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In the complex landscape of U.S. healthcare, payers face pressures from all directions. Stakeholders are looking for ways to streamline workflows so they can minimize errors and accelerate time to value without increasing costs.

Implementing a modern and digitally enabled core administrative processing system (CAPS) can enable payers to stay agile in the market and take advantage of new opportunities. The right CAPS solution seamlessly integrates within existing payer systems, allowing teams to share critical information quickly, easily and securely.

An updated CAPS is not just a tool, but a necessity for today’s market—a message HealthEdge® Chief Technology Officer Rob Duffy emphasizes in a recent episode of the Tech Talks podcast. The role of healthcare CTO is evolving alongside healthcare technology itself, and Duffy sees his role as one that can help organizations harness the full potential of digital transformation.

“This is going to be a change as important as electricity and as revolutionary as electricity. And where are we going to be in three and five years?”

Thriving Amid the Complexity of U.S. Healthcare

The U.S. healthcare industry is a multi-layered ecosystem. Each process—from patient care to claims adjudication—demands precision, transparency, and speed. Payers are tasked with ensuring these processes run smoothly, even while adjusting to new regulations.

To keep up with the evolving demands, payer leaders are turning to CAPS tools to streamline operations and improve data sharing. Legacy systems, while reliable in the past, can become barriers to progress if they can’t provide integrations with other solutions. The modern healthcare environment requires systems that are flexible and scalable based on payers’ evolving needs.

Core Administrative Processing Systems (CAPS) and Digital Transformation

CAPS have become integral components to streamlining operational efficiency for health plans. Working with an established CAPS vendor can provide your team with the ongoing support and resources they need to achieve their goals.

The HealthRules® Payer solution, for example, delivers seamless app integrations, intuitive navigation, and on-demand training resources that empower your teams to get more from your investment in less time. Digital transformation is more than a buzzword. In healthcare, it’s a path to better care and improved efficiency. But, as Duffy highlights in the podcast, successful digital transformation for health plans requires careful planning and execution.

However, transition from legacy systems to advanced CAPS isn’t just about technology—it’s about reimagining processes and fostering a culture of innovation.

Healthcare CTOs can help shape organizational investment by evaluating current systems, identifying inefficiencies, and screening new solutions that align with organizational objectives. This proactive approach ensures that organizations remain competitive and responsive to industry changes.

The Importance of Change Management

Successful healthcare digital transformation depends on effective change management. Success is not just about adding new technology, but ensuring that individuals and teams are aligned with organizational goals.

A modern CTO can help secure internal buy-in through transparent internal communications, taking part in information sessions, and accepting feedback from the organization. By involving employees in the transition process and providing the necessary training, organizations can minimize resistance and foster a collaborative environment.

“The way health plans fall down is generally by underestimating the amount of change management they have to do with their people, and help educate their internal users. Help get them excited about the future, help them have some agency in some of the decisions being made.”

Building a Culture of Innovation

The role of a Chief Technology Officer in healthcare extends beyond technical leadership. A CTO must have the foresight to anticipate future trends and understand what actions they can take today to prepare their organization. In addition to technical knowledge, healthcare CTOs need strategic leadership skills to position their organizations as pioneers of industry advancements.

Addressing Challenges in Healthcare Digital Transformation

Digital transformation is fraught with challenges, particularly for healthcare payers. Legacy systems, regulatory requirements, and internal resistance to change can hinder progress. However, CTOs can help identify potential roadblocks early in the implementation process and develop strategies to address them. By anticipating challenges and creating contingency plans, health plans can stay on track and achieve their technology goals.

The Future of Healthcare Technology

The future of healthcare technology is bright, with endless possibilities for innovation. CTOs must stay informed about emerging technologies and evaluate their potential impact on the organization. By leading digital transformation efforts and fostering a culture of innovation, healthcare CTOs can drive organizational success and improve patient care.

For healthcare organizations seeking to thrive in the digital age, investing in modern CAPS and adopting a forward-thinking approach is essential. By doing so, they can position themselves as leaders in the industry and deliver exceptional value to patients and stakeholders alike.

Are you looking for more information about additional trends in healthcare technology? Read our fireside chat Q&A with GuidingCare® product leader Bobby Sherwood to discover how we’re enabling HealthEdge customers to meet compliance requirements and thrive in this new environment of real-time data sharing.

 

 

Artificial Intelligence (AI) is transforming payment integrity in the health insurance industry, particularly in detecting and preventing fraudulent payments and waste. As fraudulent claims become more sophisticated and the cost of bad data continues to rise, health plans need more advanced tools such as AI.

The healthcare industry loses billions of dollars annually due to payment errors, fraud, and overpayments.

According to the 2024 Gartner® Hype Cycle™ for U.S. Healthcare Payers, “AI-enabled fraud detection solutions:

Identify new fraud schemes that are undetectable with traditional rule-based methods.

– Support compliance efforts through state and federal report generation.

– Decrease provider abrasion and administrative burden by reducing retrospective “clawbacks” of overpayments.

– Increase special investigative unit team efficiency through integrated case capabilities that prioritize suspected fraudulent claims and create detailed reports, reducing administrative burden”

Given its positive impact on business outcomes, it is important for health plan leaders to understand the top trends in AI when it comes to payment integrity:

1. Predictive Analytics:

This involves using historical data to predict potential fraud and inaccurate payments. By analyzing patterns from past claims, AI can identify which claims are likely to be fraudulent or incorrect in the future. This helps payers move from reactive to proactive approaches.

2. Enhanced Claims Auditing:

AI automates the review of claims against changing medical guidelines and regulations for accuracy and compliance.

3. Natural Language Processing (NLP) for Unstructured Data Analysis:

NLP is a branch of AI that helps machines understand and interpret human language. In payment integrity, NLP can analyze unstructured data, such as doctors’ notes, medical records, and patient reviews, to find inconsistencies that could lead to improper payments.

4. Intelligent Automation:

AI-powered Robotic Process Automation (RPA) can handle repetitive tasks, such as data entry and claims processing. As claims become more complex, AI can automate these reviews, freeing up the team for more strategic tasks.

5. Advancing Value-Based Care:

AI can track and monitor provider performance against value-based care metrics to ensure payments match contractual terms. This supports payers’ growing focus on value-based care arrangements.

6. Real-Time Fraud Detection and Prevention:

Real-time fraud detection involves analyzing massive volumes of claims data as they come in. AI can detect and prevent fraudulent claims, such as those involving upcoding, unbundling, or billing for services not rendered. By helping to identify and prevent fraudulent or inaccurate claims before the payment is made, AI can help dramatically reduce the downstream work and waste associated with overpayments and underpayments.

The Source Advantage

HealthEdge Source™ (Source), the leading payment integrity platform by HealthEdge®, is recognized for its innovative approach, which helps payers identify, predict, and prioritize fraudulent claims. HealthEdge was recognized as a Sample Vendor in the 2024 Gartner® Hype Cycle™ for U.S. Healthcare Payers. AI-Enabled Fraud Detection has been named in the report since 2023, and we have been named as a Sample Vendor for both years – 2023 and 2024.

To enhance fraud detection and prevention, HealthEdge is developing partner integrations to provide customers with built-in fraud detection technology.

In addition, Source offers its customers advanced analytic tools and other payment integrity tools that make fraud and waste detection and prevention possible. Some of these capabilities include:

–Platform Access:

As a single platform in which all data resides, Source makes it easier for health plans to gain insights across their business, addressing the root causes of inaccurate payments and resolving issues upstream. This helps break the cycle of paying third-party contingency vendors to discover the same issues month over month. With Source, health plans can achieve continuous improvement and more accurate payments.

–Advanced Analytics:

This suite of tools provides real-time production metrics, including claims volume and financial impact of edits, giving health plans up-to-date snapshots of claims operations.

–Monitor Mode:

This feature allows health plans to evaluate what-if scenarios, giving a clear picture of the financial impact of a pricing or policy edit in real-time but before the edit is put into production.

–Retroactive Change Manager:

This tool enables health plans to proactively manage retroactive changes. With CMS making over 600 edits per year, this feature helps prevent inaccurate payments, reducing overpayments or underpayments.

Together, these tools streamline workflows, reduce costs, and improve the integrity of the claims process. By leveraging the latest AI trends and its powerful suite of solutions, Source provides a comprehensive, proactive solution making it easier for payers to identify, predict, and prioritize fraudulent claims.

GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally, and HYPE CYCLE is a registered trademark of Gartner, Inc. and/or its affiliates and are used herein

Gartner does not endorse any vendor, product or service depicted in its research publications and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

To learn more about how Source can help protect your organization from fraudulent claims and providers, visit www.healthedge.com.

Maternal morbidity rates in the U.S. are in the spotlight—particularly the disparities many Black women face compared to their white counterparts.

Despite advances in medical technology and healthcare access, systemic racism and implicit biases in healthcare continue to contribute to adverse outcomes for Black women, especially during pregnancy. On average, severe maternal comorbidity impacts between 50,000 and 60,000 women every year in the U.S., according to the Commonwealth Fund.

Pregnant people who experience severe maternal morbidity are at higher risk of postpartum hospital readmission than those who did not. A study of women in Massachusetts found that those with severe maternal morbidity were more than twice as likely to be readmitted within six weeks.

In this blog, we explore some of the unique needs of Black maternity populations, and how health plans can provide digital care management solutions that empower members and improve outcomes.

How Digital Engagement Improves Maternal Health Outcomes

Digital health tools can play a significant role in improving maternal health outcomes by extending the reach of your care teams. In a recent study, Wellframe’s Maternal Health digital care program helped increase care team capacity, contributing to more than $775,000 in annual cost avoidance. Members enrolled in the program had a significantly higher prenatal visit rate in the third trimester, as well as significantly lower emergency department usage.

By leveraging the right digital health solutions, health plans can meet the needs of high-risk members—like the Black maternity population. Wellframe’s digital care programs use technology to encourage communication and trust between members, their care teams, and their health plans. Members can use digital tools to receive holistic and accessible healthcare support where and when they need it. Increasing member engagement can not only lead to better clinical outcomes, but also higher member satisfaction scores.

A New Digital Care Program: Reduce Maternal Morbidity for Black Women

To address the ongoing maternal health crisis, Wellframe developed a digital care program targeting the unique needs of pregnant Black women.

Wellframe’s care program, “Maternal Wellness for Black Women,” was developed to provide holistic support and education to pregnant Black women to close gaps in care and improve clinical outcomes. We do this by connecting women directly to their care providers within the app, as well as delivering accessible health information and encouraging health plan engagement.

Members enrolled in the “Maternal Wellness for Black Women” care program will receive information on important topics such as:

• Importance of prenatal care
• Clinical warning signs to watch out for
• Taking an active role in your healthcare
• Lifestyle and wellness tips

The care program also includes a toolkit for members, which they can download or access in the app. It offers suggestions and support for members looking into their healthcare options. Care managers can directly share a link to the toolkit with members at any time.

Are you looking for more information about how you can reach and engage with more members to achieve your health plan’s goals? Download our eBook, “Integrated Digital Care Management: Meeting Members and Care Managers Where They Are.”

 

In the rapidly evolving landscape of healthcare technology, staying ahead of competitors requires organizational commitment to modernization. Investing in a modern healthcare core administrative processing solution (CAPS) can accelerate automation, streamline workflows, and lower operating costs.

To better support our health plan customers, HealthRules® Payer is taking a bold step forward by comprehensively updating its web user interface (UI) for the first time since 2005. In this blog post, we explore why this transformation is crucial for healthcare payers, and how it benefits them in navigating the future of healthcare.

Evolution of the HealthRules® Payer UI

Since its inception in 2005, HealthRules Payer has been serving healthcare payers with an intuitive and reliable solution. While we made cosmetic updates in 2015, the underlying technology remained unchanged.  Meanwhile, many HealthEdge® products have already transitioned from PC- to web-based platforms that offer enhanced functionality and better user experiences. Now, we’re transitioning HealthRules Payer to a cloud-based solution.

The modernization of the HealthRules Payer UI is a multi-year, multi-phase initiative aimed at transforming the user experience and providing a more unified, integrated ecosystem across HealthEdge solutions and beyond. This endeavor represents our organizational commitment to staying at the forefront of healthcare technology innovation.

5 Key Benefits of a Modern Healthcare CAPS

While planning the platform update, the HealthRules Payer team focused on the ways a modern healthcare CAPS can deliver greater value to customers through an intuitive web-based experience.

1. More Productive, Satisfied Customers

One of the primary objectives of UI modernization is to enhance productivity and satisfaction for customers. By providing a centralized and intuitive interface, healthcare payers can complete tasks more efficiently, reducing frustration and saving time.

2. Enterprise-Level System Design

The modernization of the HealthRules Payer UI includes an enterprise-level system redesign. This helps ensure the solution is scalable, reliable, and adaptable, enabling payers to handle the complexities of modern healthcare seamlessly.

3. Consistent Value Streams

Standardized UX frameworks across the HealthRules Payer solution facilitate consistent value streams that deliver consistent, high-quality experiences across the platform. This consistency builds trust and strengthens relationships with our health plan customers.

4. Scalable, Cloud-Based Workflows

Scalability is key in the healthcare industry, where demands can fluctuate significantly year over year and between member populations. The cloud-based workflows offered by the modernized HealthRules Payer UI make it easier for healthcare payers can scale their operations efficiently, without compromising performance.

5. Integrated Solution Ecosystem

The integration of HealthEdge solutions and third-party applications fosters a cohesive ecosystem that facilitates data sharing and supports informed decision-making. This seamless connectivity empowers healthcare payers to harness the full potential of their resources, driving better outcomes for patients and organizations alike.

Cutting-Edge Features of the New HealthRules Payer UI

The revamped HealthRules Payer UI comes equipped with a host of cutting-edge features designed to optimize user experiences.

• Improved Navigation and Search: Navigating complex healthcare data has never been easier. The improved navigation system, coupled with robust search functionalities, ensures that users can find the information they need quickly and accurately.
• Seamless App Integration: The app launcher and integration framework support seamless workflows involving HealthEdge and third-party applications. This integration opens up new possibilities for collaboration and innovation.
• Enterprise-Class Design System: An enterprise-class design system and component library accelerate development and reduce code maintenance across the product portfolio. This efficiency translates into faster updates and improvements for customers.
• AI, ML, and Application Personalities: HealthRules Payer is paving the way for artificial intelligence (AI), machine learning (ML), and application personalities to enhance user experiences. These technologies are expected to drastically change the way healthcare payers interact with internal data and technology solutions.
• Minimal Retraining, Maximum Impact: The modernization process has been carefully planned to minimize disruption for existing users. Extensive efforts have been made to ensure that transitioning to the new UI requires minimal retraining, allowing users to seamlessly adapt to the upgraded platform.
• On-Demand Training Resources: To support users in their transition to the web-based platform, a comprehensive Help Center is available 24/7. This resource provides access to on-demand training videos, ensuring that users can quickly get up to speed with the new features and functionalities.
• User-Centric Design Approach: The UI modernization follows a user-centered design approach, emphasizing the need for understanding and empathy before solutioning to meet the needs and expectations of healthcare payers.
• Feedback and Continuous Improvement: The modernization process incorporates feedback from our health plan users, demonstrating our commitment to continuous improvement and customer support. Our dedication to ongoing enhancement ensures that healthcare payers always have access to the latest innovations.

The Path to a Resilient Healthcare Plan

A web-based, modern healthcare CAPS solution like HealthRules Payer empowers healthcare payers to be more resilient to change across the healthcare industry by improving adaptability and efficiency, giving plans a competitive advantage.

In a competitive healthcare market, an updated CAPS solution can be a significant advantage. HealthRules Payer’s innovative approach sets healthcare payers apart, helping them attract new customers and strengthen existing relationships.

The comprehensive modernization of HealthRules Payer UI is a pivotal step toward enhancing the capabilities and experiences of healthcare payers. By adopting a modern technology stack, integrated solutions, and user-centric design, HealthRules Payer empowers healthcare payers to thrive in an ever-changing industry.

For healthcare payers seeking to stay ahead of the curve and drive meaningful change, HealthRules Payer’s modernization offers a pathway to success. Explore the future of healthcare technology and empower your organization with a modern, web-based CAPS solution that sets new standards for efficiency, innovation, and resilience.

Discover how one plan partnered with HealthRules Payer to drive modernization and expansion. Read the case study