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 Don’t let outdated technology keep your organization from seizing new...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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Health plans with home and host capabilities have set the standard for healthcare excellence since 1929—but mounting industry pressures constantly challenge these market leaders. Decreasing...
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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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This is part 1 of a blog series on Ethical AI. This content was adapted from an internal learning and development session developed by HealthEdge’s AI team, focused on educating our organization...
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When health plans modernize their core administrative systems, the conversation often centers on technology. Implementation timelines, configuration decisions, and integrations dominate planning...
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Part 2 of a 2-part series, where HealthEdge® Vice President of Product Development Bobby Sherwood discusses how a new operating model can transform care operations for health plans. In the first...
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Part 1 of a 2-part series, where HealthEdge® Vice President of Product Development Bobby Sherwood discusses how a new operating model can transform care operations for health plans. In this...
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Health plans are heading into 2026 under a level of pressure that feels fundamentally different from just a few years ago. Findings from the HealthEdge® 2026 Healthcare Payer Survey Report, “The...
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Large language models (LLMs) are inherently probabilistic, meaning the same input can produce different outputs. That variability makes traditional unit tests, which verify exact results,...
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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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When a health plan undertakes a major technology change, whether implementing a new platform, modernizing a legacy system, or rolling out new functionality, the promise is compelling: streamlined...
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Artificial intelligence (AI) is fundamentally changing how healthcare software is built. From automated test case generation to intelligent documentation and decision support, large language...
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Payment integrity has always played a critical role in payer operations, but in 2026, it has become a strategic imperative. According to the HealthEdge® 2026 Annual Payer Survey, health plan...
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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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