Key Takeaways January 1, 2027 is a major regulatory milestone. Multiple regulatory deadlines—including prior authorization API requirements, work requirement mandates, and the AMA obstetrics...
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Why manual RHC processing drives cost, complexity, and compliance risk - and how automation helps health plans regain control
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For many health plans, HEDIS® final submission feels like the finish line. In reality, it’s the moment when months of quality improvement efforts, chart retrieval activities, and data validation...
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Key Takeaways Post-hybrid review is a critical audit readiness phase: Success depends on strong documentation workflows, accurate validation, and timely support for auditor requests. Centralized...
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Key Takeaways For health plans, managing multiple vendors can create compounding operational inefficiencies that inflate costs and impede decision-making. A single integrated technology...
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Achieving a 4.5-Star rating is a major accomplishment for any Medicare Advantage health plan. But moving from 4.5 to 5 Stars is a different challenge altogether. Only a small percentage of plans...
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Artificial intelligence (AI) is no longer a future consideration for health plans. AI-powered tools are already reshaping how organizations operate, how members seek information, and how leaders...
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Shifts in healthcare regulations continually push health plans to adjust their strategies. The Centers for Medicare & Medicaid Services (CMS) introduced sweeping mandates that fundamentally shift...
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With the recently released the 2027 Medicare Advantage Final Rule and Rate Announcement, The Centers for Medicare and Medicaid Services (CMS) confirmed it is finalizing payment rates at a...
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This year marked the 20th anniversary of the RISE National Conference, but the milestone felt less like a retrospective and more like a clear signal of where health plan risk adjustment is heading...
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For the second consecutive year, 52% of health plan executives named “managing rising costs” as the top challenge, according to the 2026 HealthEdge® Annual Payer Report. In the same survey, 85% of...
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Achieving Excellence in a Complex Regulatory Landscape.
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In today’s rapidly evolving healthcare landscape, standing still isn’t an option. Health plans relying on legacy care management platforms, whether vendor-supported, homegrown, or heavily...
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Health plans are under increasing pressure: cost, compliance, member experience, and legacy system challenges all converging.
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HealthEdge today announced that it has achieved HITRUST r2 certification for demonstrating the highest level of cybersecurity and information assurance.
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Discover how Nascentia Health partnered with HealthEdge to modernize care management, achieve regulatory compliance agility, and drive measurable operational improvements.
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Industry pressures like regulatory complexity and the shift toward value-based care demand that health plans take an integrated, strategic approach to care management. Whether payers are...
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Rising costs. Relentless regulation. For health plans, the question isn’t whether these pressures are intensifying. It’s how to respond. According to new research from HealthEdge®, these twin...
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The Transparency in Coverage (TiC) final rules of 2020 promised a revolution in healthcare price transparency. The vision was bold: empower consumers with data to drive competition and lower...
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As health plans face mounting cost pressures and an increasingly complex regulatory landscape, one thing has become clear: incremental change is no longer enough. Today’s health plan environment...
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