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How Healthcare Payers Plan to Improve Provider Engagement in 2025

Posted on by HealthEdge

Effective provider engagement is fundamental to reducing administrative costs and improving member outcomes. However, as operational complexities persist and healthcare demands increase, the need for innovative approaches to provider engagement has become more urgent than ever.

Healthcare payers are now looking to the future, identifying new strategies, technologies, and processes to overcome challenges and move toward meaningful provider collaboration. Here’s how health plan executives are preparing to improve provider engagement in 2025.

Three Priorities Driving Provider Engagement Strategies

The HealthEdge® Annual Payer Market Planning Report 2025 offers critical insights into what health plan leaders are focusing on when it comes to provider engagement. The top three priorities include:

  1. Provider Network Management (33%) – Streamlining network operations to improve efficiency and provider satisfaction.
  2. Payment Integrity (22%) – Ensuring accurate, timely payments to build trust while minimizing costly errors and rework.
  3. Enhanced Provider Collaboration and Value-Based Care (VBC) Contracting (19%) – Empowering providers to deliver better outcomes through partnership-driven models.

These priorities reflect a broader trend of moving from transactional relationships to collaborative ones, where payers and providers work together to achieve shared goals.

Overcoming Key Challenges in Provider Engagement

Despite the focus on improving provider networks and payments, health plans face several prominent challenges when it comes to provider engagement. Based on survey responses:

  • Claims processing delays (60%) emerged as the leading issue, causing frustration for providers and slowing down administrative workflows.
  • Limited access to real-time data and information sharing (45%) continues to hinder seamless collaboration.
  • Lack of transparency (43%) negatively impacts provider trust and satisfaction.

Modern and integrated solutions are essential for health plans to tackle the challenge of real-time data access, identified by 71% of health plans as their biggest workflow and data communication issue. By ensuring interoperability and seamless data flow between healthcare systems, these solutions can significantly enhance provider engagement.

The Role of Provider Data Management (PDM) in Engagement

Central to streamlining provider relationships and overcoming challenges is the integrity and efficiency of Provider Data Management (PDM) systems. However, today’s market is saturated with disjointed solutions riddled with inefficiencies. Health plans often rely on scattered point solutions, fragmented systems, and subpar data integration.

For health plans looking to level up their provider engagement, modern solutions offer a holistic solution to these obstacles. Leaders in this space are prioritizing three main investments for their provider engagement solutions over the next year:

  1. Enhanced Analytics and Reporting (24%) – Tools that provide actionable insights to improve performance and guide decision-making.
  2. Real-Time API Services (23%) – Seamless, real-time interoperability to keep provider data accurate and accessible.
  3. Self-Service Digital Resources (22%) – Empowering providers with user-friendly platforms to manage their data independently.

These features ensure that  have the tools necessary to streamline workflows, improve data accuracy, and boost provider satisfaction.

Payment Integrity as a Building Block for Provider Trust

One of the most impactful ways to improve provider engagement is by investing in payment integrity technology. Accurate payments, streamlined workflows, and reduced payment delays are critical to building trust with providers. Yet, many health plans still struggle with overpayments, underpayments, and drawn-out payment reconciliation.

HealthEdge Source™ Payment Integrity Suite offers a proactive solution. By integrating industry data, proprietary rules, and a flexible configuration layer, HealthEdge Source helps ensure accurate claim editing and pricing. With tools to reduce improper payments upfront and minimize rework, health plans can significantly reduce provider abrasion.

HealthEdge Source also has the ability to adapt provider contract terms and policy guidelines into the platform as a series of edits and pricers. This allows for precise business intelligence and deployment into production with minimal IT lift.

Real Savings Through Payment Integrity

  • Time Efficiencies: Source’s workflow automation and real-time claims adjudication reduces manual hours spent correcting errors.
  • Cost Savings: Preventing improper payments up front saves both money and resources.
  • Provider Satisfaction: Efficient payment processes help maintain a positive payer-provider relationship.

Building Transparent and Collaborative Provider Relationships

In the report, 59% of executives surveyed agree that improving transparency in claims and payment processes is critical for provider satisfaction. Providers need access to the most accurate, up-to-date information to provide members with the right care.

HealthEdge’s integrated platform provides a vital foundation for these investments. Offering end-to-end solutions for everything from administrative processing and payment integrity to care management tools, the platform is carefully designed to tackle modern healthcare challenges while enabling health plans to collaborate effectively with network providers.

The path forward for healthcare payers depends on meaningful provider engagement. By prioritizing technology modernization, payment accuracy, and transparent collaboration, organizations can foster proactive partnerships that benefit both providers and patients.

Actionable Next Steps:

  1. Evaluate your existing systems for efficiency and integration gaps.
  2. Invest in integrated solutions that can provide analytics, real-time updates, and self-service capabilities to providers.
  3. Adopt proactive payment integrity solutions to streamline claim workflows and build trust.

Improving provider engagement isn’t just a vision for the future—it’s an imperative for today. Health plans committed to innovation and collaboration will position themselves as leaders in an increasingly competitive industry.

Visit our blog, 3 Ways to Reduce Provider Abrasion with your Payment Integrity Solution.

Support High-Risk Maternity Members with Digital Care Management

Posted on by HealthEdge

The U.S. maternal health system faces a troubling crisis: Disparities in maternal health outcomes disproportionately affect Black, American Indian/Alaska Native (AIAN), and Native Hawaiian/Pacific Islander (NHPI) women. Structural racism, implicit biases, and systemic barriers in healthcare can make it challenging for women of color to access the health support and information they need. Plus, Black, AIAN, and NHPI women are less likely to receive timely—or any—prenatal care than white women.

This lack of prenatal healthcare support heightens risks for both parents and infants. For example, 50,000-60,000 women experience severe maternal morbidity every year. But Black women are three times more likely to die from pregnancy-related conditions than their white counterparts.

The scope of severe maternal morbidity goes beyond pregnancy and birth. Common prenatal risks include conditions such as hypertension, depression, and preeclampsia, while postpartum risks include hemorrhaging, postpartum depression, and heart failure. Though many of these conditions and outcomes are preventable, pregnant members must have access to timely and comprehensive care.

Digital care management solutions can help your health plan support high-risk maternity members, improve clinical outcomes, and lower long-term care costs.

Maternal care transformation through digital engagement

Effective member engagement is critical for addressing maternal morbidity. Many members don’t fully understand their coverage or the importance of regular and proactive care. Digital care management tools empower high-risk maternity members to engage with their health plans, while giving them access to a dedicated care team, health education resources, and personalized support.

A digital care program integrates mobile technology, health education, two-way communication, and digital surveys to engage members, manage care plans, and uncover gaps in care. Wellframe’s Digital Care Management platform equips care teams with the tools they need to support members holistically and efficiently.

Key features of the platform include:

  • HIPAA-compliant two-way chat for members to reach their care teams.
  • Daily personalized checklists and medication reminders.
  • On-demand access to short and easy-to-understand educational materials.
  • Alerts and dashboards to help care teams prioritize high-risk members.

Wellframe’s “Maternal Wellness” program at work

Recognizing the unique needs of high-risk populations, Wellframe’s new care program, “Maternal Wellness for Black Women,” is specifically designed to support pregnant Black women through health education and advocacy.

Members enrolled in the Maternal Wellness program had higher rates of prenatal visits than non-users—a key determinant of positive clinical outcomes. Enrolled members also saw lower emergency room utilization in the third trimester than other members. In addition to improving clinical outcomes, digital engagement tools can also enhance member satisfaction. Payers using Wellframe digital engagement achieved an 8% increase in HEDIS Prenatal and Postpartum Care (PPC) outcomes.[NB1]

The program is available through a mobile app and provides enrolled members with ongoing access to their care teams and other resources. Health resources include articles on topics like prenatal care, health warning signs, how to effectively talk to providers, and more. With digital care programs, members can also set custom reminders for medications, appointments, and healthy habits to stay on track with their health goals.

5 Practical Steps For Improving Maternal Health

What should health plans look for when it comes to a comprehensive digital care program for high-risk maternity members?

1. Leverage data to drive interventions

Use digital engagement platforms to surface insights about members’ behavioral, clinical, and social needs through features like two-way chat and digital surveys. This will enable care teams to act proactively rather than reactively.

2. Engage high-risk members where they are

Invest in integrated digital tools that streamline data sharing and communication. Wellframe’s HIPAA-compliant chat makes it easy for members to stay connected with their care teams without the logistical barriers of traditional healthcare settings. And care teams can export and share data across clinical platforms.

3. Prioritize holistic, personalized care

Address non-clinical barriers such as food security, transportation, and mental health resources within your digital care platforms. Building trust with members creates a strong foundation for engagement, as well as improve outcomes and lower long-term care costs.

4. Identify and close gaps in care

Regular monitoring and communication through digital solutions ensures members are routinely prompted to complete key health milestones, from checking off medication reminders to step tracking and blood pressure monitoring.

5. Deliver culturally relevant member outreach

Use culturally appropriate, multilingual educational materials to create an inclusive experience for members of diverse backgrounds. Wellframe offers multilingual content in English, Spanish, and Haitian-Creole.

Beyond the Numbers

Outcomes like higher prenatal visit rates and reduced ER utilization don’t just lead to financial savings—they represent better, safer experiences for mothers and their babies. By leveraging integrated Digital Care Management solutions like Wellframe, your health plan is doing more than investing in healthcare innovation—you’re addressing deep-rooted inequities in maternal health.

If your health plan is ready to revolutionize the way you support maternity populations, discover how Wellframe can improve outcomes not just for your members but for the healthcare system as a whole. Learn More.

 

Leverage Next-Generation CAPS to Drive Competitive Advantage and Adaptability

Posted on by HealthEdge

Health plans today are under increasing pressure to modernize their technology and processes to adapt to the complexities of modern healthcare and take advantage of market growth opportunities. They must meet the evolving needs of their members, comply with rapidly changing regulatory requirements, and resolve operational inefficiencies.

Legacy Core Administrative Processing Systems (CAPS) create a widening capability gap that leaves health plans struggling to integrate data, adapt to new payment models, and meet rising member expectations. To remain competitive, health plans must implement a next-generation CAPS that drives efficiency, enhances adaptability, and provides exceptional experiences for members and providers.

Adopting a next-generation CAPS, such as HealthRules® Payer, enables health plans to position themselves as leaders in today’s healthcare landscape. The market dynamics that drive urgency for modernization include:

Digital transformation is unstoppable. Health plans require systems that integrate data, create seamless workflows, and adapt to ongoing industry changes to allow them to remain competitive, meet member expectations, and strengthen provider relationships, now and in the future.

  • Modern automation delivers breakthrough efficiencies. Modern CAPS enhances claims accuracy, lowers operational costs, and boosts productivity by minimizing reliance on manual processes.
  • Member expectations continue to rise. Today’s members are increasingly digitally savvy and demand transparency, convenient interactions, and personalized experiences that enhance satisfaction and retention.
  • Real-time data is essential for success. Access to accurate, actionable data supports better decision-making, care coordination, and operational efficiency.
  • New business models require modern capabilities. Flexible systems such as HealthRules® Payer enable health plans to adopt value-based care models, efficiently launch new products, and ensure compliance with changing regulations.

5 Key Next-Generation CAPS Capabilities

Modern CAPS offer advanced capabilities that transform operations and member service. These capabilities deliver significant value to growing health plans of all sizes:

Hybrid Cloud Delivery:

Modern CAPS offer the flexibility of hybrid cloud delivery, providing health plans with the scalability needed to grow and adapt without the constraints of costly infrastructure. These systems combine cloud-based and optional on-premises capabilities, reducing infrastructure expenses and freeing resources for strategic initiatives. Data access from anywhere ensures faster, better-informed decision-making and seamless operational performance.

Business-Friendly Configuration:

Advanced systems empower business users to configure processes and policies, minimizing delays caused by reliance on IT teams. Rules can be created once and reused across multiple products for consistency and efficiency. System-wide adjustments propagate instantly to enable health plans to respond quickly to market demands and regulatory changes.

Adaptable Modern Architecture:

Next-generation CAPS offer the flexibility to quickly adapt products, benefits, and contracts to align with changing regulations and market demands. With seamless updates, these systems ensure uninterrupted access to the latest features, minimizing disruption and supporting long-term agility.

Ready for Value-Based Models:

CAPS built for today’s healthcare needs support diverse payment models, including bundled payments and capitation, so that health plans can align with value-based care. In addition, data sharing fosters improved provider collaboration and streamlines administrative processes. Built-in compliance tools ensure adherence to evolving regulations, enabling innovation without sacrificing accuracy or accountability.

Seamless Ecosystem Integration:

Modern CAPS integrate seamlessly with other systems, technologies, and services using preconfigured APIs and industry-standard protocols. These platforms reduce the complexity and costs of custom coding. They are also highly adaptable for integrating new systems, creating a unified ecosystem that is efficient and effective in supporting member populations.

The advanced capabilities available today not only resolve the inefficiencies of legacy systems but also unlock a wide range of measurable benefits.

Benefits of a Next-Generation CAPS solution

Modernizing CAPS empowers health plans to thrive in today’s increasingly complex and competitive healthcare environment. By improving processes, fostering stronger provider relationships, and delivering exceptional member experiences, these systems enable measurable gains across every aspect of your organization.

  • Stay Competitive: Adapt quickly to regulatory changes, implement new benefit designs, and respond to market demands with agility.
  • Improve Provider Relationships: Streamline communication and payments while building trust through robust data sharing and transparency.
  • Enhance Member Experience: Empower members with personalized, on-demand access to information and seamless, transparent communication.
  • Mitigate Costs: Reduce administrative expenses with automation and improve claims processing, compliance, and workflow efficiency.

The Time to Act Is Now

Modernizing CAPS is more than a technology upgrade—it’s a transformative step to adapt and grow in a competitive and evolving healthcare environment. With next-generation CAPS, health plans overcome the limitations of legacy systems and drive efficiency, enhance adaptability, and deliver personalized experiences that today’s market demands.

By adopting advanced solutions like HealthRules® Payer, health plans can streamline operations, improve outcomes, and position themselves as leaders in the industry. Now is the time to bridge the gap between outdated processes and future-ready innovation.

Learn more about how the HealthRules Payer solution enabled one health plan to achieve ther digital transformation goals. View the infographic.

Improve Data Security & Compliance with a Prospective Payment Integrity System

Posted on by Diana Nguyen

The healthcare industry has long been a primary target for cyberattacks due to the vast amount of sensitive data it handles. The increasing prevalence of cyber incidents, combined with ever-evolving regulatory frameworks, has made security and compliance top priorities for health plans.

According to the Annual Payer Market Planning Report 2025 by HealthEdge, which surveyed more than 450 health plan leaders, 46% of respondents indicated that security is their primary concern. This is followed closely by concerns about regulatory compliance, with many health plans struggling to keep pace with regulations from the Centers for Medicare and Medicaid Services (CMS) like the No Surprises Act and the Transparency in Coverage​.

The Growing Importance of Data Security in Healthcare

In general, the healthcare industry has witnessed a series of high-profile cyberattacks in recent years, highlighting the critical need for robust data security. In 2024, incidents like the February breach affecting Change Healthcare and the August data breach at National Public Data exposed vulnerabilities in the healthcare system.

As a result, data security in technology and data science has quickly become the top technology concerns for health plans.

Leaders are seeking ways to protect member data while ensuring compliance with HIPAA regulations and other data privacy standards​. HealthEdge Source™ (Source), HealthEdge’s prospective payment integrity platform, offers health plans a clear path to data security by incorporating security and scalability at the beginning and consistently throughout the software development process.

In fact, Source was recently recognized as a Sample Vendor in the 2024 Gartner® Hype Cycle™ for U.S. Healthcare Payers in two categories: Prospective Payment Integrity Solutions and AI-Enabled Fraud Detection. Source incorporates AI capabilities, allowing health plans to leverage AI-driven insights for improved security and compliance.

How HealthEdge Source™ Helps Automate Compliance  

Navigating the complex web of healthcare regulations is another major challenge for health plans. Non-compliance can lead to penalties, reputational damage, and potential legal issues. Health plans must continually monitor CMS changes, update their policies and procedures, and ensure that staff members are well-versed in the evolving regulations.

According to the Market Planning Report, managing CMS fee schedules and staying compliant with evolving regulations are among the most significant pain points for health plans. More specifically, the report outlines leaders’ top 3 biggest challenges when it comes to maintaining CMS compliance:

  • Managing Fee Schedules (55%)
  • Lack of technology partners to ensure regulatory compliance (54%)
  • Lack of staff/resources to make necessary changes (50%)

The Source solutions empower health plans to address these challenges in multiple ways.

Compliance Monitoring

The Source team of regulatory compliance experts monitor and maintain CMS fee and policy changes daily. They are dedicated and well-versed in tracking the changes and helping health plans interpret and implement the necessary changes to maintain compliance. The platform continuously monitors compliance with CMS fee schedules and policy changes and generates reports, enabling health plans to stay on top of their obligations and avoid penalties.

Automated Fee Schedule Management

Keeping up with CMS fee schedule updates can be daunting, but Source simplifies this by automatically uploading fee schedule updates every two weeks. This ensures that health plans always work with the latest data and remain compliant with CMS payment regulations.

Claims Auto-Adjudication

Compliance with CMS payment rules requires accurate and timely claims processing. Source’s auto-adjudication feature reduces the risk of human error, ensuring that claims are processed in accordance with the latest regulatory standards. This helps health plans meet the strict timelines required by CMS, such as the 7-day turnaround for prior authorization decisions.

Preparing for Future Regulatory Changes

Another key finding from the report addresses compliance readiness. The bottom line: Many health plans do not feel adequately prepared for upcoming regulatory changes, particularly regarding the Payer-to-Payer Data Exchange and Advanced Explanation of Benefits. Less than half of respondents report being ready for these regulations​.

HealthEdge Source helps health plans stay ahead of regulatory changes by offering:

  • Scalable Compliance Solutions: The platform is designed to scale with evolving regulations, ensuring that health plans can easily adapt to new requirements without needing significant system overhauls.
  • Regular Updates: Source continuously updates its platform to stay compliant with the latest CMS rules and regulatory guidelines, reducing the burden on health plans to manually track and implement changes.

HealthEdge Source™: Your Strategic Partner in Data Security and Compliance

As health plans navigate the complexities of data security, regulatory compliance, and technology modernization, it is clear that having the right technology platform is critical to success. Source addresses these challenges by offering a comprehensive, integrated payment integrity platform that enhances security, automates compliance, and drives long-term operational efficiency.

Learn more about how Source can help your organization not only stay compliant but also turn regulatory challenges into opportunities for innovation. Watch a demo of the Source solution.

The Hidden Costs of Legacy Core Administrative Processing Systems (CAPS) 

Posted on by HealthEdge

Many health plans continue to rely on legacy Core Administrative Processing Systems (CAPS) as the backbone for managing critical operations such as claims processing, benefit configuration, and member enrollment. However, these systems were not designed to meet the complexities of modern healthcare. As regulatory requirements grow more stringent, payment models evolve, and member expectations for transparency, personalization, and real-time interactions continue to rise, the limitations of these outdated systems have become increasingly limiting—and costly.

At the same time, innovation in healthcare technology is accelerating, widening the gap between the functionality of legacy CAPS and the strategic capabilities and user experience provided by next-generation systems. Health plans that fail to address this capability gap risk falling behind competitors that leverage modern solutions to enhance efficiency, improve member experiences, and adapt to emerging payment models like value-based care.

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The Challenges of Legacy CAPS

Legacy CAPS impede operational agility and the seamless integration required to thrive in today’s healthcare market. The following challenges leave health plans at a strategic disadvantage, unable to capitalize on opportunities or keep pace with industry demands.

1. Limited Adaptability

Legacy systems impede health plans’ capacity to innovate and swiftly respond to shifting market conditions and operational demands. Expanding into new markets and launching innovative products tailored to meet the diverse needs of members can encounter significant delays. This results in missed growth opportunities.

Modifying benefit designs, provider contracts, or claims rules requires substantial IT involvement. This reliance diverts resources from strategic initiatives and increases operational expenses, hindering progress and flexibility.

2. Rigid Architectures

Legacy CAPS rely on outdated technology, which impedes integration, scalability, and innovation for health plans. These rigid systems often struggle to connect with modern solutions like EHRs, care management, and member experience platforms, disrupting information flow. This limits the ability to offer personalized, member-centric services crucial for success. Essentially, CAPS play a central role in the health plan technology ecosystem, either hindering or enhancing surrounding capabilities.

Increased claim volumes and market expansion can lead to latency issues that slow processing. This results in errors, denied claims, and delayed payments, which frustrate members and providers and damage trust. To cope, health plans rely on manual workarounds that increase complexity and costs. This rigidity puts them at a disadvantage in a competitive market.

3. Fragmented Data

The inability of legacy CAPS to unify and share data creates significant obstacles to compliance, operational efficiency, and member engagement. Key capabilities such as enrollment, claims processing, and cost tracking often operate in silos, preventing a cohesive flow of information. This fragmentation undermines workflow efficiency, coordinated care efforts, and integrated member experiences.

Inconsistent or incomplete data within these isolated systems also poses compliance risks. Regulatory reporting becomes an error-prone, labor-intensive process. Fragmented data deprives health plans of the insights needed to identify trends, predict member needs, or optimize provider contracts. This lack of actionable intelligence limits decision-making, stifling innovation and efficiency.

4. Costly Maintenance

Maintaining outdated systems is a resource-intensive and financially draining process that restricts strategic progress. Legacy CAPS require frequent patches and updates to stay operational. As these systems age, the likelihood of breakdowns increases, resulting in costly IT projects and extended downtime that disrupts daily operations.

The IT teams maintaining these outdated platforms must dedicate substantial time to troubleshooting and upkeep. This leaves little room for innovation, such as exploring new technologies or enhancing member services. These opportunity costs further delay health plans from achieving long-term growth and competitiveness.

5. Falling Short of Member Expectations

Members now expect health plans to provide real-time access to information, personalized interactions, and transparent communication about benefits and claims. Legacy CAPS are ill-equipped to meet these demands, leading to frustration and diminished member satisfaction.

Without real-time capabilities, members are left waiting for updates on claims status, cost-sharing details, or eligibility inquiries. This delay jeopardizes growth as it undermines trust and satisfaction with members. Additionally, legacy systems deliver generic experiences.  The inability to personalize interactions results in disengaged members who may seek a more modern experience elsewhere.

The Costs of Legacy CAPS

The challenges of legacy CAPS create a cascade of inefficiencies, compliance risks, and missed opportunities. Health plans that delay modernization face:

  • Escalating Operational Costs — IT maintenance or customizations,  manual workflows, and system inefficiencies drive up costs without creating innovation. There’s a high cost to maintaining the status quo.
  • Regulatory Exposure — Disconnected data and outdated processes increase the risk of non-compliance with ever-evolving regulations.
  • Competitive Disadvantage — Health plans with legacy systems struggle to keep pace with competitors that leverage modern, integrated technology to deliver superior member and provider experiences.

Modernizing CAPS is essential for health plans looking to thrive in a competitive, complex, and rapidly changing healthcare landscape. Addressing the limitations of legacy systems is not just a technological challenge — it’s a strategic imperative.

To further explore this topic, download our infographic on this topic or learn more about the HealthRules® Payer next-generation CAPS platform.

Elevating Member Experience Through Digital Solutions: Insights from the HealthEdge Leadership Forum

Posted on by HealthEdge

At the HealthEdge Leadership Forum in October, health plan leaders shared their insights about adopting digital member experience solutions to improve engagement and operational efficiencies. Michelle Fullerton, Vice President of Care Management at Blue Cross Blue Shield of Michigan (BCBS of Michigan), and Dr. Josette Gordon-Simet, Chief Medical Officer at Blue Cross Blue Shield of Nebraska (BCBS of Nebraska), joined a conversation with HealthEdge’s Chief Medical Officer, Sandhya Gardner, MD, on how these two prominent health plans transformed care management.

Let’s review the key takeaways from this discussion on how digital member experience led to significant improvements in member interactions and improved the efficiency of care management.

Key Takeaways: Adopting Digital Member Experience

1. Digital Engagement Solutions Improve Member Experience

Both BCBS of Michigan and BCBS of Nebraska recognized that traditional telephonic-centric processes alone no longer met members’ expectations for convenience and personalization. With the rise of digital consumer experiences, members increasingly expected similar access and immediacy in healthcare.

BCBS of Michigan began its care management transformation by adopting the Wellframe™ member experience platform. This shift allowed for automated outreach and real-time communication with members, replacing labor-intensive phone calls as the primary method of engagement. The result was a sharp increase in interactions that enabled earlier interventions and better health outcomes.

“We needed another way… We went all-in with digital care management, and the engagement numbers speak for themselves. We’ve gone from four or five interventions per case to 20-40… and we’re answering questions in real-time.” – Michelle Fullerton

Similarly, BCBS of Nebraska adopted Wellframe to address the limitations of traditional outreach. Wellframe’s app allowed members to chat directly with care managers and access digital health resources when convenient.

With Wellframe, BCBS of Nebraska also implemented a model for continuity of care. When one care manager is out of the office, interactions can be effortlessly assigned to other staff who have easy access to all the patient data needed to take the next step.

“Our ‘One Nurse, One Source, One Connection’ model ensures continuity, and Wellframe allows us to provide a seamless experience for our members.” – Dr. Josette Gordon-Simet

With a digital member experience, these health plans report that members are better supported and connected to their care teams, which leads to better engagement and interventions across the board.

2. Digital Tools Save Time and Improve Focus for Care Teams

Adopting Wellframe’s digital tools has significantly lightened the cognitive load on care teams. Streamlined workflows allow care managers to practice at the top of their licenses. Two examples highlighted are the introduction of digital assessments and a new solution, Wellframe’s AI Summarizer, of which BCBS of Nebraska was an early adopter.

BCBS of Michigan rolled out digital assessments, allowing members to submit their health information online. This shift from phone-based assessments to a digital workflow has freed up time for care teams to focus on critical interventions and member engagement.

“We integrated digital assessments into our system… nurses love it, and members like the convenience of answering digitally.” – Michelle Fullerton

For BCBS of Nebraska, Wellframe’s new AI Summarizer significantly reduced care managers’ time preparing for patient interactions. By generating concise summaries of previous engagements, the solution allows managers to quickly understand a member’s history without reviewing extensive notes or asking patients to repeat themselves.

“The AI Summarizer has been fantastic for our nurses, cutting down on time spent reviewing previous notes and letting them focus on care delivery.” – Dr. Josette Gordon-Simet

These streamlined workflows demonstrate how care teams can dedicate more time to direct member care rather than being bogged down by administrative tasks.

3. Seamless Care Management Requires Systems Integration

For BCBS of Michigan and BCBS Nebraska, integrating Wellframe into their other systems was key to their digital strategy. These integrations ensure that data—such as member assessments, alerts, and real-time updates—automatically feeds into the broader documentation and workflows care teams use, allowing for more efficient and timely care planning.

Before implementing Wellframe, care teams at BCBS of Michigan and BCBS of Nebraska often had to manually input or track down critical member information across multiple systems, leading to inefficiencies and care coordination delays. With Wellframe, all relevant member data, including health assessments and real-time alerts, is directly integrated into the existing infrastructure.

This data centralization gives care teams a comprehensive view of the member’s health journey, allowing them to make more informed decisions and act quickly.

“We integrated Wellframe into our care management system, and now nurses get real-time alerts and automatically documented updates.” – Michelle Fullerton

BCBS of Nebraska has experienced similar benefits from integrating Wellframe with its systems, and it is currently implementing HealthEdge’s GuidingCare® digital care management solution. The integrated solution combines member experience with streamlined coordination across the care spectrum.

With GuidingCare, the health plan can seamlessly manage clinical and behavioral health needs, automate care planning, and target high-risk populations to provide whole-person care.

4. Digital Member Experience Establishes Competitive Advantage

By adopting a digital-first strategy, both health plans have positioned themselves as leaders in a market where exceptional member experience is essential to success. BCBS of Michigan has found that Wellframe has been instrumental in adding new members through its commercial line of business with employers:

“Customers tell us that our use of Wellframe sets us apart… It’s been a game changer in the RFP process… Wellframe has made a competitive difference for us in the market.” – Michelle Fullerton

BCBS of Nebraska has also experienced how Wellframe provides an advantage when competing for new business:

“Consumers are much more digitally savvy than they were five years ago, three years ago even. This suite of products really allows us to be…ahead of in many spaces.” – Dr. Josette Gordon-Simet

5. Digital Transformation Success Requires Change Management Strategies

Implementing digital tools like Wellframe is not just about technology—it’s about ensuring that an organization’s people and processes are ready to adapt to new workflows.

When BCBS of Michigan first introduced Wellframe, many nurses had spent years working in familiar systems. The shift to a digital-first approach required new skills and a change in mindset. To address this, BCBS of Michigan built a team of early adopters to influence the organization:

“You need a team of champions… Our early adopters helped guide their colleagues and supported those struggling to adapt to the new digital workflows.” – Michelle Fullerton

BCBS of Michigan prioritized regular feedback loops and continuous training to ensure a smooth transition. By listening to care teams, leadership addressed pain points, refined workflows, and adapted based on real-world usage. This fostered a culture of continuous improvement that empowered care teams to provide feedback and contribute to ongoing success.

BCBS of Nebraska employed a similar approach, ensuring their internal teams were engaged throughout implementation and understanding that adopting digital tools is an ongoing process that requires continuous refinement.

“By engaging our internal teams and making iterative improvements, we’ve created a better overall experience for both members and staff.” – Dr. Josette Gordon-Simet

By listening to their teams, learning from early challenges, and adapting their strategies, these organizations ensured that Wellframe helped them accomplish their goals.

The experiences of BCBS of Michigan and BCBS of Nebraska demonstrate that Wellframe’s member experience solution enhances member engagement and streamlines care workflows, driving meaningful improvements in health outcomes and operational efficiency.

Visit the HealthEdge website to learn how Wellframe can elevate your health plan’s member experience.