Health plans are under enormous financial and regulatory pressures. Managing these pressures with a fragmented, ineffective legacy infrastructure is not a formula for success.
Health plans need a modern technology infrastructure to efficiently manage all back-office activities — claims, risk adjustment, enrollment, provider data management and more. This can’t be a series of separate applications; all parts need to be integrated.
These were insights shared during Becker’s 4th Annual Spring Payer Issues Roundtable, at a session sponsored by HealthEdge titled “Redefine Operations with BPaaS: Predictable Costs, Scalable Efficiency and Better Outcomes.” The session featured HealthEdge CEO, Kevin Adams, and chief strategy officer, Raj Sundar.
Here were three key takeaways from the session:
1. Back-office inefficiency continues to strain plans
Manual work, fragmented processes, and operational rework add avoidable cost and make it harder to respond with speed, consistency, and control. Under continued margin pressure, these inefficiencies have become a meaningful barrier to stronger financial and operational performance.
2. HealthEdge offers health plans a unique, compelling back-office model
First, HealthEdge’s operating model combines modern technology with operational expertise to transform health plans’ back office efficiency. Drawing on deep operational expertise developed across 130 health plan customers, HealthEdge supports health plans through flexible delivery models.
Particularly unique is HealthEdge’s willingness to guarantee health plans cost savings. HealthEdge partners with plans by guaranteeing that a health plan’s back-office costs will be 30% lower than previously. Following a cost-driver assessment, HealthEdge works with a plan to identify opportunities to improve efficiency and reduce administrative costs. For illustrative purposes, a plan with a baseline back-office cost of $10 PMPM may uncover cost saving opportunities with HealthEdge to lower their PMPM to $7.
“We go at risk to ensure health plans are able to achieve actual cost savings,” said Mr. Adams.
3. In the near future, AI will further transform back-office operations
Currently, most of what is considered AI in health plans’ back offices is actually a glorified version of robotic process automation (RPA), observed Mr. Adams. But he believes the next level of AI, will involve significant autonomous automation, is not far away.
A shift will occur from largely rules-based activities to autonomous automation where LLMs or agentic AI will be making decisions.
HealthEdge is using Claude by Anthropic, and has partnered with AWS and Palantir, to rapidly develop AI for the back office and make it available for health plans. Ultimately, AI in back-office operations will increase speed and accuracy, decrease costs and improve scalability.
At the Becker's 5th Annual Fall Payer Issues Roundtable, taking place November 2–3 in Chicago, payer executives and healthcare leaders will come together to discuss value-based care, regulatory changes, cost management strategies and innovations shaping the future of payer-provider collaboration. Apply for complimentary registration now.
