For Medicare Advantage plans, Star Ratings have always been a critical measure of quality and performance. But maintaining high ratings has become increasingly difficult. The numbers tell the...
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Why Health Plans Need More Than Capacity to Compete in an Era of Growth, Complexity, and AI For years, scalability was largely viewed as a technology concern. As long as claims were processing,...
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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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Key Takeaways HealthEdge® partnered with Ellipsis Health to integrate Sage, an AI-powered voice agent, directly into the GuidingCare® platform—giving health plans a scalable way to automate member...
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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 For health plans, the implementation period is one of the highest-risk, highest-stakes phases of any technology investment—and AI can significantly reduce that risk. HealthEdge...
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This is part 3 of a blog series on Ethical AI. For context on this series and why we’re writing it, see our introduction in part 1, Ethical AI: Privacy and Security. How Can Payers Address Bias in...
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Introduction This is part 2 of a series on Ethical AI. The content was adapted from an internal learning and development session developed by the Machine Learning Engineers at HealthEdge®, focused...
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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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Healthcare consumers are changing how they seek information, and increasingly, they are turning to artificial intelligence to do it. Tools powered by generative AI, including platforms like...
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Key Takeaways HealthEdge centers every product innovation around delivering three core outcomes: lower-risk implementations in less time, higher quality at a lower cost, and continuous innovation...
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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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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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Efficiencies in claims processing is a direct driver of cost management, member satisfaction, and competitive positioning. NorthWinds Technology Solutions leadership understood this when they made...
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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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Is Your Health Plan Ready for Touchless Claims Processing? The pace of change in healthcare continues to accelerate. Don’t let outdated technology keep your organization from seizing new...
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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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