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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Medicare
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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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When Your Legacy Operating Model Costs More to Maintain Than to Modernize
Key Takeaways For payers, inaction is not a neutral choice—legacy operating models carry compounding costs that erode financial performance, member satisfaction, and competitive positioning over...
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Closing the Gap: Leveraging Hybrid Records to Propel Medicare Advantage Plans to 5 Stars
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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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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CY 2027 Medicare Advantage Final Rule & Rate Announcement: 5 Updates Payers Need to Know
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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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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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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6 Executive Strategies for Optimizing Care Coordination and Delivery
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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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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Data Sheet: Future-Proof Your Health Plan with HealthEdge GuidingCare® — FHIR-Driven Solutions Enable Compliance
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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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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Navigating CMS 2027 D-SNP Requirements: Preparing Your Health Plan for HIDE and FIDE SNP Compliance
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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Adapt to CMS Standards and Improve Star Ratings with Digital Care Management
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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