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In the dynamic healthcare industry, staying current with the latest technology and regulatory changes is essential, especially with a mission-critical care management solution such as GuidingCare®. For existing tool users who have already been trained on the system, knowledge gaps may still exist. Software updates are frequent as innovation continues rapidly, making it challenging to keep care management teams fully up-to-speed. Often, there are opportunities to optimize how the technology is used. Relying solely on traditional training methods, such as live sessions and release notes, can disrupt the teams’ essential duties, requiring them to take time away from urgent tasks. Leveraging a flexible, on-demand training system can fill the gaps and provide a refresher on best practices, even with technology updates.

Continuous Learning in a Dynamic Environment

GuidingCare University addresses these challenges with a self-service, easy-to-use, digital Learning and Development platform that helps existing users continually improve their product knowledge. The platform offers on-demand training 24/7, ensuring users can learn new GuidingCare product features and stay informed and effective without disrupting their schedules. With GuidingCare University, it is easy for both users and managers to keep track of progress on assigned training modules and review the results of knowledge assessments, confirming that learning is on pace and successful.

Tailored Learning for Better Outcomes

GuidingCare University is designed to serve staff across various roles, including utilization management, nurses, medical directors, appeals and grievance staff, and population health professionals. Customized learning paths support the distinct needs of every organization and team member, ensuring that training is relevant and immediately applicable. By targeting all staff that utilize GuidingCare software, GuidingCare University ensures comprehensive training and knowledge sharing across teams. This leads to optimized solution usage, breakdown of internal siloes, and streamlined daily operations.

Staying Current with Quarterly Updates

GuidingCare University provides quarterly content updates to inform users about the latest GuidingCare product enhancements. These updates are essential for maintaining high expertise across teams and ensuring that users are always equipped with the knowledge needed to perform at their best. This commitment to continuous learning is vital in the fast-paced healthcare environment, where staying current is crucial for success.

A Scalable Training Solution

With subscription-based access, GuidingCare University offers a scalable solution that can expand alongside a health plan’s growth. Whether a health plan selects the Professional Level for essential training or the Enterprise Level for enhanced customization, GuidingCare University is designed to meet the evolving needs of each organization.

Investing in GuidingCare University keeps care management teams performing at the highest level. By providing continuous learning opportunities and real-time updates, GuidingCare University empowers staff to become more proficient and confident in their roles, leading to better outcomes for health plans and the members they serve.

Read the rest of the three-blog series to discover additional benefits of the GuidingCare solution.

Healthcare regulations continue to evolve, reshaping how health plans operate and do business in a competitive market. Amid rising costs and regulatory pressures, healthcare fraud prevention is becoming a strategic priority for health plans. Fraudulent healthcare claims cost an estimated $100 billion every year—between 3 and 10% of total healthcare spending.

Billing accuracy and fraud prevention go beyond regulatory compliance. They’re crucial in reducing costs, minimizing provider abrasion, and building trust in your organization. Here are the 5 payment integrity trends transforming the healthcare industry and highlight strategies health plans can use to fully capitalize on these trends.

Trend 1: Impact of Medical Loss Ratio (MLR) Guidelines

The Medical Loss Ratio (MLR) is a critical metric for assessing health plan solvency. MLR measures the percentage of premium funds a health plan spends on medical claims and quality improvement initiatives versus administrative costs and revenue. The Affordable Care Act (ACA) mandates insurers spend at least 80% of premium revenues on claims and quality improvement for individual and small group markets, and 85% for large group markets. The goal is to ensure that a significant portion of premiums directly benefit policyholders, rather than being absorbed by operational costs.

When health plans fail to meet the MLR thresholds, they are required to provide rebates to members. The Kaiser Family Foundation estimates that health plans will pay $1.1 billion in MLR rebates across all commercial markets in 2024.

With the ACA setting strict MLR guidelines, health plans must make substantial adjustments to spending allocation. This often means reducing administrative expenses and improving operational efficiency. To achieve these new goals, health plans are investing in integrated technologies that can help automate claims processing and enhance data analytics to better manage healthcare costs. These adjustments not only help meet MLR requirements, but also improve overall costs and streamline operations.

Trend 2: Achieving Enterprise Payment Integrity

Enterprise alignment is the foundation of a successful healthcare organization. By ensuring that all departments—from claims operations to finance—work toward common goals, organizations can implement cross-functional strategies that prevent errors, optimize reimbursement processes, and enhance financial performance.

The benefits of enterprise transformation and alignment are manifold. An integrated digital solution can help break down internal data silos to improve data-sharing and give leadership teams a holistic view of the organization. Accurate and uniform data makes it easier for executives to act quickly to  market changes and make informed decisions. Streamlining staff communication and removing silos facilitate faster identification andcorrection of claims discrepancies, reducing the risk of errors and improving efficiency. This integrated approach helps optimize reimbursement processes and improve financial performance.

An enterprise approach to payment integrity also supports health plans in deploying consistent policies and procedures that enhance payment accuracy and reliability. This consistency is important to maintain high payment integrity standards and encourages all departments to contribute to a unified strategy. By aligning internal processes, healthcare payers can minimize the risk of discrepancies that could otherwise lead to payment errors, inefficiencies, and financial losses.

To successfully implement a new payment integrity strategy, health plans must be aligned across the organization. In 2025, our experts anticipate a growing focus on establishing enterprise-wide payment integrity programs that foster collaboration and shared responsibility. The future of payment integrity is shifting towards Payment Accountability®, an enterprise-wide approach that brings together different business units to measure cost avoidance—instead of just recovery. Payment Accountability emphasizes the need for organizational transparency to address root cause inaccuracies, so health plans can pay claims accurately, quickly, and comprehensively the first time.

Trend 3: Enhancing Pre-Pay Accuracy

As we head into 2025, pre-pay accuracy isn’t just best practice. It’s a necessity for health plans to maintain financial health and regulatory compliance—as well as build trust with stakeholders in and outside the organization.

By verifying claims before payment, healthcare payers can minimize—or even eliminate— payment errors, fraud, and financial losses. This proactive step helps prevent overpayments and reduces costly post-payment recoveries. Pre-pay accuracy also makes it easier to comply with payment regulations. By identifying inaccuracies before submission,payers can avoid penalties and maintain payment integrity.

Furthermore, pre-pay accuracy can enhance a health plan’s administrative efficiency. By verifying eligibility, medical necessity, and authorizations before payment, health plans can reduce errors, denials, and manual interventions. Timely payments and fewer denials can reduce provider abrasion and contribute to a more optimized payment ecosystem.

Data analytics tools within payment accuracy solutions empower health plans to achieve pre-pay accuracy by offering a detailed look at claims data. By analyzing both historical and real-time data, health plans can spot patterns and trends that might indicate fraud or workflow inefficiencies.

Trend 4: Accessing Real-Time Data and Advanced Analytics

Real-time data analytics are in high demand as they become more important to the payment integrity process. The ability to analyze claims as they come in makes it easier to identify inaccuracies before payments are disbursed. This rapid analysis helps reduce financial losses while ensuring timely, accurate claims processing.

Payment integrity solutions that deliver advanced data analytics can provide health plans with actionable insights that enable predictive analysis and proactive decision-making. In addition to improving payment accuracy, advanced analytics can also help automate routine tasks and reduce manual efforts.

Access to real-time data and analytics is vital for health plans to adopt an enterprise approach to payment integrity. Platform integrations facilitate seamless data flow and accessibility, while maintaining accurate and reliable data across internal systems. With a single source of truth, health plans can improve transaction efficiency and reduce claims processing times. It also facilitates better monitoring and tracking of health plan’s financial data to minimize the risk of errors.

Trend 5: Transforming Healthcare Fraud Detection with Artificial Intelligence (AI)

Artificial Intelligence (AI) is expected to change fraud detection in healthcare. Its speed and precision in analyzing large datasets make it a game-changer for spotting and preventing fraud—and a crucial tool for financial integrity and regulatory compliance. Advanced automation algorithms help detect anomalies that human analysts might miss, cutting financial losses and ensuring payers meet regulatory standards.

Healthcare organizations are increasingly adopting AI for fraud detection, recognizing its transformative potential. However, adoption rates vary due to factors like:

• Existing technology infrastructure
• Budget constraints
• Data security concerns

Despite these hurdles, AI systems are becoming more sophisticated and accessible, paving the way for more secure and reliable payment systems that minimize fraud risks.

AI continues to evolve, offering more robust fraud detection solutions. Innovations in machine learning and predictive analytics will enhance AI’s ability to preemptively identify potential fraud risks, facilitating proactive interventions. As healthcare organizations continue to harness the power of AI, its role in fraud detection will be central to maintaining financial integrity and operational efficiency, shaping a more secure and efficient claims payment landscape.

Payment integrity will remain a cornerstone of financial stability and regulatory compliance. By embracing cutting-edge trends and technologies, health plans can significantly enhance operational efficiency, reduce errors, and improve claims processing accuracy.

Want to see how HealthEdge Source is leading the charge in payment integrity? Check out our HealthEdge Source™ Horizons blog series! We explore the features and tools that help health plans achieve greater accuracy, efficiency, and security in their payment processes.

The implementation of the Interoperability and Prior Authorization Final Rule mandate (CMS-0057-F) in early 2024 is more than just a compliance requirement—it’s an opportunity for health plans to modernize and streamline their operations. But for payers still dependent on outdated and legacy technology systems, it can be difficult to turn requirements into regeneration opportunities.

This was the subject of a recent IDC white paper entitled, “Compliance with Prior Authorization Mandates is a Strategic Opportunity for Payers,” by Jeff Rivkin, IDC Research Director. In the report, Rivkin explains the importance of investing in modern, highly interoperable solutions, and how these solutions can be a true catalyst for digital transformation—a goal many health plans are striving to accomplish.

5 Key Prior Authorization Takeaways for Health Plans 

Rather than viewing compliance with CMS-0057-F as a regulatory burden, health plan leaders can use it as an incentive for digital transformation. By investing in next-generation core administrative processing systems and care management platforms, health plans can achieve the following strategic advantages:

Trend 1: Operational Efficiencies through Integrated Systems

One of the key challenges posed by CMS-0057-F is the need to integrate disparate systems to support real-time data sharing and streamlined workflows. Health plans that invest in modern, integrated platforms can automate manual processes, reducing the administrative burden on staff.

For example, a transformational core administrative processing system, such as HealthEdge’s HealthRules® Payer, can automate prior authorization workflows, manage claims, and synchronize data between clinical and administrative systems. By unifying these functions, health plans can respond faster to authorization requests, improve accuracy, and reduce manual intervention.

Trend 2: Improved Provider Collaboration and Member Engagement

The transparency and data-sharing requirements of CMS-0057-F are designed to improve collaboration between health plans, providers, and members. Health plans that invest in robust care management systems can enhance provider communication, streamline care coordination, and ensure that members have timely access to the care they need.

A comprehensive platform like GuidingCare® from HealthEdge can facilitate this collaboration by providing providers with real-time access to patient data, including the status of prior authorizations. This reduces the back-and-forth communication often associated with the prior authorization process, accelerating approvals and improving the member experience.

Trend 3: Data-Driven Decision-Making and Reporting

CMS-0057-F places a significant emphasis on transparency, requiring health plans to report key performance metrics related to their prior authorization processes. Health plans that invest in business intelligence and analytics tools can not only meet these reporting requirements, but also use the data to optimize their operations.

By leveraging the robust reporting capabilities of a care management platform like GuidingCare, health plans can track key metrics like approval and denial rates, turnaround times, provider performance, and more. This data can be used to identify inefficiencies, make data-driven decisions, and continuously improve the prior authorization process—beyond remaining compliant with CMS-0057-F.

Trend 4: Scalability and Futureproofing

It is imperative that payers invest in a modular and agile technology platform to scale their operations alongside their growing member base. Legacy systems are often rigid and unable to adapt to changing regulatory requirements or market conditions. In contrast, forward-thinking CAPS and care management platforms are designed to be flexible, allowing health plans to easily adapt to new regulations or business needs.

Considering the ever-evolving Centers for Medicare & Medicaid Services (CMS) regulations, health plans that invest in scalable technology are better positioned to adapt to future changes without costly system overhauls. This futureproofing is essential for long-term operational success.

Trend 5: Choosing the Right Technology Partner

Investing in the right technology starts with finding the right partner. Look for highly interoperable solutions that work together seamlessly to offer real-time data sharing, support business rules engines, and deliver robust reporting and analytics capabilities.

While meeting the compliance requirements of CMS-0057-F is crucial, it also opens the door to much broader opportunities for health plans to become digital payers. By embracing modern, integrated technology platforms like those offered by HealthEdge, health plans can ensure compliance and also create a foundation for long-term operational success.

Learn more about how compliance with this new rule can be leveraged as a strategic opportunity for your organization. Download the full IDC whitepaper.

At HealthEdge®, we are continually seeking ways to improve our users experience and help maximize the value customers get from our solutions. That’s why we designed the HealthEdge Help Center, a one-stop online platform that helps users leverage our solutions more effectively by enabling them to quickly locate the information they need. The Help Center provides convenient access to resources like documentation and troubleshooting, as well as on-demand training assets.

Below, we’ve highlighted a few ways the Help Center benefits HealthEdge customers.

Empowering Users With An Exceptional Experience

We built the Help Center with efficiency in mind. It offers a centralized location where users can easily search and access relevant information, so teams can spend less time looking and more time doing. The Help Center even allows for printing or PDF downloads to offer flexibility and inclusivity in information access.

Comprehensive Trainings Accessible Any Time

The Help Center provides on-demand training videos, FAQs, quick tips, and other insights. It is accessible at any time, so users can find the data and documentation they need at their convenience. The Help Center includes documentation for the HealthRules® Payer, Connector, Installer, and Provider Data Management solutions, with more to come.

Through the Help Center, users can also find comprehensive documentation for all HealthEdge product releases, making it easier to stay informed about system updates and improvements.

Built For Ongoing Evolution

HealthEdge built the Help Center to be highly scalable, allowing ongoing improvement to both the content and features it provides. Platform analytics help us measure which resources and features drive the greatest value for our customers.

The Help Center is just the beginning. We are continuously working on improvements to further assist our users, such as AI-powered personalized content recommendations, and enhanced mobile support.

Accessing the HealthEdge Help Center 

The Help Center is available to all customers upgrading to HealthRules Payer 24.1. To learn more and see how you can gain access to the Help Center, contact your Upgrade/Implementation team or Customer Service Executive.

Not a current HealthEdge customer but interested in learning more? Contact us here.

Join us in this transformative journey towards a digital healthcare system. The HealthEdge Help Center is here to help you make the most of your HealthEdge experience.

Member satisfaction is vital for health plans to grow communities and improve outcomes. At the AHIP Consumer Experience & Digital Forum (CDF) 2024, Susan Beaton, Vice President of Health Plan Strategy at HealthEdge, addressed this topic with her presentation on “Driving Member Satisfaction Through an Integrated Care Management Strategy.”

The presentation highlighted how integrating digital tools with traditional workflows can transform care management delivery to drive member satisfaction. This is especially important considering care managers’ increasing responsibilities, the direct connection between member experience and satisfaction, and the rising demand for innovative digital solutions from members.

Key takeaways from the presentation include:

1. Care Managers Face Increasing Responsibilities And More Significant Challenges Than Ever Before

Care managers face rising challenges as their responsibilities expand to address a wide range of complex business and member needs. Workforce shortages make their role even more complicated, while manual administrative tasks take up valuable time that could be spent on direct member care. Members’ expectations are rising for more personalized interactions and immediate information. Navigating complex regulatory requirements only adds to care managers’ workload while they perform an essential role in a member’s care journey.

2. The Care Manager’s Experience Directly Impacts Member Satisfaction

Improving care managers’ experience through digital tools enhances efficiency, improves member outcomes, and increases satisfaction. Streamlining their workflows and providing user-friendly tools that reduce manual administrative work allows them to apply their expertise effectively, so they spend more time addressing member needs and providing personalized and proactive care. Care managers who are empowered to consistently anticipate and meet member needs foster trust with members, drive better health outcomes, and create a more positive overall member experience.

3.Members Expect Innovation And Are Comfortable With Digital Tools

As technology transforms members’ daily lives, they are increasingly comfortable using digital tools to manage their health. The 2024 HealthEdge® Consumer Survey found that 64% of members are comfortable using mobile apps to access health information, while 65% are open to utilizing AI-powered tools provided by their health insurers. These findings highlight the rising expectations for innovation and digital engagement in healthcare, as members now anticipate seamless, technology-driven interactions like those in retail, travel, and other areas of their lives.

4. It’s Time For Health Plans To Rethink Care Management Delivery

The increasing challenges for care managers, alongside rising expectations from members, present an opportunity for health plans to apply modern technology to enhance traditional workflows. Integrated Digital Care Management merges traditional care management practices with digital tools and technologies to improve efficiency, effectiveness, and reach. This approach combines clinical data, real-time member insights, and traditional care workflows to create a more efficient, member-centered approach, ultimately improving the care experience and delivering better health outcomes at lower costs.

A HealthEdge study using Wellframe data highlights how digital tools dramatically scale care management resources and boost member engagement with the same staff levels, leading to results such as:

• 2x increase in active caseload size, allowing care managers to handle more members without additional staff.
• 6x increase in member interactions, driven by enhanced digital engagement and self-service tools.
• 91% increase in successful outreach that improves care delivery and ensures members receive timely support.

This data shows how integrating digital tools can significantly enhance the effectiveness and reach of care management programs.

5. The Benefits Of Digital Tools Are Accelerating

Integrating digital tools in care management is proving transformative, significantly enhancing operational efficiencies and the scope of services to members. The benefits are only accelerating as tools become more mature and advance integrations with other platforms to streamline care team workflows. Additionally, sophisticated digital tools incorporate artificial intelligence (AI) technology into their platforms to drive further efficiencies and member personalization. These accelerated benefits support various business initiatives, from launching concierge services that provide targeted clinical support to identifying and driving new initiatives to improve the member experience and member satisfaction.

6. Successful Adoption Of Digital Tools Requires Change Management Best Practices

Organizations must prioritize robust change management strategies for digital tools to be effectively adopted by care managers and integrated into their daily workflows. This includes pillars such as focusing on the care manager’s experience with new tools and ensuring leadership commitment to transformation. Key strategies for success include digital transformation, aligning incentives, and collaborating with the right vendors to support long-term goals. In addition, health plans can benefit from intentional rollouts of new tools that focus on optimal use cases to establish high impact, early success, and internal buy-in.

7. The Time Is Now for Integrated Digital Care Management

As the healthcare industry evolves, the need for Integrated Digital Care Management is more urgent than ever to drive member satisfaction. Strategic concerns for health plans include the following:

• Market Dynamics and Consumer Expectations. With more health plan options available, members expect healthcare experiences that mirror the convenience and immediacy of digital retail services, which is crucial to drive member satisfaction.
• Regulatory Pressures. New regulations focusing on health equity and social determinants of health (SDOH) data require modern digital tools for compliance, which can impact member satisfaction scores and financial incentives like Star Ratings.
• Operational Efficiency and Cost Reduction. Digital tools, automation, and AI streamline administrative tasks, helping health plans do more with fewer resources, while alleviating the workload of care managers.
• Competitive Advantage. By adopting Integrated Digital Care Management, health plans can position themselves as innovators, gaining a competitive edge in attracting and retaining members, while preparing for future technological advancements.

Beaton’s presentation from AHIP CDF 2024 provides a roadmap for health plans to leverage digital tools to elevate care management practices, and enhance member and care manager experiences.

Using the Wellframe solution, a Blue Cross Blue Shield plan drove member engagement and increased care management capacity to better serve their 21 million members. To learn more about how the health plan improved phone call success rates, active caseload size, and member interactions, read the case study.

The ever-changing healthcare landscape requires health plans to have access to the insights and agility necessary to control costs, embrace change, and move quickly to take advantage of new opportunities. For many payers, upgrading to modernized health plan core administrative processing systems (CAPS) is a key strategy to remain flexible and competitive in the market.

To stay ahead of industry changes, many health plans are transitioning to cloud-based solutions. Doing so makes it easier for payers to consolidate their applications, reducing reliance on third-party point solutions and outdated proprietary systems. This forward-thinking approach streamlines operational efficiencies and meets the growing demand for agility in the ever-shifting healthcare regulatory environment.

Payers increasingly recognize that investing in modern health plan core administrative processing systems is essential to improving both member and provider experiences— needs that remain largely unmet by legacy systems. Leveraging cloud-based CAPS solutions make it easier for health plans to embrace the industry shift toward data accessibility and real-time claim adjudication while empowering them to react swiftly to stakeholder demands.

6 Key Trends Driving Investment in Health Plan Core Administrative Processing Systems

Healthcare payers must navigate a complex landscape of demands and opportunities to succeed. Several trends have emerged that are shaping payers’ decisions to reinvest in their existing CAPS solutions. An industry-wide shift toward a value-based care model is compelling executives to reevaluate their organizational workflows and internal processes. As a result, payers are more closely evaluating which CAPS partners will be ideal for long-term partnership in the dynamic healthcare environment.

1. Claims Processing for Non-Medical Services

One significant trend is the integration of claims processing for non-medical services. To support members holistically, payers are addressing social determinants of health (SDOH) by facilitating claims for services beyond traditional medical care. Examples of covered SDOH services include community-based programs—such as housing stabilization and emergency food access—as well as transportation to and from appointments. These offerings help support broader member needs, leading to better clinical outcomes, lower long-term care costs, and greater member satisfaction.

2. Low-Friction Support for Price Transparency and Interoperability

A regulatory focus on pricing transparency is driving payers to adopt integrated CAPS solutions that support low-friction access to updated pricing information. Delivering accurate pricing information not only satisfies compliance mandates but also empowers members to make more informed healthcare choices, fostering trust and improving satisfaction. Interoperability is the cornerstone of compliance for payers working across technology systems and disparate data sources, helping ensure seamless information sharing between stakeholders and across platforms.

3. Adoption of API & FHIR Capabilities

Data integration is vital for delivering accurate pricing information, enhancing the provider and member experience. The adoption of Application Programming Interface (API) and Fast Healthcare Interoperability Resources (FHIR) capabilities is a critical aspect of this strategy. These standards enable the efficient exchange of healthcare data between systems, empowering payers with the most accurate and up-to-date information available.

4. Transition to Commercial Cloud Hosting 

An industry-wide shift toward commercial cloud hosting demonstrates a significant increase in health plans’ agility and scalability in the market. By leveraging cloud services, payers can reduce IT overhead costs by reducing or eliminating the need for on-site hardware and servers. Cloud-based solutions also make it easier to increase data security and deploy updates more quickly—which are vital to earning and maintaining trust in the rapidly evolving healthcare industry.

5. Self-Serve Member & Provider Portals

When it comes to member engagement and support, healthcare consumers have high expectations. They’re looking for personalized, digital experiences that they can access when it’s convenient for them.

Investing in easy-to-navigate self-service portals can be valuable tools for improving member engagement and delivering more personalized support. Member care management apps or resource portals serve as hubs for provider communication, personalized resources, coverage information, and other valuable services. Solutions like these can empower members with the information they need at the right time, helping them make more informed health decisions while fostering trust in their health plan.

6. Value-Based Care Administration

Value-based care models have gained prominence in the healthcare industry and are redefining health plan operations. To take full advantage of the outcomes-based care model, health plans must shift their focus to prioritize care quality over service volume. If payers invest in CAPS solutions with robust analytics and performance tracking, they will be well-positioned in the evolving market.

Trends across the healthcare industry are pushing payers to invest (or reinvest) in CAPS solutions that facilitate data integration, transparency, and high care quality. Effectively leveraging capabilities like these can enhance operational efficiency and position health plans as trusted partners within the healthcare ecosystem. For leaders willing to adapt and embrace modern CAPS solution, there is no shortage of potential.

HealthRules® Payer is more than a health plan core administrative processing system—it is a revolutionary tool tailored to meet the demands of the modern healthcare industry. By leveraging cutting-edge technologies, including artificial intelligence (AI), HealthRules Payer provides payers with the efficiency, agility, and competitive advantage necessary to stay ahead of the market.

Not sure what to expect when it comes to a CAPS implementation? Check out our eBook, “5 Steps to a Successful CAPS Implementation”.