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Navigating healthcare regulations and compliance is an intricate challenge. To optimize the use of healthcare dollars and more effectively address population health, The Office of the National Coordinator for Health Information Technology (ONC) is passing regulations to support the improvement of interoperability and prior authorization operations. To comply with these new rules, health plans are turning to advanced, integrated technologies.

This forward-looking blog dives into the most compelling regulatory trends of 2025 and changes on the horizon, offering actionable insights to help organizations adapt and thrive. By the end of this post, you’ll better understand what’s coming and how you can actively prepare your team and strategies.

Trend 1: Interoperability Redefines Healthcare Connectivity

Across the healthcare industry, siloed health information prevents health plans and providers from anticipating member needs and offering proactive interventions. In the years since the COVID-19 pandemic, the healthcare industry has seen more widespread use of digital health tools, and the integration of these tools into care management.

For health plans, leveraging Fast Healthcare Interoperability Resources (FHIR) offers a path forward—but adoption won’t be without challenges.

Key Interoperability Milestones

2025 is shaping up to be a critical year for assessing improvements in interoperability and payer technology adoption as part of regulatory trends in 2025.

By January 2027, APIs (Application Programming Interfaces) facilitating real-time data exchange between patients, providers, and payers will become enforceable, setting a new standard for seamless information sharing.

The Problem With Siloed Data

The lack of accessible, unified healthcare data presents hurdles to both operational efficiency and patient care. Without an intentional focus on interoperability, the growth of technology use at health plans and for members can lead to internal data silos. By themselves, these pockets of information can’t tell the whole story—but collectively they could help health plans and providers better understand and anticipate the needs of various populations.

How to Prepare:

• Partner with vendors offering FHIR-compliant APIs to centralize your data strategy.
• Conduct annual interoperability assessments to ensure systems are scaling effectively to meet compliance.

Strategic Advantage of Interoperability

Beyond mere compliance, interoperability lays the groundwork for comprehensive analytics and improved member engagement, making it a long-term investment in competitive differentiation.

Trend 2: Modernizing Prior Authorization Processes

Another significant aspect of regulatory trends in 2025 is the modernization of prior authorization processes. Prior authorization workflows remain outdated, heavily paper-based, and inefficient. The lack of electronic communication not only delays care but also wastes resources for providers and payers.

Key Prior Authorization Milestones

• 2025 will serve as a prep year as health organizations monitor the progress of prior authorization improvements ahead of finalized enforcement in 2027.
• 2026 will focus on API development tailored to new advanced Explanation of Benefits (EOB) regulations.

Shifting Toward Real-Time Decisions

Mandatory FHIR APIs and shortened authorization turnaround times will accelerate data tracking and approval workflows. However, many organizations remain underprepared for these rapid shifts.

Solutions to Consider:

• Equip your team with tools that support real-time communication between health plans and providers.
• Invest in AI-powered automation to process authorizations quickly and with greater accuracy.

Long-Term Impact of FHIR APIs:

Payers aligning their tech stack with FHIR standards stand poised to rapidly enhance provider relations, reduce administrative costs, and ultimately deliver better member experiences.

Trend 3: Data Privacy and Artificial Intelligence (AI)

The increased adoption of disparate technology systems leaves the door open for data privacy and security risks. But AI is entering the healthcare regulatory space, revolutionizing how fraud, waste, abuse (FWA), and early spending trends are identified. Health plans can leverage AI features like predictive analytics and natural language processing to identify waste and potential fraud—leading to cost savings and fewer manual reviews.

Privacy Implications

With healthcare data becoming more interconnected and accessible, regulations must evolve to protect sensitive information from breaches. Health plans must address questions such as:

• Where is sensitive health data stored?
• Who can access specific data?
• How long is the data protected once shared externally?

To maintain data security, health plans can invest in data encryption and cybersecurity infrastructure for their entire organization. They can also help ensure compliance readiness by adopting technology solutions with natively embedded data security and privacy measures.

Opportunities With AI:

Beyond security concerns, AI presents tools for streamlining compliance processes, enhancing analytics-driven strategies, and improving fraud detection. Read our recent blog to see 6 key ways AI can improve payment integrity at your health plan.

Trend 4: Transparency and Enrollment Regulation

Increasing regulatory scrutiny on enrollment and data collection procedures demands health plans revisit how they handle and present information to consumers. Advanced Explanation of Benefits and the No Surprises Act are paving the way for heightened transparency in billing and claims processing.

Upcoming Transparency and Enrollment Guidelines

• Automated Solutions for Comprehensive Enrollment Oversight.
• Addressing redundancies to streamline enrollment workflows.
• Clarity on AI’s role in administering and standardizing enrollment regulations.

Supporting Health Equity

Regulation updates also emphasize reducing barriers to care—be it geographic, financial, or systemic. Responding proactively and fostering a “patient-first” approach will be integral for retaining member trust.

Action Plan for Health Plan Executives

Invest Early in Innovation

Whether you’re considering the latest FHIR API or exploring AI-driven fraud detection, early adopters will capitalize most effectively on these opportunities.

Build Strong Vendor Relationships

Strong partnerships with tech providers will ensure efficient deployment of compliant solutions, keeping operations well ahead of evolving regulations.

Develop a Long-Term Roadmap for Readiness

Map out regulatory milestones through 2028, with annual evaluations to ensure progress toward compliance and interoperability goals.

By taking a strategic, forward-looking approach, organizations can transform compliance into an operational strength.

Driving Progress through Proactive Adoption

The future of healthcare compliance lies in proactive innovation. The regulatory changes on the horizon offer payers a unique opportunity to reimagine processes, adopt cutting-edge technology, and position their organizations as leaders in the industry.

By prioritizing interoperability, leveraging AI responsibly, and addressing the critical areas of data transparency and security, health plan leaders can achieve more efficient operations while keeping patient outcomes at the center of their strategies.

Want to stay ahead of regulatory trends in 2025 and maintain your market position? Download the complimentary HealthEdge Annual Payer Market Planning Report 2025.

Section Guide:

Key investments for member engagement

Overcoming barriers to member satisfaction

7 Key strategies for boosting member engagement

Impacts of transforming member engagement

Key investments for member engagement

Today’s healthcare consumer expects seamless, digital-first interactions with their health plan. They demand transparency, self-service options, and personalized experiences—which required a departure from traditional in-person and telephonic member engagement methods. In addition to improving satisfaction and clinical outcomes, maximizing member engagement can enable health plans to meet strategic business goals.

In the HealthEdge® Annual Payer Market Planning Report 2025, we uncovered the key areas health plans are focusing on to enhance member engagement. Improving health equity and addressing disparities came in as the top priority for health plan executives (59%). The dual focus on equity (59%) and transparency (51%) signals a broader commitment to bridging care gaps while building trust. Plans that prioritize equitable access to information and services position themselves as true partners in health.

To achieve these goals, payers are investing in the following solutions to help educate and empower members while streamlining processes for payers and providers:

• Member Portals – Centralized digital hubs that give members easy access to their benefits, claims, and personal health information.
• Mobile Apps – User-friendly mobile apps designed to bridge gaps between members, payers, and providers by enabling seamless outreach and communication.
• Enhanced Member Service Centers – Deliver personalized, real-time support to resolve issues effectively.
• Overcoming Barriers to Member Satisfaction

Despite advancements in member engagement technologies, several challenges still inhibit scalability and member impact:

Legacy core administrative processing system (CAPS) can cause data sharing bottlenecks that create inefficiencies and frustrate members with inconsistent, disconnected healthcare experiences. Health plans without access to updated, integrated data and analytics will be stuck reactively addressing gaps in care.

Social determinants of health (SDoH) add layers of complexity to healthcare access and engagement, making one-size-fits-all solutions ineffective. Tailoring member engagement efforts to diverse populations is critical to earn members’ trust and build lasting relationships. But gathering and analyzing the data necessary to provide a personalized experience can be challenging with outdated and disparate systems.

In addition to data access and analysis, health plans and members are increasingly concerned about data privacy. While members expect tailored interactions, concerns about data usage and security persist. Regulations from the Centers for Medicare and Medicaid Services (CMS) encourage health plans to be transparent about data use and security measures to reduce cybersecurity risks.

Health plans must adopt modern technology to make healthcare more accessible and empower members to engage with their plans and take an active role in their wellness.

[H2] 6 Key Strategies for Boosting Member Engagement

To meet member demands and overcome barriers to member engagement, health plan leaders are developing proactive, technology-forward strategies. Based on their priorities for 2025 and beyond, we suggest 6 strategic solutions health plans can adopt to meet member engagement goals.

1. Enhance Accessibility with Self-Service Tools

Customer experience has evolved beyond face-to-face interactions, with technology playing a crucial role in customer service. This shift aligns with consumer preferences —an estimated 73% of customers prefer the ability to resolve issues on their own.

According to the Market Planning Report, 45% reported the “inability to self-serve” was one of the biggest hurdles to member satisfaction. Providing members with user-friendly tools can help give them control over their health and make more informed care decisions. Platforms like GuidingCare® and Wellframe integrate personalized health information with streamlined care workflows, helping members manage their health and benefits from a mobile device.

Self-service tools, such as member portals, digital care programs, and care management, allow members to easily:

• Check benefits and coverage.
• Access educational content tailored to their health conditions.
• Reach out to care teams and health plan representatives.

Where can we go next?

Streamlining Member Touchpoints: Focus on reducing friction in member interactions, whether digital or in-person, by eliminating silos and simplifying processes.

2. Personalize the Member Journey

Each member has unique health and wellness needs, and engagement preferences. Advanced artificial intelligence (AI) and integrated data analytics enable health plans to offer personalized health recommendations and prioritize member outreach.

AI-powered tools are helping plans stay ahead of industry shifts by anticipating member needs, simplifying care management, and creating more personalized experiences. By automating workflows, these solutions help reduce inefficiencies and reallocate vital resources. In fact, AI-enabled solutions are well received among consumers— 65% expressed a preference for health plans that leverage AI to create a more personalized experience for members.

Leveraging insights from platforms like Wellframe, health plans can suggest tailored care programs based on a member’s demographics, health goals, and survey responses—improving member engagement and satisfaction.

Where can we go next?

Deepening Personalization Through Data: Use AI and advanced analytics to deliver relevant, contextual information to improve member experiences while maintaining transparency around data use.

3. Address Health Equity

Closing the health equity gap is one of the most critical initiatives for health plans. This involves ensuring that all members, regardless of socioeconomic background or geographic location, have equal access to high-quality care. By investing in digital health management solutions, health plans can expand their reach to underserved populations.

Learn more about how digital care programs can improve outcomes for high-risk maternity populations by reading our blog, Reduce Maternal Morbidity Risk for Black Women with Digital Care Management.

Where can we go next?

Embedding Health Equity into Core Strategies: Ensure your health plan’s member engagement strategies account for potential disparities and help create equitable experiences for all members.

4. Simplify Healthcare Communications and Information Access

Healthcare data is often difficult for members to understand, which contributes to confusion and frustration. There are a few ways health plans can help members better navigate the healthcare system. Health plans should consider making the member communications and educational materials easier to understand and more accessible.  Leverage plain language, visual aids, and interactive elements to explain complex health information. This approach can help members feel more confident in managing their health and make informed decisions.

Health plans can also focus on simplifying access to key healthcare and coverage documents, including:

• Real-time benefits information
• Detailed explanations of out-of-pocket costs
• Resources for making better health and financial decisions

Clear and accessible information about healthcare coverage and access builds trust between health plans and their members. It also empowers members to make more informed and confident decisions about their health .

Where can we go next?

Promote Health Literacy and Improve Healthcare Navigation: Develop member communications and documents with the intent of improving health literacy. This helps members understand what to expect when it comes to making appointments and using their coverage.

5. Streamline Claims and Administrative Processes

Efficient claims processing ensures that members receive timely and accurate reimbursements, which directly impacts their perception of care and coverage. When claims are processed smoothly, members experience fewer billing errors, delays, and frustrations, leading to a more positive overall experience.

Transparency in billing and claims processing is equally vital, as it helps members understand their financial responsibilities and prevents surprises. By providing clear, detailed explanations of benefits, coverage, and out-of-pocket costs, health plans can build trust and reduce anxiety about unexpected bills. This transparency fosters collaboration and leads to stronger partnership, ultimately improving health outcomes.

Where can we go next?

Streamline Claims and Simplify Billing: Implement efficient claims processing and enhance transparency in billing for accurate reimbursements and clear communication. Utilize advanced solutions to manage complex needs and ensure a seamless healthcare experience for members.

6. Leverage Mobile Apps for Omnichannel Engagement

Mobile apps are more than just convenient—they’re essential. Up to 64% of health plan members are comfortable using mobile apps to engage with their health plans. This gives  health plans more opportunities to learn about members’ unique needs and provide proactive support. Integrated digital health apps combine communication tools (such as HIPAA-compliant messaging) with biometrics and activity tracking to keep members engaged and on track with their health goals.

Wellframe, for example, creates an average of 34 digital touchpoints per member per month through the mobile app. Touchpoints include a combination of high-value interactions such as:

• Dismissing medication reminders
• Logging biometrics or physical activity
• Completing digital surveys

Where can we go next?

Building Proactive Engagement Models: Shift from reactive service to proactive outreach, using insights to address potential engagement gaps before they become issues.

Impacts of transforming member engagement

When health plans integrate intelligent engagement strategies, the impact is clear:

• Higher Member Satisfaction – Clear communication, self-service tools, and accurate claims lead to decreased frustration.
• Improved Health Outcomes – Care management workflows and personalized actions encourage better adherence to care plans.
• Greater Retention – Positive experiences cultivate loyalty, ensuring members remain with their health plans longer.

By meeting members where they are and aligning strategies with consumer expectations, health plans have an opportunity to redefine their relationships with members. The integration of innovative technologies and personalized experiences will be critical in 2025 and beyond, allowing health plans to differentiate themselves in an increasingly competitive landscape.

Are you ready to make member engagement your competitive advantage?

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.

 

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.

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.