Executive Strategies for Balancing Costs and Quality for Health Plans 

By: Raj Sundar and Ryan Mooney

At HealthEdge®, we strive to understand the key challenges health plans face so we can help anticipate and address new market opportunities. Recently, HealthEdge Chief Strategy Officer, Raj Sundar, and Chief Product Officer, Ryan Mooney, led a panel of healthcare leaders to discuss a critical issue: managing mounting cost pressures.  

Panelists included: 

• Vice President of Operations at a Minnesota-based health plan 

• Senior Vice President of Operations at a regional Pennsylvania-based nonprofit healthcare company 

• Chief Performance Officer at an Arizona-based health plan 

Hear directly from health plan leaders as they share strategies for addressing cost pressures and driving operational efficiency by focusing on provider collaboration, artificial intelligence (AI), and integrating digital solutions. 

How is your health plan reducing administrative costs without compromising quality? 

Vice President of Operations: One effective strategy is to implement upfront code editing in collaboration with providers. By introducing edits at the point of claim submission, invalid diagnosis codes and similar errors are addressed before entering the system.  

This approach minimizes unnecessary claim processing, reduces resubmissions, and allows for more timely corrections. Although some providers may require time to adapt to electronic data interchange (EDI) rejections, this method has significantly improved operational efficiency. 

We also rely heavily on prepayable reports. After a claim completes its adjudication cycle but before it’s paid, we run analytics to identify potential errors. This is far more efficient than running reports after payment to process adjustments. Moving this analysis upfront prevents incorrect payments and eliminates the rework associated with them. We’re now starting to measure our rework rate to find additional opportunities to remove these inefficiencies from the system. 

Senior Vice President of Operations: We’re a Dual Eligible Special Needs Plan (D-SNP), and when we think about reducing administrative costs while maintaining the member experience, our top two member call reasons are requests for a physical ID card and a printed provider directory. So, how do we automate that? We’ve implemented a system where members can call, push a button, and have an ID card mailed to them without speaking to an agent. Similarly, they can request a provider directory for their specific zip code. This automation has significantly reduced call volume, which is a great way to lower administrative costs in the call center and maintain a positive member experience. 

“Within 6 months of introducing two-way messaging, average handle times dropped by 35%.” – Chief Performance Officer at an Arizona-based health plan 

 How have you improved member and provider service channels to drive efficiency? 

Chief Performance Officer: In April 2025, the primary service channel for both members and providers was phone-based support. Within 6 months of introducing two-way messaging between care teams and members, operational efficiencies increased significantly: Average handle times dropped by 35% in the member call center and by about 40% in the provider call center.  

Many provider inquiries focused on claim status, so resources have been dedicated to developing a digital ecosystem that enables self-service and real-time access to essential information. This digital transformation not only accelerates response times but also empowers users with direct access to the tools and data they need. 

The Role of Value-Based Care and Provider Collaboration 

What early successes can you share about bridging collaboration with providers? 

Chief Performance Officer: For value-based care (VBC) to succeed, providers and payers must work together. Success depends on establishing clear key performance indicators, tracking them regularly, and showing members the benefits of this payment model. We’ve seen per-member-per-month (PMPM) costs decrease with VBC providers compared to those not in VBC arrangements. Key metrics we monitor include primary care provider visits versus emergency room visits and PMPM rates for both medical and pharmacy, with weekly data exchanges that help ensure alignment and progress. 

With more members aging into Medicare Advantage who want digital tools for self-care, this collaborative focus is essential. We have an entire team organized around VBC to manage our Medicare Advantage population, and this collaboration helped us achieve a 4.5-star rating. It’s about giving providers the information they need and getting beneficial information from them in return. 

Leveraging Technology for Greater Efficiency 

What are some of the specific technologies you’re using that are really working to drive costs down? 

Senior Vice President of Operations: The first thing that comes to mind is Robotic Process Automation (RPA). Our third-largest call driver is members needing to change an address or phone number, so we use RPA for data-entry-heavy processes like claims and enrollment.  We also use RPA in credentialing, from information gathering to loading data into our system. This has been incredibly efficient, allowing us to launch in two new states without hiring additional staff to manage provider data. 

Beyond RPA, machine learning is powerful for population health activities. When it comes to AI integration, we recently implemented a solution to analyze cost drivers. With Medical Loss Ratios increasing significantly, we need data quickly. Now, we can ask our AI tools a simple question like, “How many childbirth claims did I have this year?” and get an accurate answer in seconds. These tools help us jump into trends and solve for cost drivers rapidly. We’ve also used large language models (LLMs) to write policies for new markets, which has phenomenally reduced the time it takes to stand up operations. 

Chief Performance Officer: We’ve dipped our toe into summarizing calls in our call center and have seen that help us significantly. Our organization has a pillar focused on AI for the next year, as it will be a huge driver for automation and efficiency. We’ve gone to all of our vendor partners to see their AI roadmaps and where they are adopting the technology. We saw some great things from HealthEdge with Agentic AI within claims processing that we’re hoping continues to grow and takes us where we need to go. 

“The cleaner your provider data is, the better your go-live will be. We went live in a new state and, two months later, had over 92% auto-adjudication. When you’re paying 92% of claims within 24 hours, you don’t get the phone calls asking about claim status. ” – Senior Vice President of Operations 

Expanding to New Markets While Driving Efficiency 

What was your strategy for expanding into new markets and lines of business? 

Senior Vice President of Operations: Provider data, one hundred percent. The cleaner your provider data is, the better your go-live will be. We went live in a new state and, two months later, had over 92% auto-adjudication. This was possible because we started analyzing provider data and reaching out to providers from day one of the project to understand their billing practices. 

Getting that data pristine across all platforms—clinical, CRM, and claims—is what differentiates the outcome. It means you don’t need to hire temporary staff or additional claims processors for manual work. When you’re paying 92% of claims within 24 hours, you don’t get the phone calls asking about claim status. 

Vice President of Operations: I’d echo that provider data is key. We’re sitting at a 94% auto-adjudication rate, and a lot of that is due to our partnerships with providers. Ensuring we get accurate and timely data as changes occur is critical to preventing logjams in claims processing. 

Chief Performance Officer: Provider data remains a significant challenge for us as we transition from a legacy system that has been in place for over 30 years. We are moving very old legacy provider data systems into new technology and working to resolve data integrity issues that frequently cause claims to fall into workbaskets for manual review. It’s very much an ongoing journey for us. Adding to the complexity, a new state regulation will require us to credential a provider in just 45 days, cutting our timeline in half from the previous 90 days. This change will require significant acceleration in our processes to meet the new requirements, so we’re actively working to address this. 

The Future of Health Plan Efficiency 

Navigating today’s complex health plan landscape requires collaboration, accurate data, and innovative solutions. By leveraging these strategies, organizations can better address challenges and adapt to the evolving needs of the healthcare industry, ensuring more effective and sustainable outcomes for all stakeholders. 

Learn more about how integrated AI tools can help health plans achieve measurable improvements in operational efficiency, care delivery, and member satisfaction. Download the data sheet: Achieve Superior Health Outcomes and Operational Efficiency with AI-Powered Care Solutions.