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To stay ahead of complex payment models and billing guidelines, healthcare payers are turning to integrated digital solutions that can help streamline operations to achieve key business goals. Approaching payment integrity using disparate systems often results in unnecessary reworks and higher administrative costs. With an enterprise payment accountability approach, health plans can avoid improper payments and reduce recovery fees.

Payment Accountability®: A Proactive Approach to Payment Integrity

Payment Accountability® from HealthEdge Source™ shifts the focus from post-payment recovery to proactive cost avoidance practices. By integrating claims processing workflows and optimizing pre-pay processes, health plans can reduce processing times and strengthen financial performance.

A Comprehensive Solution for Greater Control

HealthEdge Source Platform Access empowers health plans to enhance payment integrity at every level. Advanced analytics, custom editing tools, and real-time insights give payers more control over their payment processes, and achieve key benefits such as:

• Root-cause detection: By analyzing historical claims data, health plans can uncover policy gaps, identify outliers, and detect configuration issues before they lead to costly errors.
• Quick & easy adjustments: Advanced Custom Editing lets health plans quickly create and customize edits and analyze past claims for increased accuracy. This simplified eliminates delays and reduces dependence on external vendors for execution and maintenance.
• Enhanced transparency and control: With a centralized platform, health plans gain real-time visibility into their payment integrity processes—helping ensure payment accuracy and regulatory compliance.

Our integrated technology, combined with our consultative partnership, helps health plans proactively manage claims processing and payments. HealthEdge  Source platform gives health plans greater control over their intellectual property, addresses root cause issues, and eliminates recurring administrative waste to support enterprise payment accountability.

Payer-Source Integration

The Payer-Source integration between HealthEdge Source and  HealthRules® Payer will be another pivotal step towards achieving an enterprise approach to payment integrity. By connecting all claims processing functions through a single platform, HealthEdge Source empowers health plans to manage their payment integrity programs more effectively. This effort enhances transparency between core platform and payment integrity functions.

By aligning disparate functions into a unified system, health plans can benefit from:

• Improved Payment Accuracy: Libraries of pricing and editing data, updated biweekly, lay the groundwork for industry-leading accuracy.
• Holistic Claims Adjudication: Editing can be applied effectively at multiple stages of the workflow, minimizing errors and reducing redundancies.

This centralized approach creates a bottom-line impact for enterprises, improving productivity while reducing overhead costs associated with fragmented systems.

Real-World Impact: Transforming a National Health Plan 

A major national health plan partnered with HealthEdge Source to address key challenges with achieving payment accuracy and workflow efficiency. The health plan leveraged the HealthEdge solution suite to streamline claims processing and payment management across the organization.

After adopting the integrated HealthEdge Source solution, the health plan accomplished notable improvements across performance and financial goals. Key achievements include:

• 30-40% reduction in resource-intensive contract maintenance
• Managed 70% self-funded business on a single platform
• Eliminated processing delays and improved claims transparency

• “The flexibility, configurability, and transparency of HealthEdge Source have been pivotal in our journey, resulting in measurable savings and operational improvements,” said the payer’s VP of Operations shared. “This partnership has truly transformed our approach to payment accuracy and operational efficiency.”

With the abilities to continually adapt to both competitive market demands and evolving regulatory requirements, the organization’s enterprise-wide payment integrity transformation positions it for long-term success and industry leadership.

Opportunities in Payment Accountability

Disruption isn’t just about changing for the sake of change. It’s about understanding that yesterday’s systems weren’t built to handle tomorrow’s demands. Health plans should recognize the need to challenge outdated norms in favor of strategies that position them for long-term success.

By embracing a coordinated, technology-driven approach to payment integrity, health plans can move beyond cost savings to set new standards in transparency, accountability, and operational excellence—ensuring they are ready for the challenges of tomorrow.

See how a provider-owned health plan leveraged the HealthEdge Source Payment Integrity solution to streamline operations, improve accuracy, and enhance provider transparency. Read the case study: SummaCare’s Secret to Payment Integrity Success

 

The healthcare industry is evolving at a rapid pace. Regulatory demands, shifting consumer expectations, and the need for data-driven decision-making are placing unprecedented pressure on health plans. The challenge is clear—how can payers remain competitive while meeting the growing complexities of modern healthcare?

This is where a next-generation Core Administrative Processing System (CAPS) like HealthRules Payer comes in. Designed to empower health plans with real-time data and unparalleled flexibility, this innovative system enables organizations to expand offerings and serve new member markets with ease.

How Health Plans Can Expand to New Markets with Modern CAPS

Health plans operate in an increasingly demanding environment. The traditional, hard-coded administrative systems of the past are ill-equipped to keep up with today’s healthcare landscape. A next-generation CAPS solution does more than process claims and manage benefits—it becomes the foundation for achieving strategic growth, operational efficiency, and superior member experiences.

With a next-generation solution like HealthRules® Payer, health plans can:

• Understand diverse member populations with real-time data and analytics.
• Quickly configure and launch new benefits offerings.
• Expand into new markets to capture valuable growth opportunities.

By leveraging a modern CAPS, health plans can move faster, adapt smarter, and make better-informed decisions—all while lowering administrative costs.

Real-World Transformations with HealthRules Payer

Health plans of all sizes have chosen HealthRules Payer as a technology partner for its ability to scale, adapt, and transform payer operations. See an overview of how three different health plans leveraged the HealthRules Payer CAPS solution to configure new offerings and expand to new markets.

Medica Health Plan

Medica, a regional health plan managing over 1 million lives, partnered with HealthEdge to streamline existing lines of business and expand its benefit offerings by reducing time to market.

Key Achievements:

• Configured 81 benefit plans in just 10 days using only four resources.
• Responded to new market opportunities in real time, leveraging accurate and actionable data.
• Automated manual processes across existing business lines, significantly reducing administrative costs.

“Data is the most valuable asset that health plans have.”

-VP of Business Transformation at Medica.

McLaren Health Plan

McLaren faced mounting inefficiencies with its outdated legacy system, including a low auto-adjudication rate. With the integrated CAPS solution from HealthRules Payer enabled McLaren to modernize their operations and respond to industry changes faster—which better positions the organization for long-term growth.

Key Achievements:

• Achieved a 90% auto-adjudication rate, reducing reliance on manual claims processing.
• Increased operational efficiency, allowing staff to reallocate resources toward innovation.
• Seamlessly expanded membership to 620,000 lives, bolstering business performance.

“HealthRules Payer has made reporting better and quicker, enabling us to operate with greater efficiency as we scale.”

-VP of Business Information & Operations at McLaren Health Plan.

Presbyterian Health Plan

Processing over 9 million claims annually, Presbyterian Health Plan required a flexible CAPS to manage growing complexities and maintain compliance. They leveraged the HealthRules Payer solution to automate claims processing, improve responsiveness, and adapt to shifting industry demands.

Key Achievements:

• Reduced claims turnaround time to under 5 days, ensuring prompt provider payments.
• Increased staff productivity by 30%, measured by the number of claims processed per hour.
• Enhanced benefits configuration efficiency by 40%, enabling rapid product launches.

“The configuration capabilities within HealthRules Payer are phenomenal. We’ve been able to make changes in half the time it took us previously.”

-VP of Claims Operations at Presbyterian Health Plan

What Sets HealthRules Payer Apart from other CAPS solutions

HealthRules Payer offers distinct advantages that make it a go-to choice for health plans seeking to modernize their administrative systems. Here’s what differentiates it:

1. Flexibility, Scalability, and Resilience

The HealthRules Payer CAPS is designed for flexibility and scalability, allowing payers to adapt to regulatory shifts, market trends, and emerging member needs for long-term viability.

• Real-Time Data Insights: Access accurate data instantly to make informed decisions and respond to opportunities ahead of competitors.
• Regulatory Compliance: Easily modify rules, produce auditable information, and adapt to regulatory requirements without disrupting operations.
• Faster Time-to-Market: Configure, review, and deploy new benefit offerings with unmatched speed and precision.

For McLaren Health Plan, this adaptability enabled rapid adaptation to industry changes, providing a significant edge in a competitive market.

2. Adaptability to New Business Models

The healthcare landscape is shifting from fee-for-service to value-based care (VBC), requiring payers to adopt more complex reimbursement structures. HealthRules Payer excels in enabling value-based reimbursement by:

• Designing and implementing benefit plans in less time and at lower costs than traditional systems.
• Sharing critical insights from data analytics with providers, improving performance metrics and creating stronger partner relationships.

For example, HealthRules Payer’s natural language capabilities have improved first-call resolutions at Presbyterian Health Plan, building trust and reducing callbacks—a direct reflection of enhanced service and data transparency.

3. Automation and Efficiency

Move away from manual workarounds and legacy inefficiencies. HealthRules Payer automates major processes, driving seamless operations that save both time and money. From claims processing to reporting, automation fosters:

• Higher accuracy
• Reduced operational costs
• Scalable business expansion

For example, Medica’s adoption of HealthRules Payer eliminated costly manual processes, improving productivity across Individual & Family, Medicare, and Commercial Group business lines.

The Competitive Edge for Health Plans

By implementing HealthRules Payer, health plans gain more than just operational efficiency—they secure a competitive advantage. Some key benefits include:

• Faster Response Times: Adapt to regulatory changes and industry demands in record time.
• Cost Efficiency: Lower administrative costs with streamlined, automated operations.
• Market Growth: Launch differentiated offerings ahead of competitors, capturing new members and revenue streams.
• Superior Member Experience: Deliver accurate, personalized service with easy-to-access data and insights.

With health plans increasingly vying for consumer loyalty, having a robust CAPS solution provides the tools needed to stand out in a crowded marketplace.

Do you want to learn more about how the next-generation CAPS from HealthRules Payer can empower your health plan to expand to new markets? See how a regional health plan achieved a 90% auto-adjudication rate, opened new lines of business, and expanded to new states. Read the case study.

Health plan members no longer seek transactional healthcare interactions—they expect personalized, accessible, and engaging experiences. For health plans, meeting these expectations isn’t just desirable—it’s essential. To meet this increasing demand, payers are investing in integrated solutions that can help them streamline workflows, deliver personalized care, and empower members.

These solutions not only enhance member satisfaction and clinical outcomes but also give payers a competitive edge in an increasingly complex market.

This blog explores how leading health plans are investing in care management workflow software, AI tools, and self-service digital resources to deliver world-class member experiences and boost CMS Star Ratings.

The Shift Toward Personalized Care

Today’s healthcare consumers want to feel like more than just policy numbers. They want healthcare options that offer the convenience, clarity, and customization they’ve come to expect with their retail experiences. According to recent surveys, 59% of members expect health plans to prioritize health equity, while 52% cite a demand for self-service tools.

Personalized care has more benefits than just meeting members’ expectations. It can also help improve health literacy, increase preventive care utilization, and contribute to better care outcomes. The value of personalization for health plans goes far beyond member satisfaction—engaged members are healthier members, which translates to fewer hospitalizations, greater satisfaction, and higher retention rates.

To meet member expectations, health plan executives are turning to three core digital investments.

Top Areas of Digital Investment for Healthcare Payers 

Health plan leaders strategically dedicate resources to technologies that drive operational efficiency, reduce administrative burdens, and place members at the center of their strategies.

1. Care Management Workflow Software 

Care management workflow software provides the critical infrastructure to streamline and optimize care delivery. These tools improve coordination between care teams, reduce inefficiencies, and enable real-time data sharing for seamless decision-making.

GuidingCare® is an industry-leading solution that integrates care management, population health, and utilization management into a unified platform. With features like automated care planning and advanced care coordination tools, GuidingCare helps payers deliver whole-person care while freeing up staff to spend more time engaging directly with members.

Benefits of Care Management Workflow Software:

• Efficient Workflow Automation: Streamlines processes, reducing time-intensive manual tasks.
• Personalized Interventions: Supports tailored solutions by identifying high-risk members and alerting providers.
• Seamless Communication: Breaks down internal silos to help ensure care teams, providers, and members can communicate more effectively.

2. Artificial Intelligence  

AI is already making an impact in healthcare, with its potential to provide actionable insights, automate repetitive tasks, and predict outcomes with precision. For health plans, incorporating AI tools allows for resource allocation and streamlined decision-making.

In addition, AI-powered predictive analytics can identify high-risk members who need immediate attention, enabling plans to proactively engage these individuals and close gaps in care before conditions worsen.

How AI Benefits Health Plans:

• Early Identification of High-Risk Members: AI can forecast member health risks and recommend timely interventions.
• Improved Administrative Efficiency: Automates claims processing and fraud detection, saving valuable resources.
• Higher Member Satisfaction: AI tools can help personalize communications, making members feel valued.

3. Self-Service Digital Resources 

Instead of traditional phone calls, members increasingly demand the convenience of self-service tools that give them access to their health history, benefits information, and care programs. Empowering members to manage aspects of their health journey not only improves satisfaction but can also increase member touchpoints and extend existing resources.

The GuidingCare integration with Wellframe delivers digital checklists and personalized health reminders, helping members stay engaged with their care plans. Wellframe offers more than 70 digital care programs, an on-demand resource library, and personalized daily health checklist that supports members wherever they are on their health journeys.

Benefits of Self-Service Tools:

• Empower Members: Enable members to check coverage details, schedule preventive screenings, and access educational content.
• Reduce Friction: Lower costs and make healthcare services more accessible and transparent.
• Enhance Member Engagement: Provide reminders and tools aligned with the member’s unique health goals. Members who use the Wellframe solution average 34 interactions per member per month.

Real-Life Impact: Nonprofit Health Plan

One nonprofit health plan partnered with HealthEdge® to modernize its digital care solutions. By integrating GuidingCare with HealthRules® Payer, the payer was able to reduce administrative fragmentation and offer its million-plus members a better, more efficient healthcare experience. This transformation improved data accuracy and strengthened member trust—essential elements in a competitive healthcare marketplace.

The healthcare industry is being reshaped by rapid advancements in technology, and health plans must adapt to thrive. By investing in these innovative tools, health plans can create meaningful member experiences, improve health outcomes, and stay competitive in a field where personalization is the key differentiator.

Learn more about the trends driving health plan investment and modernization. Download the HealthEdge Annual Payer Market Planning Report 2025

Health plans face a variety of challenges when it comes to contract modeling, negotiations, and reviews. A reliance on manual processes and disparate tools can make it difficult to accurately evaluate the financial impacts of new provider contracts.

In a recent webinar, healthcare industry experts shared their experiences working with health plans to improve accuracy and scalability in the contract review process. This blog highlights key insights from the virtual session that can help transform hypothetical conversations into actionable, data-driven negotiations.

5 Challenges Health Plans Face During Contract Negotiations

During the webinar, we polled the audience to better understand their major challenges. 80% of respondents said, “inefficiencies due to manual processes” were their primary concerns, followed by “lack of accurate insights into contract terms.”

What is the biggest challenge your health plan faces during contract negotiations?

• Inefficiencies due to manual processes (80%)
• Lack of accurate insights into contract terms (20%)

1. Manual Processes: Many health plans still rely on outdated tools, such as spreadsheets and pivot tables, to model contract scenarios. These manual methods are error-prone, time-consuming, and inflexible, leading to delays in negotiations and decision-making.

2. Lack of Accurate Insights: Without timely and accurate information, health plans struggle to understand the financial implications of certain contract terms. This includes challenges in analyzing how payment term changes affect reimbursements or savings, hindering their ability to make informed decisions.

3. Disjointed Systems and Data Sources: The workflows for contract negotiations often involve disparate tools and systems. These siloed environments make it hard to analyze and reconcile data, leading to unnecessary complexity when assessing contractual impacts.

4. Configuration Challenges: After contracts are finalized, health plans sometimes discover that the terms cannot be efficiently configured into their existing claims processing systems, causing operational bottlenecks and delays in implementation.

5. Lag Time Between Contract Finalization and Execution: There is often a gap between signing a contract and getting it fully operational. This lag time can result in delays in reimbursement or improper payments, creating friction between stakeholders.

These challenges not only create inefficiencies that cost time and resources but also compromise the accuracy of contract modeling.

What-If Modeling: Our Vision for a Better Solution

At HealthEdge Source™, our team is developing a solution to eliminate these challenges by bringing advanced technology and seamless workflows into the contract negotiation process. The HealthEdge Source What-If Modeling tool will allow health plans to envision, evaluate, and execute contract scenarios with unprecedented precision.

During the webinar, we demonstrated the solution and asked what participants found most valuable about the tool for their organizations. The top answers were:

• Real-time modeling of contracting change (33%)
• Comprehensive variance reports (33%)
• User friendly interface and ease of use (33%)

Increasing Contract Value for Health Plans 

• Automation and Real-Time Modeling: HealthEdge Source What-If Modeling is designed to replace manual processes with automated workflows, allowing health plans to build, test, and analyze contract configurations in minutes. Health plans will also be able to model complex scenarios in real time, significantly reducing the time and effort required to optimize contracts.
• Precision in Financial Insights: With penny-precise modeling for various reimbursement terms, health plans will be able to better anticipate the financial impacts of their contracts with greater accuracy, increasing confidence in projections and negotiations.
• Unified Platform for Disparate Processes: The new tool will bring together all critical functions—such as claims editing, pricing, and advanced analytics into a single platform. This will eliminate the need for multiple disparate systems and create a cohesive environment for assessing data and contracts.
• Self-Service Accessibility: With a user-friendly interface, the solution will empower contract negotiation teams to independently configure, compare, and adjust contract terms. Teams will be able to run “what-if” scenarios to evaluate potential impacts without relying on external support.
• Seamless Integration with Existing Systems: It will integrate smoothly as a modular component of  HealthEdge Source. It can also function as a standalone system, allowing health plans to leverage the tool within their existing ecosystems.
• Reduced Lag Time: The tool will directly convert modeled contracts into production-ready configurations, significantly reducing the time needed to operationalize agreements. This will help ensure accurate reimbursements from the start, while preventing downstream inefficiencies and rework.

HealthEdge Source What-If Modeling will support various complex contract structures, including carve-outs for specific services (e.g., ER visits) or alternative payment models like capitation. These features were developed to make it easier for health plans to negotiate and model deals that align with their financial objectives and operational capacities.

Supporting a Collaborative Approach to Change 

With the tool, health plans can bridge the gap between contracting and configuration teams, encouraging collaboration that helps determine whether contract terms are feasible. By identifying potential configuration issues during the modeling phase, health plans can minimize surprises and shorten implementation time. This approach can also help reduce provider abrasion and better inform contracting teams of the potential impact of custom configurations.

The Road Ahead for What-If Modeling

We invite you to watch the webinar recording to see a demo of the HealthEdge Source What-If Modeling tool in action and learn more about its functionalities. Discover how this innovative solution can transform your contract modeling process and deliver unparalleled precision and efficiency. Watch the webinar on-demand

Together, we can transform the way health plans approach contract modeling and create impactful results. If you’d like to contribute feedback or participate in our beta testing phase, we’d love to hear from you! Current customers can reach out to their Customer Success Managers for more inform

The complex landscape of state and federal healthcare regulations continues to evolve, requiring payers to invest in technologies that support their compliance efforts. Next-generation Core Administrative Processing Systems (CAPS) can be adaptable and scalable solutions that help provide resilience to market changes.

1. Coverage and Pricing Transparency

Regulations like the No Surprises Act (NSA) and Transparency in Coverage Final Rule focus on protecting health plan members from surprise out-of-network costs. Compliance requires that payers have access to accurate and updated pricing data in order to configure relevant services and deliver personalized information to members. To ensure compliance, health plans must be able to easily implement payment policies and deliver accurate and automated payments.

2. Interoperability and Prior Authorization

Increasingly, healthcare regulators are emphasizing the importance of interoperability and streamlined data sharing. Technology adoption skyrocketed after the COVID-19 pandemic, highlighting the need for integration between care management solutions and other health technologies. This includes leveraging Fast Healthcare Interoperability Resources (FHIR) across digital solutions to enable seamless and secure data exchange, as well as support compliance to the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).

2025 is also a year of preparation for health plans, as they improve prior authorization processes ahead of the finalized enforcement anticipated in 2027.

3. Increase Market Visibility with New Lines of Business

Health plan members—especially Medicare members—have a variety of choices when it comes to healthcare coverage. And their expectations for a health plan experience are high. To retain and attract members, payers are increasingly looking for ways to improve member experiences and build their trust.

Health plans have new opportunities to debut and expand lines of business. Whether to meet new demands from the Centers for Medicare & Medicaid Services (CMS) or take advantage of the rise of individual products and exchanges, health plans must stay on top of industry shifts to maintain their market positions. Updated healthcare CAPS can help payers bring new and differentiated benefits to the market in less time, giving payers more flexibility to meet a variety of member needs while remaining competitive.

Next-Generation CAPS Features that Support Compliance

These are just a few of the regulations health plans must abide by. Noncompliance results in expensive fines and increases abrasion with providers and members—especially when it comes to government lines of business. To meet these demands, payers are investing in digital technologies that can break down data siloes, deliver actionable insights, and streamline workflows to reduce manual operations.

Three key CAPS features that support regulatory compliance include:

Flexible configuration options. Payers must be able to easily configure payment policies for NSA, out-of-network, and emergency services based on member needs.

Automated claims adjudication. Flexible payment structures allow payers to make accurate and automated payments using accurate and timely data.

Personalized price comparison tool. A next-generation CAPS can empower payers to deliver personalized cost-sharing information to members.

Gain Access to Advanced Compliance Support with HealthRules® Payer

The HealthRules® Payer solution delivers the agility and adaptability payers need to maintain regulatory compliance, design and implement benefit plans, and serve the needs of members and stakeholders. Real-time API empowers payers to generate accurate claims details before scheduled services and increase payment automation.

HealthRules Payer, designed specifically for complex needs of healthcare payers, leverages the exclusive HealthRules Language™ to facilitate necessary configuration changes.

What else is HealthEdge doing to support health plans to maintain regulatory compliance? When it comes to the HealthRules Payer solution, our team is dedicated to monitoring state and federal regulations to identify new guidance that may impact our payer customers.

See how your health plan can leverage a modern CAPS to stay flexible and maintain a competitive edge in the healthcare market. Read our blog post to learn more: Leverage Next-Generation CAPS to Drive Competitive Advantage and Adaptability

The Centers for Medicare & Medicaid Services (CMS) has raised performance benchmarks for Medicare Advantage (MA) and Part D plans, raising the bar for achieving high Star Ratings. By excluding the lowest-performing plans from calculations, CMS has effectively raised the “cut points,” meaning that health plans must improve their performance across multiple measures to attain or sustain a 4+ Star Rating each year.

Adjustments to the 2025 CMS Star Ratings

Due to annual adjustments to CMS Star Ratings, health plans are operating in an increasingly competitive environment and must elevate their overall performance to succeed. Examples of the impact of the 2025 Star Ratings include:

• Decline in High-Rated Plans. In 2025, only 40% of MA plans with drug coverage earned four stars or higher, compared to 42% in 2024. Yet, when weighted by enrollment, about 62% of Medicare Advantage-Prescription Drug (MA-PD) enrollees are in plans with four or more stars, a drop from 74% the previous year.
• Fewer 5-Star Plans. Only seven contracts received a 5-star rating in 2025, down from 38 in 2024. This signals a dramatic shift for some health plans, potentially affecting new member enrollment and CMS payments.

The decline in quality ratings reflects that CMS continues to focus on improving overall healthcare quality rather than measuring the advances of individual health plans.

Implications of CMS Star Rating Changes for Health Plans

The 2025 Star Ratings pose several challenges for health plans:

• Difficulty and Volatility to Achieve High Star Ratings. Over 60% of cut points have risen, which means plans must improve performance across many measures to maintain ratings.
• Reduced Bonus Payments. Fewer plans are expected to achieve 4+ stars, limiting bonus payments and potentially funds for supplemental benefits, which are important for attracting and retaining members.
• More Focus on Member Experience and Care Management Quality. With increased emphasis on member service, access, and medication adherence, plans need more robust digital engagement and personalized care to enhance outcomes.
• Need for Real-Time Adjustments. Ongoing regulatory changes demand real-time analytics to identify care gaps and adjust strategies quickly.
• Competitive Landscape. Stricter standards may prompt members to switch to higher-rated plans, complicating the member retention efforts of health plans.

How GuidingCare® and Wellframe™ Support Star Rating Improvement

Health plans can enhance Star Ratings by focusing on improving member engagement and streamlining care management to improve the quality of care. By adopting next-generation digital solutions, health plans can improve performance through exceptional care coordination, personalized member outreach, and data-driven insights that directly address key Star Rating measures.

Care-Wellframe is an integrated solution that combines HealthEdge’s care management platform, GuidingCare, with the Wellframe digital member experience platform to transform how health plans serve their members. The following are key ways that the integrated Care-Wellframe solution helps health plans elevate performance:

Enhanced Member Engagement

• Personalized Digital Care:Wellframe’s mobile-first programs and daily checklists improve member engagement, satisfaction, and outcomes, which are vital to Star Ratings. By providing reminders and self-service content tailored to individual needs, Wellframe enhances engagement.
• Medication Adherence: Wellframe’s tools include medication reminders, improving adherence which directly impacts Star Ratings.
• Access to Care: Digital communication channels reduce barriers to quick intervention and enhance member satisfaction by enabling seamless access to care teams.

Streamlined Care Management and Coordination

• Efficient Workflows: Care-Wellframe centralizes member data to enable seamless coordination and reduce administrative burdens.
• Automated Processes: GuidingCare supports care teams by streamlining caseload management, assisting with adherence to CMS requirements, and facilitating consistent follow-ups with members.
• Integrated Communication: Care-Wellframe enables seamless communication among members, care teams, and providers. This facilitates proactive management of high-risk conditions, screenings, and overall care quality.
• Holistic Care Management: By integrating physical, behavioral, and social determinants of health (SDOH) data, Care-Wellframe provides a comprehensive view of member needs, supporting coordinated, whole-person care.

Continuous Quality Improvement

• Real-time Analytics: Care-Wellframe offers advanced analytics that help health plans track compliance and close care gaps.
• Predictive Tools: The solution’s predictive capabilities help identify high-risk members and prioritize interventions, helping care teams take the right actions to improve compliance with care plans and achieve better outcomes.

Digital care management supports improved member experiences,

better outcomes, and high Star Ratings.

With CMS raising the bar for Star Ratings, health plans need comprehensive, adaptive solutions to stay competitive. Leveraging Care-Wellframe’s next-generation capabilities enables health plans to continuously improve member care and engagement, putting plans in the best position to thrive and enhance competitiveness in the ever-evolving healthcare landscape.

See how your health plan can improve Star Ratings by improving member engagement and satisfaction. Read our blog, “How health plans can increase member satisfaction and engagement using digital care management.”

Visit healthedge.com to discover how the integrated Care-Wellframe solution can help your plan achieve its Star Rating goals.