Cut Administrative Costs Up to 40% With an Integrated Operating Model 

For the second consecutive year, 52% of health plan executives named “managing rising costs” as the top challenge, according to the 2026 HealthEdge® Annual Payer Report.

In the same survey, 85% of executives reported that regulatory compliance requirements directly cut into their margins. Health plans using HealthEdge HealthRules® Payer enter this environment with the advantage of a next-generation core administrative processing system (CAPS) designed specifically for these challenges. The next opportunity is to expand that advantage across your organization’s workflows by adopting an integrated operating model.

From Next-Generation Software to a Modern Operating Model

HealthRules Payer delivers capabilities that legacy systems cannot match, including rapid configuration, high auto-adjudication rates, and the flexibility to quickly adapt to regulatory changes.

Across the industry, health plans that have modernized their CAPS still operate within traditional organizational structures and practices. Internal teams, external vendors, and contracts are organized by function, each with its own disparate accountability and performance tracking. That model leaves significant operational value on the table because of persistent inefficiencies like:

• Low visibility & fragmented accountability. Separate teams and vendors manage claims, enrollment, billing, and member services, each under distinct contracts and using unique performance tracking. This reduced transparency prevents cross-functional collaboration and efficiency.
• Downstream lag on configuration changes. The platform adjusts rapidly, but the operation around it may take weeks to catch up. Retraining staff, updating enrollment procedures, and revising compliance documentation all follow separate timelines.
• High administrative costs. Without operational transparency and integration, staffing overhead and managing multiple vendors can dilute the efficiency gains HealthRules Payer delivers.
• Compliance execution that remains reactive. Each regulatory change triggers a cross-team operational scramble managed as a special project rather than an adaptable, repeatable workflow.

These are operating model challenges and, left unaddressed, they compound. Technical debt grows, capital stays locked in maintenance, and the ability to expand into new markets or new lines of business narrows. Overcoming these challenges requires integrated platforms that can handle rapid modernization to deliver outcomes.

An Integrated Operating Model with Guaranteed Financial Outcomes

Moving to a modernized operating model is a structural change. Software ownership gives way to outcome accountability. Siloed systems and multiple vendor relationships give way to an end-to-end operating ecosystem managed by a single partner.

The HealthEdge integrated operating model consolidates technology, operational processes, and a dedicated global service delivery team under a single governance structure and set of service-level agreements (SLAs). The partner who builds the platform is also the one who operates it and is accountable for the results, with contractually guaranteed cost reductions tied to defined performance measures.

This is a different approach than patching point solutions onto an existing environment or layering new tools on top of an outdated operating structure. Those practices may address some symptoms, but they can add costs and do not change the underlying model. An integrated ecosystem replaces the model itself.

Across current deployments, health plans operating within this model have achieved:

• 30–40% reduction in administrative cost per member per month (PMPM), sustained year-over-year.
• Return on investment (ROI) within 12–15 months, compared to 24–36 months under multi-vendor approaches.
• Budget variance below 1%, against an industry benchmark of 10–15%.

With HealthEdge, these are contractual commitments—not projections.

Turning a Technology Advantage into an Operational One

For health plans already operating on HealthRules Payer, the integrated operating model means having a dedicated team with deep expertise in the platform, acting as an extension of your organization to ensure that investment works harder across every function.

One Accountable Partner, End to End

HealthEdge owns the platform, the global operations delivery team, and the outcomes. Vendor sprawl and split accountability are replaced by a single point of responsibility for performance, backed by shared risk. Ongoing platform upgrades and regulatory updates are included at no additional cost.

Configuration Changes That Execute at Platform Speed

When a benefit rule, pricing change, or regulatory update is configured in HealthRules Payer, the downstream operational response is managed by one team at a rapid pace. New lines of business that take months under traditional models can launch in days.

Administrative Costs Decrease and Stay Down

Standardized work processes, automated task processing, and economies of scale across a global delivery team of more than 7,000 drive 30–40% reductions in health plan administrative costs, sustained year over year. Savings are tied to process enhancement rather than headcount reduction. You pay for measurable results, not employee hours or resource inputs.

Compliance Built into Daily Operations

Centers for Medicare and Medicaid Services (CMS) mandates like the Transparency in Coverage final rules, state requirements, and audit readiness tools are embedded into standard workflows within HealthRules Payer. Plus, regulatory changes are operationalized as they arrive.

Real-Time Visibility Across the Full Operation

A centralized data hub in the platform surfaces performance data through unified executive dashboards. Backlogs, SLA risks, and compliance exposure become visible before they become problems.

Leadership Reclaims Time for Strategy

When a single partner manages daily execution and owns the outcomes, health plan leadership moves capacity toward growth and member experience.

The HealthEdge advisory team works alongside health plan leadership from day one to ensure operational continuity.

The New Operating Model in Practice

One regional health plan moved to an integrated ecosystem model, unifying core administration, claims, enrollment, billing, correspondence, and member services under a single HealthEdge operating structure in fewer than 12 months.

The payer’s administrative spend dropped from $11.50 to $6.90 per member per month (PMPM), a reduction of approximately 40%. Claims accuracy reached best-in-class levels, and the plan reported EBITDA uplift across every function in the model.

Operational improvements like these are still the exception among health plans, though they are available to any organization. Adopting a fully integrated technology-and-operations model can help put your health plan at the forefront of the adoption curve, giving your organization a competitive advantage.

Learn more about the power of an integrated operating model in action. Download our case study to see how one health plan successfully migrated its entire ecosystem under pressure and achieved a 99.8% auto-adjudication rate.

A Practical Way to Get Started Now

HealthEdge offers a cost-driver assessment that builds a baseline of current administrative spend, identifying where costs originate and where an integrated model would generate the greatest return. Whether a health plan moves forward with HealthEdge or not, the assessment delivers an independent, practical view of the current operation.

Contact us to learn more.