Redefining Performance in Medicare Advantage - Preparing for What’s Next
How behavioral health, program integrity, end emerging CMS priorities are reshaping health plan operations
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Medicare Advantage
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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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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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Case Study: From Underperformance to a 4+ Star Rating - How HealthEdge Propelled a Health Plan to Quality Excellence and Revenue Growth
Health plans often struggle to achieve performance goals due to limited resources, which can restrict their ability to execute critical quality improvement initiatives.
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Case Study: Health Plan Revitalization - A Strategic Oversight Program for a Leading Health Plan
For health plans, navigating the complexities of modern healthcare technology and operations is critical for sustainable success.
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Case Study: Strategic Stars Turnaround - How a Major Health Plan Stabilized Operations and Secured $1.5B in Revenue
In a dynamic healthcare environment, operational stability and continuous improvement are fundamental for health plans to ensure efficiency, effectiveness, and adaptability.
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White Paper: Turning Gaps into Solutions - Advancing Provider Tools for Quality Care
When measuring success, gaps in care can play an impactful role in HEDIS measure score. Closing gaps in care has a direct impact on HEDIS scores.
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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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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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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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Case Study: HealthRules Payer Case Study with Presbyterian
HealthEdge had the opportunity to sit down with Presbyterian Health Plan leadership to learn more about why their organization decided to make the switch to HealthRules Payer as it's CAPS partner.
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eBook: CMS Transparency in Coverage Rule
The Transparency in Coverage Guide (CMS-9915-F) is a pivotal regulation aimed at increasing transparency in healthcare pricing, enabling consumers to access price information before receiving services
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Data Sheet: HealthEdge Source — Data Reference Module
Data Reference, which can be accessed through your instance of Source, provides insight into any current or historical fee schedules, rates, payment policies, and provider-level data.
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Data Sheet: Navigating the No Surprises Act - The Right Tools for Health Plan Success
The No Surprises Act (NSA) marks a significant regulatory milestone aimed at protecting consumers from surprise medical bills and enhancing transparency in healthcare.
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Video: Source Medicare Reimbursement
Navigating the complexities of Medicare claims is increasingly challenging due to constantly evolving reimbursement policies and fee schedules.
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Data Sheet: Configuration as a Service Expedites Time-to-Value for Health Plans
HealthEdge's Configuration as a Service optimizes HealthRules® Payer system configurations, accelerating time-to-value for health plans.
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