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Health plans must balance cost containment, efficiency, and member satisfaction to remain successful in the rapidly evolving healthcare landscape. However, many plans struggle to fully optimize their technology investments, missing out on significant financial and operational benefits. Solutions like HealthRules® Payer, HealthEdge Source™, GuidingCare®, and Wellframe™ from HealthEdge® offer powerful capabilities—but without strategic optimization, health plans may be unable to maximize their return on investment.

HealthEdge’s Global Professional Services has helped hundreds of health plans unlock new efficiencies, automate critical processes, and drive down administrative costs. By leveraging these optimization initiatives, health plans can realize substantial savings while improving overall operational performance.

Below are 10 key factors health plans should consider when evaluating the ROI of system optimization. The  in this post can be found in the 2024 CAQH Index Report published in February 2025[1].

1. Dramatically Reduce Administrative Costs

The U.S. healthcare industry spends approximately $440 billion annually on administrative complexity, accounting for nearly 12% of national healthcare expenditures. By optimizing electronic transactions, health plans can save up to $20 billion per year. Automated solutions reduce labor-intensive processes, resulting in fewer manual interventions and lower administrative overhead.

2. Improve Auto-Adjudication Rates for Faster Claims Processing

Roughly 85% of claims today are auto-adjudicated, yet 15% still require manual review—often the most complex and costly claims. Manual claims processing can take days or even weeks and cost up to $25 per claim. Increasing auto-adjudication rates through system optimization can significantly cut processing times and costs, reducing outstanding claims and improving provider satisfaction.

3. Enhance Prior Authorization Efficiency and Cost Savings

Prior authorizations remain one of the most burdensome administrative tasks, with processing costs rising 22% year-over-year. Health plans can save $515 million annually by shifting to electronic prior authorization systems. The cost per manual prior authorization is $5.28, compared to $0.07 when done electronically—a savings of $5.21 per transaction.

4. Reduce Claim Errors and Rework Costs

The error rate in claims adjudication is 6.5% for commercial insurance claims. Reworking a single claim costs an average of $28. By optimizing claim validation and coding accuracy, health plans can reduce denials, minimize rework, and improve first-pass rates, leading to significant administrative savings.

5. Speed Up Provider Payments for Improved Relationships

Health plans that optimize their claims and payment workflows can accelerate provider reimbursements. Currently, manual claim payments cost up to 40% more than electronic transactions. With better integration and automation, health plans can reduce payment cycles, improving provider trust and network engagement.

6. Increase Member Satisfaction Through Faster Service

Delays in eligibility verification, prior authorizations, and claims processing contribute to poor member experiences. Optimized systems reduce approval times, minimize paperwork, and enable real-time processing, leading to a more seamless member journey. This enhances member engagement and can contribute to higher retention rates.

7. Free Up Employees for Strategic Initiatives

By automating repetitive administrative tasks, health plans can reallocate staff time toward higher-value activities such as care management, provider relations, and strategic planning. This not only improves employee satisfaction but also strengthens operational effectiveness.

8. Enhance Regulatory Compliance and Reduce Audit Risk

With evolving regulations like the No Surprises Act and CMS interoperability mandates, health plans must ensure compliance while avoiding penalties. Optimized systems can automate compliance checks, improve reporting accuracy, and enhance data transparency, reducing the risk of costly audits and fines.

9. Mitigate Cybersecurity Risks Through Advanced Technology

Cyber threats to healthcare systems are increasing, and outdated technology poses significant risks. By modernizing and optimizing IT infrastructure, health plans can strengthen security measures, reduce vulnerabilities, and ensure data integrity, protecting both member and provider information.

10. Maximize the ROI of Your HealthEdge Investment

HealthEdge’s Global Professional Services team specializes in helping health plans fully leverage their investments in HealthEdge solutions. Through strategic optimization, organizations can increase automation rates, enhance system capabilities, and drive down costs, ensuring that every dollar spent on technology delivers maximum value.

Get Started with Strategic Optimization

The cost-saving potential of health plan technology optimization is undeniable. From reducing administrative waste to improving auto-adjudication and streamlining provider interactions, optimizing solutions like those from HealthEdge can deliver significant savings and operational excellence.

Discover more about HealthEdge Optimization Services today and see how we can help you drive optimization initiatives that save money, enhance efficiency, and improve member and provider experiences.

1 All statistics in this post can be found in the 2024 CAQH Index Report published in February 2025.

If you’re responsible for managing a health plan, you’ve probably felt the strain of payment processes that don’t work as they should. Payment errors pile up, outdated systems slow you down, and fragmented data blocks you from seeing the full picture. Worst of all, these inefficiencies cost you time and money—and they cost your members, too.

With HealthEdge Source™ Platform Access, we’re making your operations easier to manage, helping you eliminate waste and save on costs. Here’s how Platform Access helps tackle the big issues holding health plans back.

Top 4 Challenges in Payment Integrity

If you’ve been dealing with payment integrity challenges, the following challenges probably sound familiar. Incorrect payments, vendor management, siloed information, and inefficient workflows can slow your processes and damage your reputation with providers—in addition to the financial costs.

1. Frequent Payment Errors

One-third of medical claims in the U.S. are paid incorrectly each year, leading to in waste from duplicate charges, coding issues, and other billing problems. These inefficiencies aren’t just a nuisance—they unnecessarily consume vital resources from your health plan and your members.

2. Too Many Vendors, Too Little Control

use two or more payment integrity vendors to manage their processes. While this piecemeal approach might seem comprehensive, it often creates inconsistent workflows, higher costs, and limited visibility into your operations.

3. Siloed Data Chaos

When your billing, claims, and clinical data are spread across separate systems, how do you connect the dots? Data silos cause delays, incorrect billing, compliance risks, and missed opportunities to improve care, making them a major pain point for many health plans.

4. Clunky, Outdated Workflows

Legacy IT systems slow down claim processing and leave your teams stuck in endless administrative loops. This creates bottlenecks, drains resources, and forces your organization to over-rely on manual processes that can’t keep up with today’s fast-paced healthcare demands.

These challenges eat up time and resources, making it harder for your teams to focus on what really matters—taking care of your members and building trust with providers.

Platform Access as a Comprehensive Solution

Platform Access from HealthEdge Source tackles these challenges with a fresh approach, giving health plans more control by improving visibility into their payment integrity processes. This offering simplifies claims processing by gathering your payment workflows into one easy-to-manage system, cutting out the need for multiple vendors and disparate systems.

By addressing payment errors at the source, you can stop payment mistakes before they snowball into bigger problems. Your health plans can get real-time insights into your workflows, so you can catch issues early, work more efficiently, and focus on delivering better care while keeping costs under control.

Root-Cause Detection

The Platform Access solution dives deep into your claims data to find and fix the root cause of errors. It stops mistakes, like coding and policy misalignments, before they require a large-scale, expensive fix. Claims rework, currently an issue for

Custom Editing Tools for Faster Adjustments

Advanced editing tools allow your health plan to create custom rules, implement changes on your timeline, and reduce dependence on external vendors. Advanced Custom Edits from HealthEdge Source uses current claim conditions, historical claim conditions, and relational criteria to create custom edits that maximize efficiency and improve payment accuracy.

One System, Full Visibility

Managing fragmented solutions from disparate vendors is inefficient. The HealthEdge Source solution brings payment data and processing together into one system, giving your health plan real-time oversight of your workflows. This centralization makes compliance, reporting, and root-cause analysis easier, while fostering transparency between payers and providers.

Analytics That Guide Savings

don’t just solve today’s problems—they help you prepare for tomorrow’s, too. Predictive tools like these can identify potential risks and help your health plan optimize contracts, reduce unnecessary spending, and flag issues before they impact your bottom line.

Break Down Silos

Platform Access tackles the challenges of siloed data by connecting information from billing, electronic health record (EHR) systems, and financial systems into one integrated platform. Instead of chasing fragmented data, you’ll make decisions based on full, unified insights.

Achieve Key Operational Goals with Platform Access

When you streamline inefficiencies with Platform Access, the results speak for themselves. Improving your Medical Loss Ratio (MLR) becomes achievable by reducing payment errors and unnecessary vendor fees, freeing up more of your budget for patient care instead of administrative costs.

Lower administrative expenses are another win for payers. By eliminating waste and connecting workflows, you can reinvest those savings into other strategic goals. Providers also feel the impact, as accurate and timely payments build trust and reduce disputes, creating smoother collaborations. Ultimately, these improvements position your health plan to offer more competitive pricing without compromising the personalized service your members value.

The healthcare industry is changing, and health plans that don’t adapt risk falling behind. HealthEdge Source Platform Access offers a comprehensive solution to tackle the major challenges of payment integrity, providing your health plan with more control, visibility, and efficiency. By fixing payment errors at their root, consolidating vendors, and breaking down data silos, you save money, streamline workflows, and, most importantly, deliver better care to your members.

At HealthEdge Source, we aim to be more than another payment integrity solution. Our mission is to be the solution to payment integrity, supporting your health plan and solving these challenges together—because real change takes a true partner.

Discover how Platform Access from HealthEdge Source can help transform your payment integrity workflows and improve efficiency. Learn more.

 

 

Healthcare payers experience consistent pressure to update and modernize their technology systems to meet evolving industry demands. From regulatory compliance to meeting member expectations and adapting to value-based care models, the opportunities are nearly endless. This is where a next-generation Core Administrative Processing System (CAPS), such as HealthRules® Payer, can make the difference.

A modern CAPS solution doesn’t just solve immediate operational inefficiencies—it empowers health plans to build an integrated technology ecosystem, thrive in complex markets, and stay ahead of the competition.

Seamless Integration with Existing Technologies

Healthcare payers often rely on outdated and disconnected systems, leading to data siloes and bottlenecks of manual reviews. These inefficiencies create unnecessary costs and barriers to innovation. A modern CAPS provides the seamless integration required to elevate operational efficiency.

Breaking Down Data Siloes

Legacy systems make integrating various technologies—such as Payment Integrity, Care Management, and Member Engagement tools—challenging. A robust CAPS eliminates these siloes by fostering real-time data exchange and seamless interoperability.

For example, HealthRules Connector, a feature of HealthRules Payer, simplifies integration with third-party systems, partner networks, and exchanges. With this, health plans benefit from:

• Faster implementations
• Lower integration costs
• Accelerated time-to-market

Proactive System Testing

Integration isn’t just about connecting systems—it’s also about ensuring reliability. A best-in-class CAPS enables automated testing to identify and resolve data disruptions or bottlenecks before they impact operations. This testing reduces downtime, increases precision, and improves provider and member satisfaction.

Real-World Impact

For instance, one health plan used HealthRules Payer to integrate payment solutions, member portals, and care management systems seamlessly. The result? Reduced manual errors, real-time data sharing, and an adaptable technology foundation.

Access Actionable Business Insights

Modern healthcare leaders need accurate, real-time data to make informed decisions. A next-generation CAPS serves as the backbone for data-driven business insights, ensuring health plans can monitor performance, anticipate challenges, and optimize operations.

Real-Time Data for Better Decision-Making

A modern CAPS like HealthRules Payer provides access to performance metrics across specific lines of business, enabling you to:

• Analyze underperforming products
• Monitor provider performance in value-based contracts
• Gain a complete view of member utilization trends

These actionable insights empower IT decision-makers and healthcare payers to stay one step ahead in the competitive landscape.

Compliance and Member Satisfaction

Regulatory requirements are non-negotiable in healthcare. A next-generation CAPS helps ensure compliance with features like HIPAA-compliant audit logs to track historical records. Additionally, tools like HealthRules Payer’s Benefit Predictor and Trial Claim improve member satisfaction by offering personalized, transparent experiences.

Being prepared for audits and offering member-centric tools fortifies trust and ensures smooth operations, even in the face of regulatory scrutiny.

Health plans like McLaren Health Plan implemented HealthRules Payer to track operational inefficiencies and improve data-sharing transparency with providers. The results included lower administrative costs and improved member outcomes.

Build and Deliver New Business Models

Adapting quickly to market demands is one of the most pressing needs for healthcare payers. A next-generation CAPS is essential for designing innovative benefit plans, adopting value-based care models, and scaling efficiently over time.

Rapid Implementation of New Benefits

Unlike legacy systems, HealthRules Payer enables healthcare payers to design and launch new benefit plans faster, thanks to customizable templates and streamlined workflows.

For example:

• Health plans can model complex pricing methodologies and tailor benefit plans more efficiently
• Real-time communication tools keep providers informed on the progress of contracting, population health strategies, or value-based agreements

Perfect Fit for Value-Based Care

The shift toward value-based care requires plans to manage intricately linked payment and benefit models. A CAPS solution designed for adaptability enables quick configuration of these models while keeping administrative costs low. With HealthRules Payer, you can facilitate seamless data-sharing with providers to keep performance goals aligned.

Scalability for Future Growth

Business expansion demands flexibility. A next-generation CAPS grows with your health plan, supporting seamless integrations, robust testing, and go-to-market strategies, so you’re ready for every opportunity.

Medica Health Plan, a regional provider managing over one million lives, leveraged HealthRules Payer to launch 81 new benefit plans in just ten days. Efficient modeling and automation allowed them to capture new markets while reducing administrative overhead.

Why Choose HealthRules Payer for Your Next-Generation CAPS?

Not all CAPS solutions are created equal. HealthRules Payer stands out as a comprehensive platform combining financial, administrative, and clinical integration.

Here’s what sets HealthRules Payer apart:

• Seamless ecosystem integration through the HealthRules Connector
• Real-time data exchange to reduce inefficiencies
• Scalable architecture that adapts to future demands and growth
• Automation tools that minimize reliance on manual processes
• Regulatory compliance at the forefront of operations

With over 100 standard third-party interfaces and seamless integration capabilities, HealthRules Payer empowers health plans with the tools to stay flexible, innovative, and competitive.

Transform Your Health Plan Today

The healthcare industry is rapidly evolving, and health plans need modern systems to thrive. A next-generation CAPS like HealthRules Payer is no longer optional—it’s a necessity.

By enabling seamless integration, improving data-driven insights, and facilitating new business models, a modern CAPS positions your health plan as a leader in innovation and member satisfaction.

Discover how a health plan built a member-centric digital ecosystem with HealthRules Payer.

Healthcare doesn’t wait—and neither should your health plan. Take the next step today.

 

For health plans, payment errors and discrepancies aren’t just frustrating—they can be costly. Without access to updated pricing information, health plans face payment delays and inaccuracies that can negatively impact provider relationships, regulatory compliance, and administrative processes.

Many payers rely on a patchwork system of point solutions to address individual business needs. While disparate systems may work well for their specific niche, a network of disparate tools can lead to siloed data, cumbersome workflows, and a reliance on manual intervention. An integrated digital ecosystem can empower your health plan to respond faster to market demands and scale your offerings.

HealthEdge Source™ breaks the paradigm of disjointed point solutions by integrating the industry’s leading third-party payment integrity solutions directly into a unified ecosystem. This approach helps payers directly address inefficiencies while providing actionable insights and analytics.

3 Benefits of an Integrated Payment Integrity Solution

A third-party payment integrity ecosystem rewrites how payers approach payments and billing, creating clarity while enhancing operational outcomes. Here’s what the shift to an integrated solution can do for your organization.

1. Reduce Administrative Burdens

Every new vendor a payer adopts comes with its own learning curve—oversight responsibilities, system compatibilities, and manual review processes can take valuable time away from strategic action. It’s not uncommon for payers to find themselves juggling multiple vendor contracts, managing system redundancies, and comparing siloed data from disparate systems.

For example, HealthEdge Source delivers automated updates to help streamline workflows, ensuring your systems stay up to date without requiring manual intervention. The solution also automates fee schedule updates, allowing payers to reclaim critical hours and focus on achieving organizational goals.

Integrating third-party tools can be a game-changer. For one HealthEdge Source customer, the integrated solution led to a 30-40% reduction in resource-intensive contract maintenance processes. By embedding pricing, compliance, and editing solutions directly into the payment integrity ecosystem, payers can reduce their reliance on disconnected systems to streamline workflows and reduce administrative burden.

2. Driving Cost Savings

Efficiency and accuracy can help drive cost savings for healthcare payers. From minimizing vendor contracts to automating updates, the scalability of integrated payment integrity tools enables payers to capture immediate savings—and sustain those reductions over time.

By aligning teams around a unified third-party ecosystem, payers can reduce the hidden costs of operational silos. Whether it’s avoiding duplicated effort, cutting contract negotiation delays, or auto-adjudicating claims with high accuracy, streamlined functionalities create long-term financial advantages for payers.

For one health plan, leveraging the HealthEdge Source solution led to a 500% increase in savings. The integrated pricing and editing functions allowed the payer to achieve these significant saving by streamlining processes and reducing manual intervention.

3. Compliance Confidence

Keeping up with consistent regulatory updates (like the No Surprises Act and updates from the Centers for Medicare and Medicaid Services (CMS) is a never-ending task for health plans. Falling out of compliance isn’t simply an inconvenience—it can damage provider relationships, tarnish payer reputations, and lead to significant penalties.

Compliance with evolving regulations begins and ends with accurate, accessible information. HealthEdge Source helps simplify this process by embedding compliance updates within the ecosystem, ensuring you remain aligned with the latest mandates. For instance, automatic CMS fee schedule uploads every two weeks guarantee health plans operate with current policy information. Additionally, automated features—like real-time claims adjudication—help ensure accuracy.

With these safeguards in place, payers aren’t rushing to adjust systems or scrambling in response to regulatory shifts. Instead, they operate with confidence, delivering value to both providers and members.

Discover the Third-Party Ecosystem Built for Growth

HealthEdge Source transforms its integrated ecosystem into more than just a platform—it’s a strategic partner that evolves with you. By incorporating third-party payment integrity solutions into one centralized system, the solution eliminates unnecessary complexities while enabling smarter decision-making.

Key advantages of the HealthEdge Source solution include:

• One-Stop Access to Top Solutions: Industry-leading libraries like RJ Health and FAIR Health are embedded directly into the solution.
• Automated Updates: Continuous updates to the solution and available data reduce the workload for your team.
• Reduced IT Overhead: HealthEdge Source doesn’t require custom coding or high-maintenance integrations.
• Proactive Cost Savings: Innovations like auto-adjudication and customizable workflows deliver ongoing value.
• Future-Proof Compliance: Easily adapt to new regulations without system overhauls.

From the American Society of Anesthesiologists’ billing data to real-time fraud prevention tools from Codoxo, every element of the HealthEdge ecosystem is designed to enhance accuracy, elevate outcomes, and diminish inefficiencies across the board.

Healthcare leaders know that piecemeal solutions can’t keep pace with modern demands. HealthEdge Source weaves together the industry’s best third-party solutions into a unified ecosystem that’s built to scale and evolve. By integrating editing, pricing, and compliance solutions in one system, payers can achieve unprecedented levels of clarity and precision.

Leave the inefficiencies behind—learn more about how HealthEdge Source can help your health plan leverage integrated third-party payment solutions and make sure you’re prepared for the future of payment integrity.

Medicaid programs nationwide are increasingly requiring and incentivizing health plans to incorporate whole-person care and the social determinants of health (SDOH) into their service models. Recognizing SDOH’s significant influence on health outcomes and costs, Medicaid programs are encouraging payers to move beyond traditional clinical care and focus on holistic approaches that address the underlying social needs of vulnerable and high-risk populations.

Initiatives such as California’s CalAIM exemplify this shift, implementing high-touch member services and support for housing, food, and other physical, behavioral, and social needs. These efforts are especially important for high-risk populations.

Similarly, other state programs, including North Carolina’s Healthy Opportunities Pilot, Michigan’s Health Equity Project, and Arizona’s Whole Person Care Initiative, challenge payers to adopt integrated care strategies that meet members’ social needs alongside their medical needs. These programs set new care management standards, often requiring partnerships with community organizations to deliver services that can positively impact long-term health outcomes.

Integrating SDOH into Digital Care Management

Adapting to these new standards calls for a comprehensive approach to addressing SDOH. This is where technology platforms integrated with social care networks, such as Unite Us, become essential. The integrated GuidingCare and Unite Us solution provides health plans with the ability to seamlessly coordinate social services, creating a more efficient, impactful whole-person care model that aligns with evolving Medicaid requirements across the U.S.

By incorporating SDOH data into the GuidingCare platform, care managers can gain a 360-degree view of their members’ health, allowing for more personalized and effective care plans. This holistic approach addresses not just clinical care needs through GuidingCare but also provides referrals to services that improve social and environmental factors, which significantly impact health outcomes

What Is Unite Us?

Unite Us is a technology company that builds coordinated care networks of health and social service providers. Their platform offers health plans access to one of the nation’s largest networks of social service providers, enabling efficient referrals for housing, food, transportation, and employment services across the United States.

The GuidingCare and Unite Us SDOH Integration

The integration between GuidingCare and Unite Us enables seamless data exchange and document sharing directly within the GuidingCare interface.

Key benefits of this integration include:

• Improved Interventions. GuidingCare users can effectively identify social care needs, refer members to appropriate services, confirm service delivery, and track outcomes.
• Access to Coordinated Care Networks. The Unite Us coordinated care network allows care managers to connect members to a wide range of social services and resources within GuidingCare.
• Holistic View of Member Health. Care managers have access to a comprehensive view of members’ health, covering both clinical and non-clinical factors that impact outcomes.
• Improved Quality Measures. By addressing social factors, health plans can positively impact member outcomes while strengthening their organization’s quality measures
• Streamlined Workflow. SDOH interventions can be efficiently incorporated into care plans and managed directly within the GuidingCare platform.

GuidingCare and SDOH

The integration with Unite Us is just one part of HealthEdge’s broader approach to embedding SDOH data into care management workflows. By systematically incorporating SDOH into the GuidingCare platform, health plans can better adapt to evolving Medicaid programs. Care managers, in turn, can efficiently coordinate whole-person care and connect members to vital services.

HealthEdge is committed to innovation, collaboration, and delivering solutions that address all aspects of members’ health. To learn more about how GuidingCare’s SDOH integrations can transform healthcare for your organization, visit our website or contact us today. Together, we can work towards a healthcare system that addresses all aspects of members’ health.