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The Foundation: End-to-end Business Automation

Health plans have historically struggled with high operational costs, often driven by a combination of complex business processes and manual-intensive workflows that require human intervention and decision-making. In an effort to reduce costs, most health plans have tried to implement software systems that automate repeatable processes. However, the automation remain confined to functional silos, and spreadsheet gymnastics remain the dominant way to share data between systems and lines of business. The many promises of business automation continue to fall short of expectations.

As the industry becomes increasingly complex and consumers play a larger role in the selection of their health insurance, payers are recognizing that their complex processes and manual-intensive workflows are no longer sustainable. Mountains of work that sit in a queue waiting for a human to move it to the next step is slow, expensive, and prone to error.

The time has come for payers to lean more heavily on their software system vendors and technology advancements to automate business processes from one end of their business to the other. This fundamental principle of end-to-end automation is a key component of HealthEdge’s product investment strategy today.

Everyone is Doing It

We need not look far to see how other industries are using technology to create end-to-end automation. Consider Amazon, whose transaction costs are in the micro-cents and whose customer experience is revolutionizing consumers’ purchasing expectations. Netflix upended the entertainment industry with its use of modern technology to deliver content directly to the homes of its 214 million active subscribers.

At HealthEdge, we consider disrupters like these to be role models. Why? Because they think differently about how to solve problems. They focus first on the consumer experience and work through the options from there. With healthcare, the problems are extremely complex, driven by ever-evolving, ever-growing regulations and consumer demands. Therefore, we have to think about things differently, too. We can’t keep applying the old fixes to the rapidly evolving problems of today. And that’s exactly what we’re focused on helping our customers do.

This is the type of first-principles thinking that drives us at HealthEdge. Instead of just thinking about the status of a claim in our core administration system, we think about how that data can be used to empower nurses in care management, how to expedite eligibility checks, or how to help members select the right benefit package prior to enrollment. Instead of trying to improve second-pass claims editing, let’s get it right the first time. Instead of looking down into the functional silos, we look across the whole business of healthcare and seek to automate every business process possible to reduce operational costs and improve accuracy.

Enabling End-to-End Automation

With all of a health plan’s primary business systems, including core claims administration, care management, payment integrity, and member engagement, under one roof at HealthEdge, we are able to think more holistically about solving problems and driving innovation faster across the entire spectrum.

While powerful as individual solutions, the integration of these best-of-breed solutions gives us the unique advantage to improve accuracy, timeliness, and accessibility of data across multiple touchpoints, which is necessary to drive smarter, more automated workflows. As more workflows are automated, we can layer in leading edge technology advancements like artificial intelligence (AI) decision-making and machine learning to accelerate the time-to-value our customers experience when working with all our solutions. We take a unified view of the business processes that achieve desired outcomes, a key enabler of digital experiences for members and providers.

Business processes such as prior authorizations, claims adjudication, eligibility checks, enrollment, and even member correspondence are driven automatically through rule-based workflows that require little to no manual intervention. Plus, our open API interfaces make it easy to embrace third party systems that depend on accurate and timely delivery as well.

Realizing the Benefits of End-to-End Automation

When payers move toward end-to-end automation, they are able to free more resources to focus on innovation while also dramatically reducing transaction costs associated with claims processing, care management, and member engagement.

In its December 2020 report entitled “Strategic Automation Decision Framework,” Gartner estimates the cost to rework a claim is equal to $25 per claim. By automating more of the claims payment processes, health plans have the opportunity to get it right the first time and significantly reduce claims processing costs.

“It won’t be long before end-to-end automation becomes an expectation, rather than an outlier, and digital is simply business.”

– Gartner Group, Strategic Automation Decision Framework report, Dec. 2020

End-to-end automation is also fundamental to improving the member experience. Empowering care managers with information about member-specific benefits directly from within the care manager’s interface will help them not only build more informed care plans, but also better guide members along their care journeys. Equally as important is the ability to empower members with engagement capabilities. Solutions such as HealthEdge’s Wellframe® digital member engagement platform give members the opportunity to engage more directly with their care managers, which typically results in better care plan adherence and member satisfaction.

Creating a frictionless provider experience will also be a by-product of end-to-end automation, as the accuracy and timeliness of the claims adjudication process improves. For example, one HealthEdge customer was able to save hundreds of thousands of dollars by completing accurate pricing and editing in a single pass with HealthEdge’s Source payment integrity solution. The ability to eliminate manual pricing processes results in a time savings of 25% and a 40% reduction in claims volume that require rekeying.

At HealthEdge, we remain committed to helping our customers automate more of their business processes so they can drive down transaction costs and drive-up member and provider satisfaction. To learn more about how we are enabling end-to-end automation for our customers, visit or email [email protected].