Improve Claims Operations & Efficiency with HealthEdge Source™ Professional Services

Maintaining efficient claims processing workflows can become an overwhelming task for many health plans. Claims teams have to process every claim accurately and on time, keep up with changing rules, and meet the expectations of both providers and members.

Doing all this work with internal teams alone can leave health plans juggling multiple systems, relying on manual processes, and constantly creating new configurations. With shifting regulations and workloads piling up, it’s easy for mistakes, delays, and frustration to creep in.

The challenges only magnify for large-scale operations. Health plans that manage millions of claims each year will find that even a 1% error rate in claims processing can result in millions lost to overpayments, with added costs to correct mistakes, respond to audits, and restore the trust of members and providers.

4 Common Challenges in Claims Operations

Managing complex workflows, constant regulatory changes, and a flood of incoming claims isn’t easy. Mistakes and bottlenecks are bound to happen. Keeping everything running smoothly requires consistent attention. Here are 4 of the top claims processing challenges that can impact performance, drive up costs, and create friction across many health plans:

1. Escalating administrative costs

In 2023, a report from Council for Affordable Quality Healthcare (CAQH) found that the medical industry spends $83 billion annually on administrative tasks—like verifying eligibility, coordinating benefits, submitting claims, compliance reporting, and fixing errors. These rising costs take a big toll on health plans, shrinking financial margins and funding available for member care, which can adversely affect medical loss ratio (MLR). As manual processes and inefficiencies persist, health plans face real challenges in staying compliant, adaptable, and cost-effective.

2. Inaccurate payments and overpayments

Across the healthcare industry, it’s estimated that 3% to 7% of claims contain errors, though some health plans report inaccuracies exceeding 10%. In 2024, 16 federal agencies reported $162 billions in improper payments, with over $135 billion attributed to overpayments. These payment errors lead to labor-intensive audits, repeated provider outreach, and potential reputational damage.

3. Keeping pace with regulatory changes

The Centers for Medicare & Medicaid Services (CMS) issues new rules and updates every year—sometimes several times a year—on both a fiscal and calendar schedule. For health plans, this means constantly adjusting to new requirements, reporting changes, and payment system updates. These ongoing changes add additional complexity to claims processes and stretch internal teams as they try to interpret, implement, and keep pace with each update. It’s easy to fall behind, and even a small oversight can disrupt daily operations or risk compliance. As the pace of regulatory changes picks up and expectations grow, maintaining compliance becomes a constant, high-stakes challenge for health plans.

4. Resource strain and workforce fatigue

With medical costs projected to rise by 8% year-over-year, health plan teams are under growing pressure to manage expenses while also responding to escalating demands from members, providers, and other key stakeholders. At the same time, healthcare staff face widespread burnout and fatigue, driven by high work intensity and long hours. As requirements multiply and resources remain limited, the risk of missed deadlines, errors in compliance, and staff turnover grows. These intertwined challenges make it increasingly difficult for health plans to keep teams effective while adapting to an environment defined by relentless change and rising expectations.

Simplify Claims Processing with HealthEdge Source™ Professional Services

HealthEdge Source Professional Services make it easier for payers to manage the increasing demands on internal teams and digital solutions. The HealthEdge Source Professional Services team works directly with health plan users to address specific organizational challenges—whether it’s managing heavier workloads, navigating complex regulations, or supporting overwhelmed teams.

At HealthEdge®, we don’t just implement the technology and walk away. We provide hands-on support and practical solutions to alleviate pressure where it’s needed most. Our goal is to simplify daily tasks, help maintain compliance, and give your team time to focus on meaningful work instead of small, repetitive tasks. With Professional Services, health plans receive expert support so they can adapt and move forward, even with ever-growing demands.

Claims Solution Implementation & Configuration

Every health plan has its own way of working, so our team meets payers where they are. We start by reviewing workflows, identifying how existing systems connect, and outlining a plan that fits specific organizational goals. Working side by side with the health plan team, we customize system settings, business rules, and workflows to fit each team’s needs. This hands-on, data-informed process ensures the final setup aligns with a health plan’s operational goals and regulatory standards.

In addition, our team sets up automated processes that take care of repetitive tasks like claims validation and contract updates. With this approach, health plans have seen up to 50% faster configuration times and as much as a 90% reduction in managed configuration. Our goal is to get claims teams up and running with fewer disruptions to increase benefits from smoother processes, fewer errors, and more time for high-value work from day one.

Providing Ongoing Support

Support doesn’t stop at launch. We provide regular system updates and monitor performance to keep systems running smoothly. Our team works alongside payers to adjust workflows and settings as regulations and business needs shift. With proactive steps like quarterly regulatory briefings and hands-on training for new rules, we have seen up to 30% faster turnaround time for updates and adoption of changes.

Frequent check-ins and direct user access to our technical experts mean issues get caught early and audit findings are kept to a minimum, so operations stay on track. This ongoing support helps health plans respond quickly to industry changes, maintain compliance, and ensure consistent day-to-day performance.

Enhancing Payment Integrity

We use advanced analytics and data studies to help health plans identify the root causes of payment errors, like inconsistent contract terms or misapplied policy rules. By analyzing claim patterns and operational data, we create targeted edits and corrective actions to fix these recurring issues. Health plans we’ve worked with have seen up to 50% faster savings realization from edits compared to traditional methods.

We work closely with health plans to validate improvements and monitor results, making sure payment accuracy is achieved and maintained over time. By creating a feedback loop between analytics, operations, and system configurations, we help payers improve financial performance, maintain compliance, and adapt to industry changes.

How A Regional Health Plan Streamlined Maintenance & Helped Ensure Claims Accuracy

One large regional health plan, supporting commercial, Medicaid, and Medicare members, ran into daily problems with contract consistency and managing the volume of contract updates. Duplicate records and missing information kept popping up as they tried to keep everything current across their systems. Plus, the constant flow of policy updates meant their teams were always working to avoid falling behind on compliance.

HealthEdge Source stepped in with a hands-on support model designed to address these ongoing issues. Our subject matter experts worked closely with the plan to streamline contract maintenance and ensure accuracy. We provided dedicated support through bi-weekly release note walkthroughs, summary matrices, and actionable recommendations, making it easier for the plan to adapt to regulatory changes and integrate updates efficiently. A dedicated support analyst was assigned to guide the team through new requirements and enhance readiness for upcoming changes, allowing the plan to focus on strategic priorities.

As a result of partnering with HealthEdge Source, the health plan was able to:

• Eliminate duplicate contract records and improve overall reliability
• Realize significant reduction in manual contract maintenance efforts through consistent, expert-led support
• Maintain compliance with evolving regulations
• Improve workflow efficiency, freeing up staff to focus on advancing core objectives
• Strengthen operational readiness to respond quickly without disrupting daily operations

What’s Ahead for Payment Integrity?

Health plans deal with complex challenges every day—handling them alone often leads to more risk and higher costs. The HealthEdge Source team offers the expertise and support health plans need to keep operations accurate, accountable, and efficient.

Set your organization up to handle whatever comes next with confidence. Check out our resources to learn more about Professional Services offerings from HealthEdge Source.