HealthEdge's Strategic Vision for the Future
The healthcare payer market is at a critical juncture, driven by increasing market pressures, consumer demands, and the need for technological modernization. At HealthEdge®, we believe payers have the opportunity to transform challenges into opportunities by leveraging cutting-edge tools and next-generation solutions. With over 110 million covered lives using our platforms and a proven track record of innovation, HealthEdge is uniquely positioned to empower payers to advance administrative efficiencies, improve patient outcomes, and make complex operations more cohesive.
This blog outlines the core components of HealthEdge’s vision, addressing current market forces, the challenges payers face, and how HealthEdge delivers actionable solutions that align with future industry needs.
Industry Pressures for Healthcare Payers
The payer landscape is undergoing an immense transformation, influenced by shifts towards value-based care models, rising cybersecurity threats, and increased regulatory demands around interoperability. Additionally, organizations face growing pressure to contain costs and enhance operational efficiency.
Some of the most prominent payer industry pressures include:
- Decreasing Margins: Payers face significant financial strain due to record-high medical and labor costs and rate changes
- New Products and Value-Based Care: Payers need to manage complexity associated with implementing innovative product design and value-based payments
- Security Risks: Recent cyber security breaches have increased payer focus on ensuring deployment of infrastructure and technology to manage potential threats
- Need for Data Interoperability: Payers are under significant (regulatory) pressure to improve interoperability and enhance patient engagement and outcomes
This is coupled with the emergence of advanced technology:
- Opportunity for AI and Automation: 97% of payers expect to increase funding for generative AI (approximately 40% spend increase)
- Critical service cost savings can only be realized with a next-gen underlying code
- Technical Flexibility:83% of payers expect to increase funding for app modernization (approximately 30% spend increase)
- Payers can only manage increasing complexity with robust core technology
- Cloud: 80% of payers expect to increase investments in the cloud (approximately 30% spend increase)
- Moving to the cloud is essential for payers to maintain robust stability while scaling and managing security
- Mobile and Cross-System Compatibility:90% of payers expect to increase funding integration tech (approximately 20% spend increase)
- Payers need a connected system that enables better patient engagement and stakeholder collaboration
These challenges have created an ‘inflection point’ for healthcare payers, signaling a clear need for solutions that offer operational resilience and enable transformational change. The modernization of IT systems is critical for healthcare payer CIOs, with digital payers being 3x more likely to achieve above-industry revenue and margin growth.
HealthEdge’s Vision for an Optimized Future
At HealthEdge, our vision is to innovate a world where healthcare can focus on people. Our mission is clear: to drive healthcare transformation through a single digital ecosystem that delivers advanced automation and clinical engagement among healthcare payers, providers, and patients.
With a strong foundation of products and a forward-thinking approach to innovation, we aim to revolutionize payer operations while keeping customer needs at the forefront.
The HealthEdge Ecosystem: Delivering Synergies with Scalability
Healthcare payers need a partner that not only understands their challenges but also provides a clear roadmap for overcoming them. HealthEdge delivers this by addressing payer concerns at both the administrative and strategic levels.
Integrated Benefits to Core Operations
Unlike standalone solutions, HealthEdge product combinations result in highly synergistic, integrated benefits to payers’ core operations.
Benefits of Integrated Digital Solutions:
- HealthRules® Payer + HealthEdge Source™:
- Accelerates accurate adjudication by incorporating pre-adjudication pricing and editing in one call
- Reduces strain on payer IT infrastructure by providing integrated support services
- HealthRules Payer + HealthEdge GuidingCare®Ensures appropriate-utilization by ensuring utilization and care managers have access to real-time benefits and claims information
- Facilitates accurate claims adjudication by HealthEdge GuidingCare submitting appropriate claims prior auth information to HealthEdge HealthRules Payer in required format
- HealthEdge Wellframe™ + GuidingCare
- Decreases duplicate data entry in clinical platforms
- Integrates and streamlines communication between member, provider and payer
- Aggregates member data to establish best practices that improve care journey recommendations
- Wellframe + HealthEdge Provider Data ManagementSynthesizes real-time provider information to ensure the latest credentialing, directories, and repositories are accurate and accessible to members seeking care
- HealthRules Payer + HealthEdge Provider Data Management
- Eliminates data mismatches in provider information between systems and timely updates provider data in claims processing to reducing claim delays, denials or rework
These synergistic benefits allow organizations to achieve cost savings, improve scalability, enhance compliance and ultimately, deliver better member experiences. Combinations of three or more products further emphasize the value of HealthEdge’s product suite offering and provide outsized returns to payers.
Core System-of-Record and Mission Critical Solutions
HealthEdge provides the core system-of-record and mission critical solutions that enable key payer technology workflows.
HealthEdge Core Solutions
Claims Management
HealthEdge HealthRules Payer helps payers manage and adjudicate claims submitted by providers. It serves as the integrated source of truth for payer tech stacks
Payment Integrity
HealthEdge Source provides a range of pre-pay capabilities with a differentiated pricing solution (and also includes claims editing)
Care Management and Digital Member Engagement
HealthEdge GuidingCare streamlines and automates care management workflows. At the same time, HealthEdge Wellframe enables digital member engagement and integrates with HealthEdge GuidingCare to facilitate clinical and administrative communication with members
Provider Data Management
HeathEdge’s Provider Data Management solution creates a “golden record” of provider data – it ingests, enhances, and distributes provider data to all other required systems and processes.
HealthEdge Enabled Solutions
Business Strategy
HealthEdge HealthRules Payer provides critical business intelligence to shape payer strategy, including analyzing customer segments and identifying profitability improvement opportunities
Product Development
HealthEdge HealthRules Payer and HealthEdge Source provide critical data to inform pricing and actuarial; data also informs refinement of existing products and build of new products
Marketing and Sales
Payers leverage combination of customer and HealthEdge HealthRules Payer data to respond to RFPs and set pricing using data analytics
Enrollment and Billing
Payers enroll members in respective systems to ensure products and benefits are configured properly and submitted claims are paid promptly and accurately via HealthEdge HealthRules Payer
4 Core Pillars of the HealthEdge Innovation Strategy
HealthEdge’s future vision is anchored by four strategic pillars, which serve as guiding principles for our solutions and organizational goals.
1. Touchless Transaction Processing
Our vision is seamless integration, with the long-term benefit of 100% touchless transaction processing in production. We envision a future where all transactions can be processed without human intervention, creating meaningful operational efficiencies for payers.
2. Payment Accuracy Transformation
Our vision is the elimination of payment recoveries with 99%+ payment accuracy. By integrating pricing and edits capabilities upstream, our solutions can eliminate administrative overhead, reduce provider abrasion, and enable accurate payments.
3. Care Integrity Optimization
Our vision is to increase care delivery effectiveness to optimize medical spend and payer performance. Our solutions GuidingCare and Wellframe work in tandem to optimize the care patients receive.
4. AI-Powered Business Intelligence
Our vision is to drive analytics for benchmarking, next-level operational insights, and proactive recommendations. Our approach to AI revolves around consolidating fragmented data and making it actionable, empowering organizations to make data-driven decisions in real time.
A Future Built on Innovation and Collaboration
While the healthcare payer landscape keeps evolving, our commitment to delivering innovative solutions remains constant. HealthEdge’s vision is centered not just on creating premium technology but enabling payers to experience the business attributes of improved end-user and consumer centricity, ever-reducing transaction costs, ever-increasing quality and ever-increasing service levels and business transparency.
Are you ready to explore a smarter, more efficient way forward? Discover how HealthEdge can help your organization adapt, optimize, and thrive amidst today’s challenges.
