eBook: Rural Health Clinic Reimbursement - The Hidden Cost in Claims Operations
Why manual RHC processing drives cost, complexity, and compliance risk - and how automation helps health plans regain control
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Medicaid
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Safeguarding HEDIS Compliance: 5 Strategies for Post-Hybrid Review Documentation and Audit Support
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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Mastering CMS Compliance: Bridging X12 and FHIR
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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Brochure: Plans With Home and Host Capabilities - How to Stay Ahead of the Curve
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RISE National 2026: A Turning Point for Risk Adjustment—and the Work Ahead
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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Real-Time Risk Adjustment in 2026: Modernizing Medicare Advantage Programs
Risk adjustment programs are entering a new phase of maturity. Historically, health plans approached Medicare Advantage risk adjustment retroactively, reviewing charts after...
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White Paper: Getting Risk Adjustment Right - A Guide for Modern Health Plans
In 2024, Americans spent approximately $5.3 trillion on healthcare, about $15,474 per person, and healthcare expenditures accounted for 18.0% of the country’s GDP.
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Cut Administrative Costs Up to 40% With an Integrated Operating Model
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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Executive Strategies for Balancing Costs and Quality for Health Plans
At HealthEdge®, we strive to understand the key challenges health plans face so we can help anticipate and address new market opportunities. Recently, HealthEdge Chief Strategy Officer, Raj...
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New Research: How Rising Costs and Regulatory Pressures Are Reshaping Health Plan Priorities
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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From Petabytes to Practicality: Navigating the New CMS Transparency Rule
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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What Wellframe’s New NCQA Certifications Mean for Health Plans and their Members
As regulatory and quality expectations intensify, the National Committee for Quality Assurance (NCQA) vendor certification offers health plans a trusted signal that their technology partners can...
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Professional Services Spotlight: Helping Texas Health Plans Stay Compliant and Efficient with MNLOC Assessment Enhancements
When state regulations change, health plans must be ready to respond—particularly when those changes impact core Medicaid services. That was the case in 2025 when the State of Texas mandated...
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Building Regulatory Compliance Agility: Lessons from Nascentia Health’s Success Story
Implementing new care management technology is about more than just meeting a go-live date. For Medicaid and Long-Term Services and Supports (LTSS) plans navigating evolving state mandates,...
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Meeting OBBBA Demands: A Digital Approach to Medicaid Member Engagement
As the healthcare industry prepares for the ripple effects of the One Big Beautiful Bill Act (OBBBA), few payer segments face more immediate challenges than health plans focused on Medicaid...
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Navigating Dual-Eligibility: Regulatory Compliance and Strategic Opportunities for Health Plans
Dual-eligible individuals—those who qualify for both Medicare and Medicaid—represent one of the most complex and high-need populations in the U.S. healthcare system.
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Health Plan Tactics for Medicaid Retention after the One Big Beautiful Bill Act (OBBBA)
Extensive legislative reform is shifting the healthcare landscape. The One Big Beautiful Bill Act (OBBBA) introduces significant changes to eligibility requirements across Medicaid, Medicare, and...
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A Care Management Guide for Health Plans: Navigating the One Big Beautiful Bill
The One Big Beautiful Bill Act (OBBBA) is reshaping healthcare, especially for Medicaid and Medicare plans. With tighter budgets, closer oversight, and an emphasis on population health in rural...
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What Medicare, Medicaid, and Dual Eligible Members Want from Their Health Plan: Key Findings from the HealthEdge® 2025 Consumer Study
In today’s evolving healthcare landscape, understanding what members want and need is more important than ever. To uncover those insights, HealthEdge conducted its 2025 Healthcare Consumer Study,...
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Video: Medicaid Maternal Health With HealthEdge Wellframe™
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