Transform Health Plan Operations with AI-Powered Core Administration
Artificial intelligence (AI) has become the catalyst for transformation across various industries, and healthcare is no exception. For health plans, the integration of AI is no longer just a future aspiration; it is a present-day necessity. From enhancing operational efficiency to improving member outcomes, AI-powered core administration solutions are reshaping how health plans operate on virtually every level.
HealthEdge® endeavors to be at the forefront of this transformation by thoughtfully integrating AI tools across our suite of digital solutions. Within HealthRules® Payer, our core administrative processing system (CAPS), we’re leveraging AI to help payers streamline workflows, reduce administrative costs, and modernize member experiences.
Explore a few of the ways AI-powered core administration solutions are transforming healthcare operations and how HealthEdge is developing digital solutions to put health plans at the forefront.
The Growing Role of AI in Healthcare
Healthcare organizations across the industry are adopting AI at an unheralded pace, largely driven by the promise of improved operational efficiency, reduced costs, and better care outcomes. According to one McKinsey analysis, for every $10 billion of payer revenue, AI solutions could save $150 million to $300 million in administrative costs.
And more than 80% of health plans are already integrating AI into their workflows.
AI-driven solutions can enable health plans to achieve critical business goals such as:
- Facilitating Intelligent Claims Operations. Using AI, payers can automate more of the claims process to enhance accuracy, improve fraud detection, and reduce payment friction.
- Delivering Proactive and Integrated Care. AI tools can surface predictive insights that enable providers to deliver personalized care that meets members’ holistic needs.
- Elevating Member and Provider Experiences. AI-enhanced solutions can make it easier for payers to personalize interactions at scale with intelligent tools.
- Enhancing Cost Efficiency. Automating data validation, streamlining workflows and reducing the need for manual intervention can help payers lower administrative costs without sacrificing scale.
- Ensuring Regulatory Compliance. AI-powered tools can help track and organize essential information necessary for reporting and other regulatory guidelines.
AI-Driven Innovation in the HealthRules Payer CAPS Solution
HealthRules Payer exemplifies how AI can revolutionize healthcare operations. Designed with automation, agility, and intelligence in mind, HealthRules Payer enables health plans to adapt to the rapidly evolving market.
HealthRules Payer is driving transformation across health plan operations with targeted AI-powered tools:
Automating Claims Administration
With intelligent claims processing, steps such as claims adjudication, contract management, and financial validation are automated to achieve consistently high accuracy. For example, HealthRules Payer helped one health plan achieve a 90% first-pass auto-adjudication rates, significantly reducing manual intervention and associated costs.
Real-Time Decision-Making
AI-enabled tools within the proprietary HealthRules Language helps simplify benefits configuration and enhance accuracy through real-time recommendations. This feature allows health plans to streamline decision-making processes while maintaining flexibility in adapting to market demands.
Unstructured Data Automation
Extracting and structuring data from documents, faxes, and forms is traditionally a time-consuming process. By automating this task, HealthRules Payer removes administrative bottlenecks and accelerates workflows.
Claims Summarization and Support
The Claims Summarizer, an AI-powered feature, offers concise summaries of pending or denied claims. This helps claims processors quickly identify issues and make informed decisions, further enhancing efficiency.
Elevating Member Interactions
Through AI-powered chatbots, HealthRules Payer supports members and customer service teams with instant, accurate answers to questions about claims, benefits, and membership. This strengthens member satisfaction and engagement.
HealthRules Payer also integrates seamlessly with other solutions in the HealthEdge digital ecosystem, creating a unified platform that leverages automation and real-time data to deliver unmatched value.
How HealthEdge AI Tools Can Transform Core Healthcare Functions
The power of AI-driven solutions extends well beyond claims processing to other critical areas of healthcare operations. HealthEdge integrates AI capabilities across its suite of solutions to fully realize its potential. Key applications include:
Payment Integrity
HealthEdge Source
enables payers to drive payment accuracy and integrity through customizable edits and automated contract setup to help reduce payment friction, maintain compliance, and improve payer and provider experiences.
Provider Network Management
AI simplifies the management of provider data with tools that intelligently match and merge records, reducing the need for manual reconciliation. The HealthEdge® Provider Data Management solution acts as a single source of truth for accurate and consistent provider information.
Care Management
HealthEdge GuidingCare® uses AI to automate tasks for care teams and surface actionable insights to facilitate proactive outreach. Tailored care recommendations help prioritize next steps and improve care outcomes.
Member Engagement
HealthEdge Wellframe combines real-time insights with intelligent automation to create personalized, seamless experiences for members. AI supports care managers by suggesting message responses and flagging high-risk members based on their interactions.
By addressing these operational pain points, HealthEdge is helping to set a strong foundation for the future of healthcare operations.
Responsible AI Development at HealthEdge
HealthEdge understands that deploying AI in healthcare must include a commitment to transparency and ethical practices. That’s why HealthEdge has built a robust framework focused on responsible AI that prioritizes security, fairness, and compliance.
HealthEdge’s approach to responsible AI development includes:
- Transparency and Risk Mitigation: Proactively addressing concerns related to data privacy, governance, and algorithmic biases.
- Alignment with Industry Frameworks: Following guidelines such as the Artificial Intelligence Risk Management Framework (AI RMF 1.0) and the Coalition for Health AI (CHAI).
- Collaborative Innovation: Partnering with health plans, end users, and industry stakeholders to align AI capabilities with real-world needs.
By adhering to these principles, HealthEdge is helping ensure that our solutions are not only innovative but also trusted by our customers.
The Future of Healthcare Operations
With its cutting-edge AI capabilities, HealthRules Payer is empowering health plans to redefine how they operate, serve members, and deliver care. Whether it’s managing claims, engaging members, or facilitating care coordination, the opportunities AI presents are immense.
Are you looking for a new CAPS solution, but aren’t sure which vendor is the right partner for your organization? Download your complimentary copy of the Gartner® Market Guide for U.S. Healthcare Payers’ Core Administrative Processing Solutions.
