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Maintaining efficient claims processing workflows can become an overwhelming task for many health plans. Claims teams have to process every claim accurately and on time, keep up with changing rules, and meet the expectations of both providers and members.

Doing all this work with internal teams alone can leave health plans juggling multiple systems, relying on manual processes, and constantly creating new configurations. With shifting regulations and workloads piling up, it’s easy for mistakes, delays, and frustration to creep in.

The challenges only magnify for large-scale operations. Health plans that manage millions of claims each year will find that even a 1% error rate in claims processing can result in millions lost to overpayments, with added costs to correct mistakes, respond to audits, and restore the trust of members and providers.

4 Common Challenges in Claims Operations

Managing complex workflows, constant regulatory changes, and a flood of incoming claims isn’t easy. Mistakes and bottlenecks are bound to happen. Keeping everything running smoothly requires consistent attention. Here are 4 of the top claims processing challenges that can impact performance, drive up costs, and create friction across many health plans:

• Escalating administrative costs

In 2023, a report from Council for Affordable Quality Healthcare (CAQH) found that the medical industry spends $83 billion annually on administrative tasks—like verifying eligibility, coordinating benefits, submitting claims, compliance reporting, and fixing errors. These rising costs take a big toll on health plans, shrinking financial margins and funding available for member care, which can adversely affect medical loss ratio (MLR). As manual processes and inefficiencies persist, health plans face real challenges in staying compliant, adaptable, and cost-effective.

• Inaccurate payments and overpayments

Across the healthcare industry, it’s estimated that 3% to 7% of claims contain errors, though some health plans report inaccuracies exceeding 10%. In 2024, 16 federal agencies reported $162 billions in improper payments, with over $135 billion attributed to overpayments. These payment errors lead to labor-intensive audits, repeated provider outreach, and potential reputational damage.

• Keeping pace with regulatory changes

The Centers for Medicare & Medicaid Services (CMS) issues new rules and updates every year—sometimes several times a year—on both a fiscal and calendar schedule. For health plans, this means constantly adjusting to new requirements, reporting changes, and payment system updates. These ongoing changes add additional complexity to claims processes and stretch internal teams as they try to interpret, implement, and keep pace with each update. It’s easy to fall behind, and even a small oversight can disrupt daily operations or risk compliance. As the pace of regulatory changes picks up and expectations grow, maintaining compliance becomes a constant, high-stakes challenge for health plans.

• Resource strain and workforce fatigue

With medical costs projected to rise by 8% year-over-year, health plan teams are under growing pressure to manage expenses while also responding to escalating demands from members, providers, and other key stakeholders. At the same time, healthcare staff face widespread burnout and fatigue, driven by high work intensity and long hours. As requirements multiply and resources remain limited, the risk of missed deadlines, errors in compliance, and staff turnover grows. These intertwined challenges make it increasingly difficult for health plans to keep teams effective while adapting to an environment defined by relentless change and rising expectations.

Simplify Claims Processing with HealthEdge Source™ Professional Services

HealthEdge Source Professional Services make it easier for payers to manage the increasing demands on internal teams and digital solutions. The HealthEdge Source Professional Services team works directly with health plan users to address specific organizational challenges—whether it’s managing heavier workloads, navigating complex regulations, or supporting overwhelmed teams.

At HealthEdge®, we don’t just implement the technology and walk away. We provide hands-on support and practical solutions to alleviate pressure where it’s needed most. Our goal is to simplify daily tasks, help maintain compliance, and give your team time to focus on meaningful work instead of small, repetitive tasks. With Professional Services, health plans receive expert support so they can adapt and move forward, even with ever-growing demands.

Claims Solution Implementation & Configuration

Every health plan has its own way of working, so our team meets payers where they are. We start by reviewing workflows, identifying how existing systems connect, and outlining a plan that fits specific organizational goals. Working side by side with the health plan team, we customize system settings, business rules, and workflows to fit each team’s needs. This hands-on, data-informed process ensures the final setup aligns with a health plan’s operational goals and regulatory standards.

In addition, our team sets up automated processes that take care of repetitive tasks like claims validation and contract updates. With this approach, health plans have seen up to 50% faster configuration times and as much as a 90% reduction in managed configuration. Our goal is to get claims teams up and running with fewer disruptions to increase benefits from smoother processes, fewer errors, and more time for high-value work from day one.

Providing Ongoing Support

Support doesn’t stop at launch. We provide regular system updates and monitor performance to keep systems running smoothly. Our team works alongside payers to adjust workflows and settings as regulations and business needs shift. With proactive steps like quarterly regulatory briefings and hands-on training for new rules, we have seen up to 30% faster turnaround time for updates and adoption of changes.

Frequent check-ins and direct user access to our technical experts mean issues get caught early and audit findings are kept to a minimum, so operations stay on track. This ongoing support helps health plans respond quickly to industry changes, maintain compliance, and ensure consistent day-to-day performance.

Enhancing Payment Integrity

We use advanced analytics and data studies to help health plans identify the root causes of payment errors, like inconsistent contract terms or misapplied policy rules. By analyzing claim patterns and operational data, we create targeted edits and corrective actions to fix these recurring issues. Health plans we’ve worked with have seen up to 50% faster savings realization from edits compared to traditional methods.

We work closely with health plans to validate improvements and monitor results, making sure payment accuracy is achieved and maintained over time. By creating a feedback loop between analytics, operations, and system configurations, we help payers improve financial performance, maintain compliance, and adapt to industry changes.

How A Regional Health Plan Streamlined Maintenance & Helped Ensure Claims Accuracy

One large regional health plan, supporting commercial, Medicaid, and Medicare members, ran into daily problems with contract consistency and managing the volume of contract updates. Duplicate records and missing information kept popping up as they tried to keep everything current across their systems. Plus, the constant flow of policy updates meant their teams were always working to avoid falling behind on compliance.

HealthEdge Source stepped in with a hands-on support model designed to address these ongoing issues. Our subject matter experts worked closely with the plan to streamline contract maintenance and ensure accuracy. We provided dedicated support through bi-weekly release note walkthroughs, summary matrices, and actionable recommendations, making it easier for the plan to adapt to regulatory changes and integrate updates efficiently. A dedicated support analyst was assigned to guide the team through new requirements and enhance readiness for upcoming changes, allowing the plan to focus on strategic priorities.

As a result of partnering with HealthEdge Source, the health plan was able to:

• Eliminate duplicate contract records and improve overall reliability
• Realize significant reduction in manual contract maintenance efforts through consistent, expert-led support
• Maintain compliance with evolving regulations
• Improve workflow efficiency, freeing up staff to focus on advancing core objectives
• Strengthen operational readiness to respond quickly without disrupting daily operations

What’s Ahead for Payment Integrity?

Health plans deal with complex challenges every day—handling them alone often leads to more risk and higher costs. The HealthEdge Source team offers the expertise and support health plans need to keep operations accurate, accountable, and efficient.

Set your organization up to handle whatever comes next with confidence. Check out our resources to learn more about Professional Services offerings from HealthEdge Source.

For many payers, maintaining accurate provider information is complicated. Managing disparate data sources, analyzing information, and reviewing existing records can feel like trying to solve a puzzle with mismatched pieces.

But establishing and maintaining updated provider information is key to essential health plan operations. An accurate database ensures claims are paid correctly and on time, helps members access timely care, and enables regulatory compliance for health plans.

Adopting next-generation Provider Data Management tools can make it easier for health plans to streamline data management workflows, improve outcomes, and foster stronger relationships with providers and members.

The Pitfalls of Outdated Provider Data Management

Healthcare payers spend an estimated $2.1 billion every year to maintain provider information—and yet, almost half of Medicaid Advantage online provider directories had at least one inaccuracy.

Legacy solutions and outdated workflows can cause unnecessary challenges for payers. Common practices like using disjointed digital solutions and reliance on manual updates can lead to:

• Administrative friction caused by duplicate or outdated records
• Higher operating costs from addressing claim errors
• Member and provider dissatisfaction due to unreliable directories and claims processing delays
• Missed opportunities for payers to improve care coordination and delivery

With healthcare payers spending billions annually on maintaining provider directories, the need for streamlined, accurate, and scalable solutions is urgent.

3 Ways to Enhance Provider Relationships with Advanced Data Management

Strong partnerships between health plans and providers drive better member outcomes and operational success. Leveraging a modern Provider Data Management solution empowers health plans to strengthen these vital relationships.

1. Maintain Accurate Information About Your Provider Networks

Providers expect health plans to maintain accurate databases. Advanced Provider Data Management solutions facilitate data accuracy by:

• Reducing duplicate records and incorrect data entries
• Enabling stronger compliance with healthcare mandates like the No Surprises Act and interoperability regulations
• Improving navigation for members, increasing trust and reducing provider abrasion

2. Streamline Administrative Processes 

Administrative waste can strain provider relationships, especially when inefficiencies impact finances. Provider Data Management tools help eliminate errors and expedite workflows, saving valuable time for healthcare administrators and providers.

• Reduce manual reconciliation with intelligent data mastering features
• Automate provider terminations or reinstatements, ensuring no outdated or orphaned data in the system
• Free up resources by removing repetitive manual tasks, allowing employees to focus on high-value priorities

One case study, featuring the Public Employees Health Program (PEHP), highlighted how the HealthEdge® Provider Data Management solution helped eliminate the manual review workload of five full-time employees. This allowed PEHP to reallocate their valuable time to higher-value and higher-impact tasks.

3. Enhancing Provider Trust and Transparency 

Provider relationships thrive on transparency. Provider Data Management systems empower health plans to:

• Leverage accurate, real-time data for provider directories that improve member access to timely care.
• Streamline claims processes, bolstering trust between payers and providers by reducing payment delays and inaccuracies.

Broader Business Benefits of Optimized Provider Data Management 

Beyond enhancing provider relationships, next-generation Provider Data Management solutions offer business-wide advantages in today’s digital-first era.

Greater Operational Efficiency: Centralized and automated data ingestion, review, and editing processes reduce the reliance on manual review, which can be slower and more error prone. Advanced matching algorithms within Provider Data Management solutions reduce the risk of errors, deliver faster updates, and work within an integrated digital ecosystem, leading to leaner operations and reduced costs.

Improved Member Outcomes: If health plans don’t provide accurate provider directories, it’s that much harder for members to access timely and in-network care. Ensuring online provider directories are up to date can help members get the right care in less time—and without the frustration of unexpected out-of-network bills.

Future-proofing Against Regulatory Change: Healthcare regulations are continuously evolving, and compliance is non-negotiable for payers who want to avoid hefty fines. Advanced Provider Data Management platforms are tailored for regulatory adaptability, helping ensure health plans stay prepared for what’s next.

What Makes a Next-Generation Provider Data Management Tool?

Modern Provider Data Management platforms are built for efficiency and scalability. These advanced platforms combine innovative automation capabilities and seamless data integration to create a single source of truth. They address the most pressing challenges with features designed for health plans operating in a highly competitive and regulated industry.

What features matter most when your health plan is assessing Provider Data Management solutions?

1. Data Automation: Pre-built and customizable “match and merge” rules reduce manual data entry and reduces update time.
2. Real-Time Updates: Event-based APIs notify users of provider status changes to help ensure data is accurate and consistently updated.
3. Native Quality Checks: Built-in data validation ensures reliability across your entire ecosystem. The HealthEdge® Provider Data Management solution includes more than 300 built-in data quality checks.
4. Cloud-Native Scalability: SaaS architecture enables your health plan to meet the needs of growing provider networks and member populations.

Preparing for the Future with Provider Data Management

Healthcare is rapidly evolving, and staying competitive means adopting innovative, scalable solutions like next-generation Provider Data Management tools. By streamlining operations, enhancing provider relationships, and prioritizing compliance, health plans can build a future-ready foundation.

Learn more about how the HealthEdge Provider Data Management platform is leading the way in ensuring provider data integrity. Read the data sheet.

In today’s evolving healthcare landscape, understanding what members want and need is more important than ever. To uncover those insights, HealthEdge conducted its 2025 Healthcare Consumer Study, collecting feedback from more than 4,500 healthcare consumers nationwide.

This summary focuses on a crucial subset of that group: the 2,210 respondents enrolled in Medicare, Medicaid, or those who are Dual Eligible. These populations face more complex health challenges and greater systemic barriers, making their experiences critical for health plans aiming to improve satisfaction, loyalty, and retention.

Why Being a Partner in Care Matters for Health Plans

Health plans that go beyond paying claims and act as partners in care to their members are rewarded with stronger member relationships.

Survey data shows that:

• 60% of Dual Eligible,
• 54% of Medicaid, and
• 53% of Medicare members already see their plan as a care partner, not just a payer.

This shift delivers measurable business benefits:

• 52% of partner-oriented members say they’re unlikely to switch plans (vs. 40% of payer-oriented members).
• 75% would recommend their plan to others (vs. 58%).

4 Common Member Pain Points and Barriers to Care

Despite growing digital engagement, members still face persistent challenges with cost and access to care. 

• High Costs – 17% of Medicare and Medicare Advantage members cite insurance premiums and out-of-pocket costs as a primary concern.
• Limited provider choice – 15% of Medicaid and 13% of Dual Eligible members are frustrated by narrow provider networks, which can make it harder to access timely care.
• Surprise billing – Unexpected medical bills are a significant issue for 31% of Medicaid members, leading to confusion and financial stress.
• Access delays – 43% of Medicaid members say they “never” or only “sometimes” receive timely healthcare, compared to 31% of the general member population, putting them at greater risk of complications later in life.

What Members Want Most from their Health Plan Experience

When asked which innovations would most improve their experience, members ranked the following offerings as their top choices:

• 24/7 access to knowledgeable support reps
• Greater focus on preventive care and wellness
• Proactive, transparent communication about available resources

Digital tools and AI-driven solutions play a growing role in meeting member expectations for more accessible and personalized healthcare conversations.

Mobile app usage is rising across member populations: 81% of Medicaid, 77% of Dual Eligible, and 68% of Medicare members say they already use or are open to using mobile apps for managing benefits and care. While AI adoption is still emerging among these populations (25% Medicaid, 21% Duals, 16% Medicare), members show strong interest in AI-powered assistants that offer tailored support and insights.

Better Serve High-Risk Members with AI-Powered Insights

To better serve and retain Medicare, Medicaid, and Dual Eligible members, health plans must shift from being seen as just a payer of claims to a true partner in care. Health plans that deliver personalized support, clear communication, and timely access to care earn more trust and loyalty.

By combining integrated data, AI-driven insights, and a human-centered approach, health plans can improve care coordination and scale outreach that drives member satisfaction and long-term retention. This is not just a member experience strategy; it’s a growth strategy.

To explore the full findings and actionable insights from the 2025 HealthEdge Consumer Study, watch an on-demand recording of the Association of Community Affiliated Plans (ACAP) webinar, From Payers of Claims to Partners in Care.

Discover how the HealthEdge® Customer Operations team makes it easier for HealthRules® Payer customers to meet their business goals.

Health plans across the U.S. depend on the HealthEdge HealthRules® Payer solution every day for streamlined and integrated core administrative processing. The HealthEdge Customer Operations team is focused on ensuring the platform runs as seamlessly as possible, so our customers can worry less about accessing the tools they need and spend more time serving their members.

How the HealthEdge Customer Operations Team Supports Health Plans

Internally, HealthEdge teams make a commitment to being “customer obsessed,” and team members consistently strive to learn more about our customers—from the ways they work to their key operational goals—to provide a personalized experience.

As part of our commitment to customer excellence, our team leaders work to humanize the healthcare technology experience for our end users. We go beyond solving technical problems to make sure that key functions happen seamlessly—like eligibility files going through correctly so that a mother can get the medication for her sick child, or a grandmother can get the medical procedure she needs to experience the joys of playing with her grandchild.

These scenarios remind the HealthRules Payer Customer Operations team members of their purpose: to improve platform quality and access for our customers so their teams can do what is best for their members.

“Our team’s deep industry knowledge allowed us to make informed decisions with confidence, while HealthEdge experts guided us through configurations, troubleshooting, and ongoing refinements.”

-Chief of Staff to the CTO, Health Plan

Our 4-Prong Approach to Customer Operations

The Customer Operations team is comprised of four different groups that work cohesively together to ensure customers have the best possible experience:

1. The Infrastructure Operations team ensures the company’s private cloud, networks, and operational spaces are secure and available.
2. The Technical Support Services team manages the response to all inbound customer product inquiries and support tickets by coordinating with customers and product team members to facilitate fast responses and resolutions to any issues that may arise.
3. The Customer Success team is ultimately responsible for understanding the current and future needs of HealthRules Payer customers and prioritizing the work for the rest of the organization. They are the customer “captains” who understand each customer end-to-end from an operations perspective.
4. The Business Intelligence team works with the data to allow the rest of the team and customers to gain actionable insights so they can proactively address opportunities for improvement.

Although much of this work sounds technical, the “north star” for this group of hard-working, seasoned professionals is all about helping HealthEdge customers give their members access to the healthcare benefits and services they need when they need them.

“Overall, the migrations away from our legacy system to HealthRules Payer went very well. As with any large project, there is an initial learning and adjustment period, but the HealthEdge team of experts was with us every step of the way.”

-VP of Claims Operations, Health Plan

The Future of Customer Operations

As the HealthEdge customer community continues to expand, the Customer Operations leadership team is looking to improve our team’s own experiences. By establishing more standardized processes and proactively addressing the demand for unplanned work items, they are giving employees more time to discover innovative ways to support the growing customer base – all for the betterment of HealthEdge customers.

In addition, the team is working toward more standardized processes and a more integrated experience for customers of multiple HealthEdge solutions, including HealthEdge Source™ for payment integrity, HealthEdge® Provider Data Management for managing provider networks, GuidingCare® for care management, and Wellframe™ for digital member engagement. As more integration points across these solutions become available, customers will have a more seamless experience working with HealthEdge.

“I was extremely impressed with the HealthEdge team’s depth of knowledge and blown away with the ideas that they already had in preliminary meetings”

-Director, Eligibility and Operational Support, Shared Services Organization

Finally, as the organization encourages and enables health plans to become digital payers, HealthEdge is adopting more digital-centric capabilities that automate manual tasks and improve productivity. Modern technologies that proactively monitor and adjust server capacity are also being implemented to benefit team members and customers alike.

The HealthEdge Customer Operations team is more than just a group of engineers and technical resources who support clients. They are members of a dedicated group focused on making a difference in people’s lives by enabling high-quality healthcare at the right time and the right place.

To learn more about optimizing your experience using HealthRules Payer, visit our data sheet: Optimization Assessment for HealthRules Payer Customers.

Care managers enter the healthcare field to support patients—not drown in paperwork. Yet for many, that’s the daily reality: hours spent sorting through handwritten notes, summarizing past encounters, and piecing together a member’s story before the next touchpoint. It’s time-consuming, mentally exhausting, and pulls focus from what matters most—delivering meaningful, one-on-one care.

The increasingly heavy documentation burden is one of the leading causes of burnout in care management. According to a recent study, nearly 75% of health workers say documentation impedes patient care. Each member interaction can generate pages of notes—some structured, some freeform, captured through chats, assessments, or phone calls. Without a tool to bring it all together, care managers are left to manually sift through scattered information just to surface key facts and decide what to do next. It’s not just inefficient—it’s unsustainable.

The Care Management Note Summarizer from HealthEdge GuidingCare® aims to change that.

What is the Care Management Note Summarizer?

This generative AI-powered feature, embedded within the GuidingCare platform, transforms how care managers work by summarizing lengthy, complex notes in a matter of seconds. Instead of spending 30 minutes manually reviewing past documentation, care managers can quickly understand what information matters most, freeing up time and mental bandwidth for more personalized, effective care.

The summarizer pulls in everything from historical care manager notes to chat transcripts and distills it into a clear, actionable summary. It’s not just a passive reporting tool; it actively identifies gaps, flags new opportunities, and suggests additional goals or interventions that can be added to a member’s care plan. It even surfaces personal context—like a member mentioning their pet was sick—to allow care managers to personalize interactions, build rapport, and strengthen trust.

This isn’t a one-size-fits-all solution. The Care Management Note Summarizer is purpose-built for the data environments and workflows that exist within GuidingCare. It’s also been specifically trained to understand how clinical information is documented and how that documentation translates into care decisions. That means it delivers more relevant, targeted insights than generic AI tools—insights that align with both compliance needs and care quality goals.

The Hidden Costs of Administrative Work

Without this feature, hidden costs of administrative work can pile up quickly. Care managers must spend excessive time digging through notes, which delays care, strains team capacity, and increases the likelihood of missed information. In the worst cases, members may have to remind their care managers about prior conversations, eroding trust and confidence.

Early users are already seeing a difference. Initial feedback from care managers using the Care Management Note Summarizer points to meaningful time savings and a noticeable improvement in the quality of member interactions. Care managers also report feeling more prepared going into encounters—and less overwhelmed by documentation afterward.

Responsible AI Innovation at HealthEdge®

As with any AI innovation, responsible development is critical. HealthEdge has established a robust internal AI Governance Committee that includes leaders from product, engineering, compliance, and security. This team ensures that every AI use case meets evolving industry standards for ethics, transparency, and fairness. They also actively monitor external frameworks—such as guidance from the NIST AI Risk Management Framework and the latest discussions from the NIST AI Healthcare Council—to align internal practices with leading regulatory and ethical standards in the healthcare space.

This transparency and accountability are key to adoption and ongoing evolution. HealthEdge understands that organizations can’t just tack on an AI solution—they need confidence in how it’s designed, deployed, and maintained. That’s why every implementation is guided by best practices and clear communication with customers.

The current summarization capability is just the first step. HealthEdge is already working on expanded functionality, including digital assistants that can fetch and present information on command, conversational interfaces, and AI-driven automations that draft messages or update care plans directly.

These tools aren’t replacing care managers—they’re amplifying their capacity. By lightening the administrative load, AI gives care managers more time to do what they do best: support, guide, and build lasting relationships with members.

The Care Management Note Summarizer is a step forward in modernizing care management. And it’s only the beginning of what’s possible with AI-powered innovation from HealthEdge.

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

 

Healthcare consumers are raising the bar for what they expect from their health plans. Members want experiences that are personalized, convenient, and responsive. Meeting these expectations across large, diverse member populations is a growing challenge for health plans. That’s where artificial intelligence (AI) can make a meaningful impact.

By using AI to scale member engagement and streamline interactions, health plans have the opportunity to deliver more relevant, proactive, and efficient experiences, without adding administrative burden. Yet according to the 2025 Healthcare Consumer Study from HealthEdge®, only 21% of healthcare consumers say they’ve used—or even know they have access to—AI-powered tools from their health plan.

These survey findings show a big opportunity for health plans. Consumers are ready to embrace AI assistance—but health plans must make it accessible, trustworthy, and demonstrate its value. Below, we explore what the data tells us, the strategies health plans can use to meet rising expectations, and why HealthEdge is uniquely positioned to help with solutions like GuidingCare® and AI-powered workflow tools.

Survey reveals strong interest in AI, despite low user adoption

The 2025 Healthcare Consumer Study highlights a clear disconnect between interest and usage. Only 1 in 5 members have already used an AI tool offered by their health plan—but 64% say they’re open to it.

The members interested in these tools place particular value on AI features like:

• Chatbots, virtual assistants, and coaches (94%)
• Personalized health education and resource suggestions (92%)
• Cost-saving benefit tools and provider recommendations (90%)
• Tracking health goals and progress (86%)

So why is adoption of AI tools still so low?

The answer lies in how health plans have historically implemented AI. To date, most AI investment has focused on supporting backend operations, such as improving claims processing, ensuring payment accuracy, and detecting fraud. While these applications are important, they’re often invisible to members.

Even when health plans do use member-facing AI-driven tools, they may not provide information on the technologies behind AI or machine learning (ML) tools. As a result, healthcare consumers are largely unaware of how AI is currently being used across the industry and what value it brings—or could bring—to their experience.

To bridge this gap, health plans need to shift more of their AI focus to member-facing tools that directly enhance engagement, education, and care navigation—which impact health plan costs and operational savings.

Consumer skepticism remains a barrier to AI adoption

Despite their openness to using AI, many healthcare consumers still have reservations. The survey uncovered several key concerns:

• 26% worry about the quality and accuracy of AI-generated health information
• 20% are concerned about data privacy
• 20% cite data security as a barrier to using AI tools from their health plan

To overcome this skepticism, healthcare consumers said health plans could earn their trust by increasing transparency on how and when AI tools are being used, as well as providing data privacy certifications and explanations on how personal data is used and protected.

Ultimately, health plans that take a thoughtful, transparent approach can turn AI from a point of hesitation into a driver of member confidence.

Why now is the right time for AI-powered member engagement

There are several industry trends converging to make AI a strategic priority. Consumer expectations have shifted—they want self-service tools, quick answers, and proactive engagement. At the same time, health plans face rising cost pressures and administrative complexity. AI-driven tools can help summarize and surface key member information to help providers prioritize member outreach.

Evolving healthcare regulations aim to encourage payers to streamline workflows, improve data transparency, and enhance proactive care coordination and delivery. AI-powered solutions can help reduce administrative burden while giving payers more effective ways to engage and retain members.

By deploying AI thoughtfully, health plans can meet members’ expectations and operational needs at the same time.

HealthEdge solutions for AI-driven engagement

HealthEdge is leading the way in delivering AI-powered tools that help health plans transform care and services, while keeping member needs at the center.

Enterprise AI strategy for health plans

At HealthEdge, our comprehensive approach to AI focuses on using these tools responsibly, building trust, and layering capabilities incrementally. This ensures health plans don’t treat AI as a bolt-on feature, but as a core capability embedded across care and operations.

GuidingCare leverages AI for care coordination

GuidingCare uses AI to simplify complex care pathways: triaging cases, identifying care gaps, and summarizing key clinical data. This allows care teams to focus on high-impact interactions while AI handles routine administrative details. It drives both efficiency and personalization in member outreach.

Wellframe’s AI-driven member engagement

Wellframe leverages AI to transform member engagement, creating concise, actionable summaries of member data. This empowers care teams to deliver personalized, timely support, focus on high-impact interactions, and drive greater efficiency and improved member outcomes.

Transforming operations with HealthRules® Payer

Within HealthRules Payer, our core administrative processing system (CAPS), AI helps payers streamline and accelerate workflows, reduce administrative costs, and modernize member experiences.

AI-powered workflow in HealthEdge Source™

HealthEdge Source integrates machine learning to improve payment integrity and claims processing. AI-driven analytics detect patterns, highlight high-risk claims, and enable faster, more accurate reviews, improving the overall member experience.

Intelligently merge data with AI-powered Provider Data Management

The HealthEdge® Provider Data Management solution leverages advanced AI that enables payers to develop a single source of truth for provider data. AI-driven data ingestion and matching help ensure accuracy, consistency, and complete data lineage across all health plan operations.

Dig deeper on the benefits of AI-powered tools

The 2025 Healthcare Consumer Survey shows that healthcare consumers are ready for more intuitive, digital-first engagement powered by AI, but they also want reassurance, clarity, and trust.

HealthEdge leads the way, embedding AI into core platforms like HealthRules Payer, HealthEdge Source, HealthEdge Provider Data Management, GuidingCare, and Wellframe to empower health plans to modernize operations and meet rising expectations. By focusing on transparency, accuracy, and member value, health plans can build confidence while scaling their impact.

To explore these insights and more, download the full 2025 Healthcare Consumer Survey report here.