Top 10 Benefits of Strategic Optimization Services for Health Plans

Health plans must balance cost containment, efficiency, and member satisfaction to remain successful in the rapidly evolving healthcare landscape. However, many plans struggle to fully optimize their technology investments, missing out on significant financial and operational benefits. Solutions like HealthRules® Payer, HealthEdge Source™, GuidingCare®, and Wellframe™ from HealthEdge® offer powerful capabilities—but without strategic optimization, health plans may be unable to maximize their return on investment.

HealthEdge’s Global Professional Services has helped hundreds of health plans unlock new efficiencies, automate critical processes, and drive down administrative costs. By leveraging these optimization initiatives, health plans can realize substantial savings while improving overall operational performance.

Below are 10 key factors health plans should consider when evaluating the ROI of system optimization. The statistics in this post can be found in the 2024 CAQH Index Report published in February 2025[1].

1. Dramatically Reduce Administrative Costs 

The U.S. healthcare industry spends approximately $440 billion annually on administrative complexity, accounting for nearly 12% of national healthcare expenditures. By optimizing electronic transactions, health plans can save up to $20 billion per year. Automated solutions reduce labor-intensive processes, resulting in fewer manual interventions and lower administrative overhead.

2. Improve Auto-Adjudication Rates for Faster Claims Processing

Roughly 85% of claims today are auto-adjudicated, yet 15% still require manual review—often the most complex and costly claims. Manual claims processing can take days or even weeks and cost up to $25 per claim. Increasing auto-adjudication rates through system optimization can significantly cut processing times and costs, reducing outstanding claims and improving provider satisfaction.

3. Enhance Prior Authorization Efficiency and Cost Savings

Prior authorizations remain one of the most burdensome administrative tasks, with processing costs rising 22% year-over-year. Health plans can save $515 million annually by shifting to electronic prior authorization systems. The cost per manual prior authorization is $3.41, compared to $0.05 when done electronically—a savings of $3.36 per transaction.

4. Reduce Claim Errors and Rework Costs

The error rate in claims adjudication is 6.5% for commercial insurance claims. Reworking a single claim costs an average of $28. By optimizing claim validation and coding accuracy, health plans can reduce denials, minimize rework, and improve first-pass rates, leading to significant administrative savings.

5. Speed Up Provider Payments for Improved Relationships

Health plans that optimize their claims and payment workflows can accelerate provider reimbursements. Currently, manual claim payments cost up to 40% more than electronic transactions. With better integration and automation, health plans can reduce payment cycles, improving provider trust and network engagement.

6. Increase Member Satisfaction Through Faster Service

Delays in eligibility verification, prior authorizations, and claims processing contribute to poor member experiences. Optimized systems reduce approval times, minimize paperwork, and enable real-time processing, leading to a more seamless member journey. This enhances member engagement and can contribute to higher retention rates.

7. Free Up Employees for Strategic Initiatives

By automating repetitive administrative tasks, health plans can reallocate staff time toward higher-value activities such as care management, provider relations, and strategic planning. This not only improves employee satisfaction but also strengthens operational effectiveness.

8. Enhance Regulatory Compliance and Reduce Audit Risk

With evolving regulations like the No Surprises Act and CMS interoperability mandates, health plans must ensure compliance while avoiding penalties. Optimized systems can automate compliance checks, improve reporting accuracy, and enhance data transparency, reducing the risk of costly audits and fines.

9. Mitigate Cybersecurity Risks Through Advanced Technology

Cyber threats to healthcare systems are increasing, and outdated technology poses significant risks. By modernizing and optimizing IT infrastructure, health plans can strengthen security measures, reduce vulnerabilities, and ensure data integrity, protecting both member and provider information.

10. Maximize the ROI of Your HealthEdge Investment

HealthEdge’s Global Professional Services team specializes in helping health plans fully leverage their investments in HealthEdge solutions. Through strategic optimization, organizations can increase automation rates, enhance system capabilities, and drive down costs, ensuring that every dollar spent on technology delivers maximum value.

Get Started with Strategic Optimization

The cost-saving potential of health plan technology optimization is undeniable. From reducing administrative waste to improving auto-adjudication and streamlining provider interactions, optimizing solutions like those from HealthEdge can deliver significant savings and operational excellence.

Discover more about HealthEdge Optimization Services today and see how we can help you drive optimization initiatives that save money, enhance efficiency, and improve member and provider experiences.

1 All statistics in this post can be found in the 2024 CAQH Index Report published in February 2025.