals for housing, food, transportation, and employment services across the United States.

The GuidingCare and Unite Us SDOH Integration

The integration between GuidingCare and Unite Us enables seamless data exchange and document sharing directly within the GuidingCare interface.

Key benefits of this integration include:

• Improved Interventions. GuidingCare users can effectively identify social care needs, refer members to appropriate services, confirm service delivery, and track outcomes.
• Access to Coordinated Care Networks. The Unite Us coordinated care network allows care managers to connect members to a wide range of social services and resources within GuidingCare.
• Holistic View of Member Health. Care managers have access to a comprehensive view of members’ health, covering both clinical and non-clinical factors that impact outcomes.
• Improved Quality Measures. By addressing social factors, health plans can positively impact member outcomes while strengthening their organization’s quality measures
• Streamlined Workflow. SDOH interventions can be efficiently incorporated into care plans and managed directly within the GuidingCare platform.

GuidingCare and SDOH

The integration with Unite Us is just one part of HealthEdge’s broader approach to embedding SDOH data into care management workflows. By systematically incorporating SDOH into the GuidingCare platform, health plans can better adapt to evolving Medicaid programs. Care managers, in turn, can efficiently coordinate whole-person care and connect members to vital services.

HealthEdge is committed to innovation, collaboration, and delivering solutions that address all aspects of members’ health. To learn more about how GuidingCare’s SDOH integrations can transform healthcare for your organization, visit our website or contact us today. Together, we can work towards a healthcare system that addresses all aspects of members’ health.

To stay ahead of complex payment models and billing guidelines, healthcare payers are turning to integrated digital solutions that can help streamline operations to achieve key business goals. Approaching payment integrity using disparate systems often results in unnecessary reworks and higher administrative costs. With an enterprise payment accountability approach, health plans can avoid improper payments and reduce recovery fees.

Payment Accountability®: A Proactive Approach to Payment Integrity

Payment Accountability® from HealthEdge Source™ shifts the focus from post-payment recovery to proactive cost avoidance practices. By integrating claims processing workflows and optimizing pre-pay processes, health plans can reduce processing times and strengthen financial performance.

A Comprehensive Solution for Greater Control

HealthEdge Source Platform Access empowers health plans to enhance payment integrity at every level. Advanced analytics, custom editing tools, and real-time insights give payers more control over their payment processes, and achieve key benefits such as:

• Root-cause detection: By analyzing historical claims data, health plans can uncover policy gaps, identify outliers, and detect configuration issues before they lead to costly errors.
• Quick & easy adjustments: Advanced Custom Editing lets health plans quickly create and customize edits and analyze past claims for increased accuracy. This simplified eliminates delays and reduces dependence on external vendors for execution and maintenance.
• Enhanced transparency and control: With a centralized platform, health plans gain real-time visibility into their payment integrity processes—helping ensure payment accuracy and regulatory compliance.

Our integrated technology, combined with our consultative partnership, helps health plans proactively manage claims processing and payments. HealthEdge  Source platform gives health plans greater control over their intellectual property, addresses root cause issues, and eliminates recurring administrative waste to support enterprise payment accountability.

Payer-Source Integration

The Payer-Source integration between HealthEdge Source and  HealthRules® Payer will be another pivotal step towards achieving an enterprise approach to payment integrity. By connecting all claims processing functions through a single platform, HealthEdge Source empowers health plans to manage their payment integrity programs more effectively. This effort enhances transparency between core platform and payment integrity functions.

By aligning disparate functions into a unified system, health plans can benefit from:

• Improved Payment Accuracy: Libraries of pricing and editing data, updated biweekly, lay the groundwork for industry-leading accuracy.
• Holistic Claims Adjudication: Editing can be applied effectively at multiple stages of the workflow, minimizing errors and reducing redundancies.

This centralized approach creates a bottom-line impact for enterprises, improving productivity while reducing overhead costs associated with fragmented systems.

Real-World Impact: Transforming a National Health Plan 

A major national health plan partnered with HealthEdge Source to address key challenges with achieving payment accuracy and workflow efficiency. The health plan leveraged the HealthEdge solution suite to streamline claims processing and payment management across the organization.

After adopting the integrated HealthEdge Source solution, the health plan accomplished notable improvements across performance and financial goals. Key achievements include:

• 30-40% reduction in resource-intensive contract maintenance
• Managed 70% self-funded business on a single platform
• Eliminated processing delays and improved claims transparency

• “The flexibility, configurability, and transparency of HealthEdge Source have been pivotal in our journey, resulting in measurable savings and operational improvements,” said the payer’s VP of Operations shared. “This partnership has truly transformed our approach to payment accuracy and operational efficiency.”

With the abilities to continually adapt to both competitive market demands and evolving regulatory requirements, the organization’s enterprise-wide payment integrity transformation positions it for long-term success and industry leadership.

Opportunities in Payment Accountability

Disruption isn’t just about changing for the sake of change. It’s about understanding that yesterday’s systems weren’t built to handle tomorrow’s demands. Health plans should recognize the need to challenge outdated norms in favor of strategies that position them for long-term success.

By embracing a coordinated, technology-driven approach to payment integrity, health plans can move beyond cost savings to set new standards in transparency, accountability, and operational excellence—ensuring they are ready for the challenges of tomorrow.

See how a provider-owned health plan leveraged the HealthEdge Source Payment Integrity solution to streamline operations, improve accuracy, and enhance provider transparency. Read the case study: SummaCare’s Secret to Payment Integrity Success

 

The healthcare industry is evolving at a rapid pace. Regulatory demands, shifting consumer expectations, and the need for data-driven decision-making are placing unprecedented pressure on health plans. The challenge is clear—how can payers remain competitive while meeting the growing complexities of modern healthcare?

This is where a next-generation Core Administrative Processing System (CAPS) like HealthRules Payer comes in. Designed to empower health plans with real-time data and unparalleled flexibility, this innovative system enables organizations to expand offerings and serve new member markets with ease.

How Health Plans Can Expand to New Markets with Modern CAPS

Health plans operate in an increasingly demanding environment. The traditional, hard-coded administrative systems of the past are ill-equipped to keep up with today’s healthcare landscape. A next-generation CAPS solution does more than process claims and manage benefits—it becomes the foundation for achieving strategic growth, operational efficiency, and superior member experiences.

With a next-generation solution like HealthRules® Payer, health plans can:

• Understand diverse member populations with real-time data and analytics.
• Quickly configure and launch new benefits offerings.
• Expand into new markets to capture valuable growth opportunities.

By leveraging a modern CAPS, health plans can move faster, adapt smarter, and make better-informed decisions—all while lowering administrative costs.

Real-World Transformations with HealthRules Payer

Health plans of all sizes have chosen HealthRules Payer as a technology partner for its ability to scale, adapt, and transform payer operations. See an overview of how three different health plans leveraged the HealthRules Payer CAPS solution to configure new offerings and expand to new markets.

Medica Health Plan

Medica, a regional health plan managing over 1 million lives, partnered with HealthEdge to streamline existing lines of business and expand its benefit offerings by reducing time to market.

Key Achievements:

• Configured 81 benefit plans in just 10 days using only four resources.
• Responded to new market opportunities in real time, leveraging accurate and actionable data.
• Automated manual processes across existing business lines, significantly reducing administrative costs.

“Data is the most valuable asset that health plans have.”

-VP of Business Transformation at Medica.

McLaren Health Plan

McLaren faced mounting inefficiencies with its outdated legacy system, including a low auto-adjudication rate. With the integrated CAPS solution from HealthRules Payer enabled McLaren to modernize their operations and respond to industry changes faster—which better positions the organization for long-term growth.

Key Achievements:

• Achieved a 90% auto-adjudication rate, reducing reliance on manual claims processing.
• Increased operational efficiency, allowing staff to reallocate resources toward innovation.
• Seamlessly expanded membership to 620,000 lives, bolstering business performance.

“HealthRules Payer has made reporting better and quicker, enabling us to operate with greater efficiency as we scale.”

-VP of Business Information & Operations at McLaren Health Plan.

Presbyterian Health Plan

Processing over 9 million claims annually, Presbyterian Health Plan required a flexible CAPS to manage growing complexities and maintain compliance. They leveraged the HealthRules Payer solution to automate claims processing, improve responsiveness, and adapt to shifting industry demands.

Key Achievements:

• Reduced claims turnaround time to under 5 days, ensuring prompt provider payments.
• Increased staff productivity by 30%, measured by the number of claims processed per hour.
• Enhanced benefits configuration efficiency by 40%, enabling rapid product launches.

“The configuration capabilities within HealthRules Payer are phenomenal. We’ve been able to make changes in half the time it took us previously.”

-VP of Claims Operations at Presbyterian Health Plan

What Sets HealthRules Payer Apart from other CAPS solutions

HealthRules Payer offers distinct advantages that make it a go-to choice for health plans seeking to modernize their administrative systems. Here’s what differentiates it:

1. Flexibility, Scalability, and Resilience

The HealthRules Payer CAPS is designed for flexibility and scalability, allowing payers to adapt to regulatory shifts, market trends, and emerging member needs for long-term viability.

• Real-Time Data Insights: Access accurate data instantly to make informed decisions and respond to opportunities ahead of competitors.
• Regulatory Compliance: Easily modify rules, produce auditable information, and adapt to regulatory requirements without disrupting operations.
• Faster Time-to-Market: Configure, review, and deploy new benefit offerings with unmatched speed and precision.

For McLaren Health Plan, this adaptability enabled rapid adaptation to industry changes, providing a significant edge in a competitive market.

2. Adaptability to New Business Models

The healthcare landscape is shifting from fee-for-service to value-based care (VBC), requiring payers to adopt more complex reimbursement structures. HealthRules Payer excels in enabling value-based reimbursement by:

• Designing and implementing benefit plans in less time and at lower costs than traditional systems.
• Sharing critical insights from data analytics with providers, improving performance metrics and creating stronger partner relationships.

For example, HealthRules Payer’s natural language capabilities have improved first-call resolutions at Presbyterian Health Plan, building trust and reducing callbacks—a direct reflection of enhanced service and data transparency.

3. Automation and Efficiency

Move away from manual workarounds and legacy inefficiencies. HealthRules Payer automates major processes, driving seamless operations that save both time and money. From claims processing to reporting, automation fosters:

• Higher accuracy
• Reduced operational costs
• Scalable business expansion

For example, Medica’s adoption of HealthRules Payer eliminated costly manual processes, improving productivity across Individual & Family, Medicare, and Commercial Group business lines.

The Competitive Edge for Health Plans

By implementing HealthRules Payer, health plans gain more than just operational efficiency—they secure a competitive advantage. Some key benefits include:

• Faster Response Times: Adapt to regulatory changes and industry demands in record time.
• Cost Efficiency: Lower administrative costs with streamlined, automated operations.
• Market Growth: Launch differentiated offerings ahead of competitors, capturing new members and revenue streams.
• Superior Member Experience: Deliver accurate, personalized service with easy-to-access data and insights.

With health plans increasingly vying for consumer loyalty, having a robust CAPS solution provides the tools needed to stand out in a crowded marketplace.

Do you want to learn more about how the next-generation CAPS from HealthRules Payer can empower your health plan to expand to new markets? See how a regional health plan achieved a 90% auto-adjudication rate, opened new lines of business, and expanded to new states. Read the case study.

Health plan members no longer seek transactional healthcare interactions—they expect personalized, accessible, and engaging experiences. For health plans, meeting these expectations isn’t just desirable—it’s essential. To meet this increasing demand, payers are investing in integrated solutions that can help them streamline workflows, deliver personalized care, and empower members.

These solutions not only enhance member satisfaction and clinical outcomes but also give payers a competitive edge in an increasingly complex market.

This blog explores how leading health plans are investing in care management workflow software, AI tools, and self-service digital resources to deliver world-class member experiences and boost CMS Star Ratings.

The Shift Toward Personalized Care

Today’s healthcare consumers want to feel like more than just policy numbers. They want healthcare options that offer the convenience, clarity, and customization they’ve come to expect with their retail experiences. According to recent surveys, 59% of members expect health plans to prioritize health equity, while 52% cite a demand for self-service tools.

Personalized care has more benefits than just meeting members’ expectations. It can also help improve health literacy, increase preventive care utilization, and contribute to better care outcomes. The value of personalization for health plans goes far beyond member satisfaction—engaged members are healthier members, which translates to fewer hospitalizations, greater satisfaction, and higher retention rates.

To meet member expectations, health plan executives are turning to three core digital investments.

Top Areas of Digital Investment for Healthcare Payers 

Health plan leaders strategically dedicate resources to technologies that drive operational efficiency, reduce administrative burdens, and place members at the center of their strategies.

1. Care Management Workflow Software 

Care management workflow software provides the critical infrastructure to streamline and optimize care delivery. These tools improve coordination between care teams, reduce inefficiencies, and enable real-time data sharing for seamless decision-making.

GuidingCare® is an industry-leading solution that integrates care management, population health, and utilization management into a unified platform. With features like automated care planning and advanced care coordination tools, GuidingCare helps payers deliver whole-person care while freeing up staff to spend more time engaging directly with members.

Benefits of Care Management Workflow Software:

• Efficient Workflow Automation: Streamlines processes, reducing time-intensive manual tasks.
• Personalized Interventions: Supports tailored solutions by identifying high-risk members and alerting providers.
• Seamless Communication: Breaks down internal silos to help ensure care teams, providers, and members can communicate more effectively.

2. Artificial Intelligence  

AI is already making an impact in healthcare, with its potential to provide actionable insights, automate repetitive tasks, and predict outcomes with precision. For health plans, incorporating AI tools allows for resource allocation and streamlined decision-making.

In addition, AI-powered predictive analytics can identify high-risk members who need immediate attention, enabling plans to proactively engage these individuals and close gaps in care before conditions worsen.

How AI Benefits Health Plans:

• Early Identification of High-Risk Members: AI can forecast member health risks and recommend timely interventions.
• Improved Administrative Efficiency: Automates claims processing and fraud detection, saving valuable resources.
• Higher Member Satisfaction: AI tools can help personalize communications, making members feel valued.

3. Self-Service Digital Resources 

Instead of traditional phone calls, members increasingly demand the convenience of self-service tools that give them access to their health history, benefits information, and care programs. Empowering members to manage aspects of their health journey not only improves satisfaction but can also increase member touchpoints and extend existing resources.

The GuidingCare integration with Wellframe delivers digital checklists and personalized health reminders, helping members stay engaged with their care plans. Wellframe offers more than 70 digital care programs, an on-demand resource library, and personalized daily health checklist that supports members wherever they are on their health journeys.

Benefits of Self-Service Tools:

• Empower Members: Enable members to check coverage details, schedule preventive screenings, and access educational content.
• Reduce Friction: Lower costs and make healthcare services more accessible and transparent.
• Enhance Member Engagement: Provide reminders and tools aligned with the member’s unique health goals. Members who use the Wellframe solution average 34 interactions per member per month.

Real-Life Impact: Nonprofit Health Plan

One nonprofit health plan partnered with HealthEdge® to modernize its digital care solutions. By integrating GuidingCare with HealthRules® Payer, the payer was able to reduce administrative fragmentation and offer its million-plus members a better, more efficient healthcare experience. This transformation improved data accuracy and strengthened member trust—essential elements in a competitive healthcare marketplace.

The healthcare industry is being reshaped by rapid advancements in technology, and health plans must adapt to thrive. By investing in these innovative tools, health plans can create meaningful member experiences, improve health outcomes, and stay competitive in a field where personalization is the key differentiator.

Learn more about the trends driving health plan investment and modernization. Download the HealthEdge Annual Payer Market Planning Report 2025