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The healthcare industry is entering a critical phase of reinvention. Legacy technologies and decades-old operational models are no longer sufficient in today’s complex, data-rich, and high-demand healthcare environment. Especially for health plans, the pressure to modernize and transform is more urgent than ever—and the stakes are high.

Outdated core systems and fragmented processes are holding health plans back. From the inability to harness AI and automate core functions to struggles with regulatory compliance, cybersecurity risks, and declining margins, the burden of operating on legacy infrastructure is growing too heavy to bear. In fact, the switch rate for core administration processing systems (CAPS) from homegrown or legacy platforms is expected to rise to 15–20% over the next five years—a signal that a major shift is underway.

Addressing these challenges is only the beginning. To truly drive meaningful change, health plans must move beyond fragmented point solutions. Unlocking the full potential of emerging technologies—and the valuable data they generate—requires a unified platform that brings everything together in one place.

The Era of Convergence: Where Health Plans and Providers Meet

Healthcare is evolving toward greater collaboration, bringing health plans and providers together like never before. This integrated approach better serves the entire system and, most importantly, the member. To truly transform the healthcare experience, we must bridge the gap between payer and provider operations. This alignment is not only necessary—it’s foundational.

At its core, convergence means bringing together clinical and financial data, technology, and operations across the healthcare continuum. When payers and providers are synchronized, everything flows more smoothly:

• Claims are processed faster and with fewer errors.
• Providers can spend more time with patients instead of managing paperwork.
• Members get a seamless, digital-first experience that drives satisfaction and better health outcomes.

And this isn’t just a theory. For example, 20% of pended claims, which is a claim that requires additional information prior to completing the adjudication process, are due to incomplete or inaccurate provider data. With advanced provider data management (PDM) powered by AI, that 20% can be resolved—delivering immediate, measurable impact. That’s the power of convergence in action.

The North Star: The Ideal Member Experience

Ultimately, the goal isn’t just modernization for its own sake. The real destination is a frictionless, personalized, and digital healthcare journey—the ideal member experience. But this experience is only possible when technology and data are unified across systems and when payers and providers collaborate deeply and consistently.

To get there, organizations must invest in the four pillars of one next-generation platform:

• Touchless Transaction Processing: Trusted automation to correctly process transactions, reducing manual interventions and making member interactions more productive.
• Prospective Payment Accuracy: Plans need payments to be right the first time, reducing provider abrasion as well as the time and costs associated with recovering funds.
• Care Integrity: With greater efficiency and access to reliable, synthesized information, health plans can improve care coordination and delivery.
• AI-Driven Business Intelligence: AI and machine learning can sift through mountains of data to provide detailed, business-level intelligence critical to informed decisions.

What’s Driving the Shift?

Let’s break it down by industry vs. technology challenges:

Industry Challenges

• Rising operating costs and shrinking margins
• Complex regulatory compliance requirements
• The shift to value-based care models

Technology Challenges 

• Inability of legacy systems to scale or support AI
• High reliance on third parties for updates and integration
• Cybersecurity vulnerabilities and data silos

Each of these challenges reinforces the need for convergence across systems, data, workflows, and relationships. But alone, transformation isn’t enough. The solution is convergence across systems, data, workflows, and relationships.

The Future of Healthcare Starts Here

Healthcare stands at an inflection point. The convergence of health plan and provider data, technology, and operations is not just the next step—it’s the only viable path forward. And it all points to one guiding principle: the member experience as the North Star.

By embracing this convergence, we can finally break through the inefficiencies of the past 50 years and heal a broken system.

Learn more about how your team can Converge Without Limits with HealthEdge®.

The healthcare payer market is at a critical juncture, driven by increasing market pressures, consumer demands, and the need for technological modernization. At HealthEdge®, we believe payers have the opportunity to transform challenges into opportunities by leveraging cutting-edge tools and next-generation solutions. With over 110 million covered lives using our platforms and a proven track record of innovation, HealthEdge is uniquely positioned to empower payers to advance administrative efficiencies, improve patient outcomes, and make complex operations more cohesive.

This blog outlines the core components of HealthEdge’s vision, addressing current market forces, the challenges payers face, and how HealthEdge delivers actionable solutions that align with future industry needs.

Industry Pressures for Healthcare Payers

The payer landscape is undergoing an immense transformation, influenced by shifts towards value-based care models, rising cybersecurity threats, and increased regulatory demands around interoperability. Additionally, organizations face growing pressure to contain costs and enhance operational efficiency.

Some of the most prominent payer industry pressures include:

• Decreasing Margins: Payers face significant financial strain due to record-high medical and labor costs and rate changes
• New Products and Value-Based Care: Payers need to manage complexity associated with implementing innovative product design and value-based payments
• Security Risks: Recent cyber security breaches have increased payer focus on ensuring deployment of infrastructure and technology to manage potential threats
• Need for Data Interoperability: Payers are under significant (regulatory) pressure to improve interoperability and enhance patient engagement and outcomes

This is coupled with the emergence of advanced technology:

• Opportunity for AI and Automation: 
  • 97% of payers expect to increase funding for generative AI (approximately 40% spend increase)
  • Critical service cost savings can only be realized with a next-gen underlying code
• Technical Flexibility:
  • 83% of payers expect to increase funding for app modernization (approximately 30% spend increase)
  • Payers can only manage increasing complexity with robust core technology
• Cloud: 
  • 80% of payers expect to increase investments in the cloud (approximately 30% spend increase)
  • Moving to the cloud is essential for payers to maintain robust stability while scaling and managing security
• Mobile and Cross-System Compatibility:
  • 90% of payers expect to increase funding integration tech (approximately 20% spend increase)
  • Payers need a connected system that enables better patient engagement and stakeholder collaboration

These challenges have created an ‘inflection point’ for healthcare payers, signaling a clear need for solutions that offer operational resilience and enable transformational change. The modernization of IT systems is critical for healthcare payer CIOs, with digital payers being 3x more likely to achieve above-industry revenue and margin growth.

HealthEdge’s Vision for an Optimized Future 

At HealthEdge, our vision is to innovate a world where healthcare can focus on people. Our mission is clear: to drive healthcare transformation through a single digital ecosystem that delivers advanced automation and clinical engagement among healthcare payers, providers, and patients.

With a strong foundation of products and a forward-thinking approach to innovation, we aim to revolutionize payer operations while keeping customer needs at the forefront.

The HealthEdge Ecosystem: Delivering Synergies with Scalability

Healthcare payers need a partner that not only understands their challenges but also provides a clear roadmap for overcoming them. HealthEdge delivers this by addressing payer concerns at both the administrative and strategic levels.

Integrated Benefits to Core Operations

Unlike standalone solutions, HealthEdge product combinations result in highly synergistic, integrated benefits to payers’ core operations.

Benefits of Integrated Digital Solutions: 

• HealthRules® Payer + HealthEdge Source™:
  • Accelerates accurate adjudication by incorporating pre-adjudication pricing and editing in one call
  • Reduces strain on payer IT infrastructure by providing integrated support services
• HealthRules Payer + HealthEdge GuidingCare®
  • Ensures appropriate utilization by ensuring utilization and care managers have access to real-time benefits and claims information
  • Facilitates accurate claims adjudication by HealthEdge GuidingCare submitting appropriate claims prior auth information to HealthEdge HealthRules Payer in required format
• HealthEdge Wellframe™ + GuidingCare
  • Decreases duplicate data entry in clinical platforms
  • Integrates and streamlines communication between member, provider and payer
  • Aggregates member data to establish best practices that improve care journey recommendations
• Wellframe + HealthEdge Provider Data Management
  • Synthesizes real-time provider information to ensure the latest credentialing, directories, and repositories are accurate and accessible to members seeking care
• HealthRules Payer + HealthEdge Provider Data Management
  • Eliminates data mismatches in provider information between systems and timely updates provider data in claims processing to reducing claim delays, denials or rework

These synergistic benefits allow organizations to achieve cost savings, improve scalability, enhance compliance and ultimately, deliver better member experiences. Combinations of three or more products further emphasize the value of HealthEdge’s product suite offering and provide outsized returns to payers.

Core System-of-Record and Mission Critical Solutions

HealthEdge provides the core system-of-record and mission critical solutions that enable key payer technology workflows.

HealthEdge Core Solutions

Claims Management

HealthEdge HealthRules Payer helps payers manage and adjudicate claims submitted by providers. It serves as the integrated source of truth for payer tech stacks

Payment Integrity

HealthEdge Source provides a range of pre-pay capabilities with a differentiated pricing solution (and also includes claims editing)

Care Management and Digital Member Engagement

HealthEdge GuidingCare streamlines and automates care management workflows. At the same time, HealthEdge Wellframe enables digital member engagement and integrates with HealthEdge GuidingCare to facilitate clinical and administrative communication with members

Provider Data Management

HeathEdge’s Provider Data Management solution creates a “golden record” of provider data – it ingests, enhances, and distributes provider data to all other required systems and processes.

HealthEdge Enabled Solutions

Business Strategy

HealthEdge HealthRules Payer provides critical business intelligence to shape payer strategy, including analyzing customer segments and identifying profitability improvement opportunities

Product Development

HealthEdge HealthRules Payer and HealthEdge Source provide critical data to inform pricing and actuarial; data also informs refinement of existing products and build of new products

Marketing and Sales

Payers leverage combination of customer and HealthEdge HealthRules Payer data to respond to RFPs and set pricing using data analytics

Enrollment and Billing

Payers enroll members in respective systems to ensure products and benefits are configured properly and submitted claims are paid promptly and accurately via HealthEdge HealthRules Payer

4 Core Pillars of the HealthEdge Innovation Strategy

HealthEdge’s future vision is anchored by four strategic pillars, which serve as guiding principles for our solutions and organizational goals.

1. Touchless Transaction Processing

Our vision is seamless integration, with the long-term benefit of 100% touchless transaction processing in production. We envision a future where all transactions can be processed without human intervention, creating meaningful operational efficiencies for payers.

2. Payment Accuracy Transformation

Our vision is the elimination of payment recoveries with 99%+ payment accuracy. By integrating pricing and edits capabilities upstream, our solutions can eliminate administrative overhead, reduce provider abrasion, and enable accurate payments.

3. Care Integrity Optimization

Our vision is to increase care delivery effectiveness to optimize medical spend and payer performance. Our solutions GuidingCare and Wellframe work in tandem to optimize the care patients receive.

4. AI-Powered Business Intelligence

Our vision is to drive analytics for benchmarking, next-level operational insights, and proactive recommendations. Our approach to AI revolves around consolidating fragmented data and making it actionable, empowering organizations to make data-driven decisions in real time.

A Future Built on Innovation and Collaboration

While the healthcare payer landscape keeps evolving, our commitment to delivering innovative solutions remains constant. HealthEdge’s vision is centered not just on creating premium technology but enabling payers to experience the business attributes of improved end-user and consumer centricity, ever-reducing transaction costs, ever-increasing quality and ever-increasing service levels and business transparency.

Are you ready to explore a smarter, more efficient way forward? Discover how HealthEdge can help your organization adapt, optimize, and thrive amidst today’s challenges.

Contact Us to Learn More

Healthcare is at a crossroads. Legacy platforms, endless point solutions, and mounting regulatory pressure are all warning signs on the road to change. The need for transformation is clear, even if the path forward is foggy.

What worked 10 years ago just won’t cut it anymore. Best-in-class point solutions without deep integration are expensive, inefficient, and ultimately unsustainable. Siloed data is a strategic liability in an era where intelligence and automation are table stakes.

So how do we move forward?

The Problem: Fragmentation Everywhere

We’ve been told for years that picking the “best tool for the job” is the smart play. But in healthcare, that’s led us to a situation where every team uses different tools, none of them talk to each other, and the data is scattered everywhere. It’s hard enough to do basic business intelligence when data is stuck in silos, let alone leverage advanced analytics or employ artificial intelligence (AI). The truth is that siloed data never becomes intelligent.

This fragmentation also slows everything down—product delivery, regulatory response, customer experience. And just as AI tools explode into the market, we’re further splintering our infrastructure trying to keep up.

The Pivot: From Point Solutions to Unified Platforms

At HealthEdge®, we believe the only way to solve this is with deep, foundational integration—across data, user experience, and development.

The Experience Platform

HealthEdge is addressing this challenge head-on by bringing its products together into a single, cohesive experience platform. This standardizes the user interface across all applications—delivering consistency in design, workflows, and functionality.

That consistency reduces friction. That’s what the HealthEdge Experience Platform delivers for healthcare operations. Whether you’re a claims processor or an administrator, you know how to navigate, where to click, and how to get things done. It’s intuitive. It’s efficient. It’s scalable.

The Intelligence Platform

On the back end, we’re merging all our data into a unified intelligence layer—a modern data lake and warehouse that supports real-time reporting, cross-platform analytics, and AI-powered insights—all without requiring advanced technical skills.

This platform opens the door to advanced capabilities like touchless transaction processing, where manual workflows, such as claims adjudication, can be significantly reduced or even eliminated through automation and intelligent decision support. This is the foundation of truly intelligent healthcare: built-in AI that reduces manual work, flags inefficiencies, and helps automate decision-making.

The Regulatory Landscape: Interoperability as an Opportunity

Interoperability is often viewed through the lens of regulatory burden, but there’s a bigger opportunity here. By enforcing common standards for data exchange, interoperability done right is a business enabler.

Think of it like a typical USB. At some point, the tech industry decided to stop shipping different cables and adapters for every device. USB became the standard. That’s what healthcare needs and what these new regulations are driving toward.

When data is standardized and systems can plug into each other seamlessly, everyone wins—payers, providers, and most importantly, patients.

The Ecosystem Is the Platform

An ecosystem isn’t a list of vendors. It’s not a hodgepodge of tools that don’t interact or work together. It’s a connected, intelligent, outcomes-driven platform.

Our integration layer, HealthEdge Hub, delivers standardized and documented APIs that ensure seamless interoperability across our entire product suite. And we’re backing it with an integration platform that connects with 200+ healthcare systems out of the box.

When a health plan needs to connect claims data with care management or benefits transparency tools, it’s not a six-month project anymore. It just works.

Repositioning IT: From Overhead to Strategic Growth Driver

Historically, IT has been seen as a cost center—something to manage and contain. But that mindset is changing. With HealthEdge’s integrated platform, CIOs and CTOs are empowered to shift from managing technology to enabling innovation.

That’s the opportunity here. Our platforms give health plans real-world ROI—not just by shaving margins, but by employing a highly integrated, single platform that leverages AI to create next generation experiences, automation, and intelligence in near real-time. The result? Smarter decisions, faster execution, and measurable business value.

The Bottom Line

Healthcare doesn’t need more tools. It needs a better foundation. The future demands a technology foundation that’s unified, intelligent, and interoperable by design.

HealthEdge’s platform-driven approach:

• Unifies user experience across all products
• Consolidates data for meaningful, actionable insights
• Simplifies and strengthens compliance efforts
• Accelerates integration across the entire ecosystem
• Powers automation and intelligent decision-making

This isn’t just an upgrade—it’s a necessary transformation for organizations that want to stay competitive, compliant, and truly responsive to the needs of the healthcare landscape.

To learn more about how HealthEdge is enabling health plans to transform operations and care delivery, view the Converge without Limits video.

For modern health plans, enhancing auto-adjudication rates is more than a technical upgrade. It is a strategy for payers aiming to stay competitive by increasing automation, improving efficiency, and strengthening organizational agility.

Current statistics show that a significant 15 and 20% of claims still require manual processing. This not only increases costs by up to $25 per claim, but also extends processing times by days or even weeks. In this blog, we cover why auto-adjudication rates can decrease over time, the benefits of enhancing your claims auto-adjudication process, and how HealthEdge® can help clients unlock the full potential of their health plan technology.

How Do Auto-Adjudication Rates Impact a Health Plan’s Business?

Auto-adjudication rates directly impact a health plan’s operational costs and efficiency. Achieving higher auto-adjudication rates means fewer claims require manual intervention and review resulting in reduced processing times and minimizing the risk of errors. Lower auto-adjudication rates mean more claims require manual reviews, which lead to inflated administrative costs and payment delays.

Manual claims processing can lead to workflow bottlenecks and reduced operational agility. Inefficient adjudication processes also strain health plan resources and can lead to compliance risks and member satisfaction issues. Improving auto-adjudication rates helps ensure the business runs optimally while keeping providers and members happy with timely and accurate payments.

[H2] What Causes a Health Plan’s Auto-Adjudication Rates to Decline?

Auto-adjudication rates are impacted by several factors. Regulatory changes and new payment rules require health plans to update their system configurations to remain compliant. When new payment rules go into effect, some health plans rely on manual reviews until they update internal systems. But over time, manual interventions can accumulate and drag auto-adjudication rates down. Updating configurations to align with new rules can reduce the need for manual reviews and improve payment accuracy.

Some health plans also face auto-adjudication issues when introducing new lines of business. Internal teams may replicate configurations for existing lines of business that are not optimized for the new offering. If not addressed, health plans can face workflow inefficiencies and a permanent decrease in auto-adjudication rates.

A third barrier is that many health plans miss opportunities to leverage the full spectrum of features or capabilities their technology solutions deliver. Staying up to date with system upgrades can enable more streamlined workflow automation and more accessible configurations.

What Are the Impacts of Decreased Auto-Adjudication Rates?

Falling auto-adjudication rates don’t just impact operational efficiency—they impact a health plan’s financial health. Manual claims review costs time and money, which could otherwise be allocated to strategic priorities. It also introduces the risk of human error, which can lead to expensive rework or member dissatisfaction.

Relying on manual reviews also creates inefficiencies in handling claims. For example, reviewers might need to investigate multiple systems to process a single claim. That additional complexity drives up processing times and fragments workflows, making it harder for teams to deliver consistent results.

3 Common Issues That Can Impact Auto-Adjudication Rates

1. Claim Authorization Matching

A claim may be denied if it does not clearly align with the service provided. This is common in areas like inpatient hospital stays or physical therapy services, where the nuances of care delivery can create multiple mismatches.

2. Coordination of Benefits

Effective coordination of benefits means determining the order in which multiple insurers are responsible for a claim. This process is incredibly complex and highly specific to configuration. If the data being fed to the system is delayed, incomplete or inaccurate, it can cause pending claims that require a significant manual effort to resolve.

3. Shifting Regulations

Regulations and payment guidelines are constantly shifting, with some—like the No Surprises Act—directly impacting auto-adjudication rates. When a wide-reaching regulation like this is introduced, health plans may elect to pend relevant claims while they update their configurations to align with the new rules, causing delays.

Improve Auto-Adjudication with Advanced Solutions from HealthEdge

At HealthEdge, we work closely with our health plan partners to understand their holistic needs and how we can support them in achieving their optimization goals. Our Global Professional Services team is comprised of healthcare industry veterans who can partner with your organization to better leverage the HealthEdge solutions available to improve auto-adjudication rates and enhance your claims processes.

What is the Process to Improve Auto-Adjudication with HealthEdge?

We start with an optimization assessment. This is where our internal experts examine a health plan’s existing workflows and configurations and deliver a set of actionable recommendations. Following the assessment, our team can be contracted for additional engagements to support the execution of the optimization assessment recommendations. To start, our team works with the health plan to prioritize recommendations based on their potential return on investment (ROI) and operational readiness. Available resources, like staff availability, often determine both the approach to the engagement and which recommendations get tackled first.

Our team can also offer a collaboration engagement with a health plan’s configuration and testing teams to assist with implementing the suggested changes. This involves developing test cases, running scenarios, and demonstrating proof-of-concept solutions. While each health plan ultimately owns the changes to their operations, our team acts as their guide to help direct the process and maximize results.

This collaborative approach ensures health plans not only address their current challenges, but they are also enabled to future-proof their configurations for ongoing improvements.

One customer was notably struggling to match claims with authorizations. By working with HealthEdge to assess their systems and identify opportunities to improve their claims-authorization matching, this customer was able to achieve a 56% reduction in their pend rate for authorization-related claims—that’s a 56% reduction in claims requiring manual work.

How Do I Know if My Health Plan Would Benefit from Enhanced Auto-Adjudication Support?

The healthcare payer landscape is constantly evolving— and so are the digital solutions available. Most health plans could benefit from regular evaluations and updates to their configurations with a focus toward auto-adjudication improvements. We do see areas where optimization can have a significant impact.

First, health plans undergoing significant growth or bringing on new lines of business typically face challenges that make an optimization assessment especially valuable. The more complex their digital ecosystem, the greater the potential for impactful improvements.

Second, health plans whose systems have not been optimized in several years or who have smaller configuration teams often achieve significant improvements. These organizations are more likely to have areas for configuration improvement that an optimization assessment can help identify and address quickly.

Are you a HealthEdge customer interested in optimizing your claims processes? Contact your Customer Success Executive to learn more about optimization assessment.