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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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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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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At a recent roundtable, the HealthEdge® Chief Medical Officer led executives from three leading health plans in a discussion centered around optimizing care delivery and...
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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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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 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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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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HealthEdge’s GuidingCare® platform is at the forefront of enabling healthcare interoperability. By combining deep technical expertise with a visionary approach, GuidingCare equips health...
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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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Health plans serving dual-eligible populations face significant regulatory changes from the Centers for Medicare & Medicaid Services (CMS). The 2027 D-SNP requirements introduce significant...
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The Centers for Medicare & Medicaid Services (CMS) has raised performance benchmarks for Medicare Advantage (MA) and Part D plans, raising the bar for achieving high Star Ratings. By excluding the...
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HealthEdge Source™ is a cloud-based platform for healthcare claims management. It combines claims pricing, editing, and analytics in one system for Medicare, Medicaid, and Commercial claims. All prici
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A strategy to comply with the final rule issued by the U.S. Centers for Medicare & Medicaid Services suggests that payers should unify systems around their core claims and care management platforms...
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Motivating Medicare members to take action to improve their health is a high priority for health plans. Empowering behavior change improves health outcomes among members, builds trust and loyalty, and
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HealthEdge’s Regulatory Compliance Manager Maggie Brown and VP of Sales Solutions Diane Pascot recently addressed a large audience of AHIP members on an AHIP webinar that focused specifically on...
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