Month: January 2025

Protecting Healthcare Data: Part 2 – A Conversation with HealthAxis Experts

In the second part of our Data Privacy Day series, we are focusing on compliance-related questions. We are joined by HealthAxis team members Milonda Mitchell, Compliance Officer; Ralph Pugh, Information Security Analyst III; and Tony Gambino, Cyber Security Engineer.  

Q: With HIPPA adding new requirements around how we handle incidents and new safeguards, how should IT teams approach these updates?  

Ralph:  

  • Revamp Incident Response Plans: The first step is to update existing protocols to ensure rapid detection, reporting, and mitigation of data breaches in compliance with the new standards. 
  • Enhance Safeguards: Strengthening technical controls, such as multi-factor authentication, endpoint security, and advanced firewalls, will help ensure compliance with the new updates. 
  • Audit and Test Systems: Perform regular audits and simulate incident scenarios to validate the effectiveness of new safeguards.  

Tony:  

  • Understand the New Regulations: Conduct a detailed analysis of the updated requirements, focusing on incident response and new safeguards. 
  • Invest in Staff Training: Educate employees on the updated regulations and start new training programs to ensure compliance is met. 
  • Engage Compliance Experts: When new requirements emerge, it is ideal to collaborate with legal and regulatory experts to ensure thorough adherence to HIPAA updates. 

 

Q: What steps are ideal to evaluate and improve privacy practices regularly? 

Milonda: 

  • Privacy Audits: Conduct routine internal audits to evaluate data collection, processing, storage, and sharing practices. 
  • Gap Analysis: Compare existing practices against applicable privacy regulations (e.g., HIPAA, GDPR, or CCPA) and industry standards. 
  • Training & Awareness: Regularly train staff on data protection policies, emerging threats, and compliance requirements. 
  • Risk Assessments: When implementing new processes, tools, or systems that handle sensitive data, perform privacy impact assessments (PIAs). 
  • Update Policies: Review and update privacy policies to reflect changes in regulations, technology, or organizational practices. 

 

Q: How do you ensure secure data sharing between internal departments and external stakeholders? 

Milonda: 

  • Encryption: Use end-to-end encryption for all data transfers, whether internal or external. 
  • Access Controls: Implement role-based access controls (RBAC) to limit data sharing to authorized personnel only. 
  • Data Transfer Agreements: Establish formal agreements (e.g., business associate agreements or data-sharing contracts) with external stakeholders. 
  • Secure Channels: Utilize secure file transfer protocols (e.g., SFTP, HTTPS) or enterprise-grade sharing tools. 
  • Data Minimization: Share only the minimum necessary data required for the specific purpose. 

 

Q: What processes are best practices to have in place to handle data deletion requests under applicable privacy laws? 

Milonda: 

  • Centralized Request Portal: Implement a secure, centralized platform for receiving and tracking data deletion requests. 
  • Verification Process: Verify the identity of the requestor to prevent unauthorized access or deletion. 
  • Data Mapping: Maintain an updated data inventory to quickly identify where personal data resides across systems. 
  • Defined Workflows: Establish detailed workflows for processing requests, including timelines and approvals, to meet regulatory requirements (e.g., GDPR’s 30-day timeframe). 
  • Documentation: Log all deletion requests, including the action taken and the timeline, for compliance tracking. 

 

Q: How do we assess the compliance and security practices of third-party vendors who handle our data? 

Milonda: 

  • Vendor Risk Assessments: Conduct thorough initial due diligence, including security questionnaires and audits, before onboarding vendors. 
  • Contractual Obligations: Include detailed data protection requirements and audit rights in vendor agreements. 
  • Certifications: Require vendors to provide certifications (e.g., ISO 27001, SOC 2) or demonstrate compliance with applicable laws. 
  • Periodic Reviews: Perform regular assessments of vendor practices, especially when regulations or business needs change. 
  • Incident Reporting: Ensure vendors have robust breach notification procedures in place. 

 

Q: How do we monitor and verify third-party adherence to our data privacy requirements? 

Milonda: 

  • Audits & Inspections: Conduct periodic audits, either internally or via third-party services, to verify compliance. 
  • Reporting Obligations: Require vendors to provide regular compliance reports or certifications. 
  • Performance Metrics: Define KPIs and SLAs for privacy and security compliance in contracts and monitor their adherence. 
  • Incident Management: Monitor incident reports from vendors to evaluate their response effectiveness. 
  • Continuous Monitoring: Automated tools are used to monitor vendors’ data protection practices, especially for critical services. 

 

Q: What is the best practice for documenting compliance with data privacy regulations, and how accessible should these records be during an audit? 

Milonda: 

  • Centralized Repository: Maintain a secure, centralized system to store all compliance documentation, such as risk assessments, training logs, data inventories, and incident response records. 
  • Retention Policy: Establish a clear data retention policy to ensure records are kept for the legally required duration. 
  • Version Control: Keep all policy updates, audit findings, and corrective actions version-controlled and timestamped. 
  • Audit-Ready Format: During an audit, ensure records are structured, searchable, and accessible to relevant personnel. If possible, use automated compliance management tools. 
  • Transparency: As necessary, share relevant compliance documentation with regulators, auditors, and stakeholders, ensuring alignment with confidentiality policies. 

 

At HealthAxis, we are committed to supporting health payers in these efforts. Our solutions are designed to improve member engagement, streamline communication, and ensure compliance, ultimately enhancing the overall member experience. Connect with our experts for more detailed insights and practical strategies on how we can support your healthcare organization.

 

Authors:

Milonda Mitchell
Compliance Officer

Ralph Pugh
Information Security Analyst III

Tony Gambino
Cyber Security Engineer

Protecting Healthcare Data: Part 1 – A Conversation with HealthAxis Experts

For this year’s Data Privacy Day, we sat down with our very own Tony Gambino, Cyber Security Engineer, Ralph Pugh, Information Security Analyst III, and Milonda Mitchell, Compliance Officer, to discuss the future of data privacy in the healthcare world.  

In this two-part blog series, we will break down the following:  

  • Risks and Challenges with Data Privacy 
  • Emerging Trends in Cybersecurity 
  • How HealthAxis Addresses Data Privacy 
  • Essential Technologies 
  • Regulations and Compliance Around Healthcare-related Data Privacy 

What Is Data Privacy Day? 

First initiated in Europe in 1981 as “Data Protection Day,” with the signing of Convention 108 on January 28th, which was the first legally binding international treaty dealing with privacy and data protection. In more recent years, this day has become known as “Data Privacy Day” and is celebrated across the world.1 

The National Cyber Security Alliance (NCSA) assumed leadership of Data Privacy Day in 2011. A distinguished advisory committee of privacy professionals advises the NCSA. It is a nonprofit, public-private partnership dedicated to promoting a safer, more secure, and more trusted Internet. 

In the context of healthcare, this translates to the protection of member information, a responsibility that healthcare payers take seriously. The Health Insurance Portability and Accountability Act (HIPAA) in the United States is a testament to the importance of data privacy, ensuring that member information is kept confidential and secure.  

Q: Why is data privacy more critical in the healthcare insurance industry today more than ever?  

Ralph: The rise of data-sharing initiatives, interoperability standards, and artificial intelligence introduces new privacy concerns, requiring healthcare payers to adopt robust safeguards to maintain trust and regulatory compliance. In the world of healthcare, data privacy transcends regulatory compliance—it directly impacts real lives. Safeguarding our members’ sensitive information is more than a duty; it’s a daily commitment to trust. 

Tony: Data privacy is more critical than ever due to the increasing digitization of healthcare, the proliferation of interconnected systems, and the growing reliance on electronic health records (EHRs). Healthcare payers are prime targets for cyberattacks because the data they handle—medical histories, financial information, and personal identifiers—is incredibly sensitive and lucrative on the black market. 

Q: What are some of the emerging trends in cybersecurity that healthcare payers should be prepared for?  
Ralph: As we see regulations continually evolve, this creates a moving target for healthcare organizations trying to keep member data safe and compliant.  

  • Technology Transformations: AI-driven analytics are becoming more common. These innovations now require fresh thinking about increased security measures. For example, we now have to look at keeping data safe when it moves from a smartwatch to a provider’s network to a plan’s claims processing system. 
  • Rising Cyberthreats: Phishing and malware are just two examples of growing cyber threats. KnowBe4 recently shared that last year saw a 40% increase in phishing attacks coming from generic top-level domains (gTLDs).2 As well as a 703% increase in credential phishing attacks.3 These are topics that members should be made aware of while avoiding fearmongering. 
  • Balancing Speed and Security: Innovation in claims processing is fantastic for quicker reimbursements but ensuring IT and Security teams have fully vetted and tested the technology is key. Pushing the envelope on efficiency is a common goal among companies, but taking time to understand these new processes and test their security is the best way to keep member data secure. 

Tony: 

  • Ransomware-as-a-Service (RaaS): Increasingly sophisticated ransomware attacks are targeting healthcare organizations, requiring advanced detection and response strategies. Setting up regular tests and training for this kind of attack will help decrease the risk and improve the internal culture around privacy awareness.  
  • Zero Trust Architecture: Healthcare payers are moving toward “never trust, always verify” models to limit insider and external threats. Having systems in place like 2-factor authentication (2FA) helps mitigate instances where internal accounts can be accessed.  
  • AI-Driven Threat Detection: Artificial intelligence is being used for real-time threat monitoring and predictive analytics. This is a great way to ensure your systems are being monitored at all times, for example, during non-work hours and holidays.  
  • Third-Party Risk Management: Increased reliance on vendors and partners necessitates stronger oversight of external risks. Taking the time to review all third-party vendors and their own technology and processes can help mitigate risks when onboarding a new partner. Once onboarded, regular risk management testing and analysis is ideal to maintain security.  
  • Data Privacy Enhancements: With regulations tightening, healthcare payers must adopt encryption, anonymization, and secure data-sharing practices. These safeguards can be done both by internal security and IT teams. However, it is ideal to have a trusted third-party company analyze your security practices to ensure data protection.  

 

Q: How does HealthAxis currently address the unique cybersecurity challenges in the healthcare industry? 

Ralph: At HealthAxis, we are constantly monitoring our defenses. This includes rigorous testing, both from internal and external sources. We employ a Security Operations Center (SOC) that monitors our applications 24/7/365, on top of our own team’s monitoring.   

Staying ahead of the threat is vital to protecting the data. HealthAxis implements monthly external third-party phishing simulations, quarterly internal phishing exams, as well as yearly external third-party penetration testing.   

Tony: Comprehensive training ensures our teams are equipped to identify and mitigate security risks effectively. This includes training that strengthens awareness and promotes compliance with a focus on reducing human error. A well-trained team fosters a workplace culture that prioritizes security, encouraging proactive behavior like reporting incidents and following best practices for data protection. 

Q: What technologies are essential for maintaining data privacy?  

Ralph:  

  • Advanced Encryption Standards: All sensitive data should be encrypted in transit and at rest, ensuring secure communications and storage. 
  • Real-time Threat Monitoring: Continuous surveillance of networks and systems can ensure quick detection and response to threats as they arise, ensuring that potential security breaches are identified and mitigated swiftly. This proactive approach helps to safeguard sensitive information against emerging cyber threats. 
  • Regular Security Audits: Frequent internal and external audits ensure systems align with the latest industry standards and regulations. This can also help detect and avoid new types of threats, as they are continuously evolving. 
  • Anonymization: This best practice includes employing data anonymization techniques to protect personal and sensitive information while removing or masking identifiers that tie data to specific individuals. This not only helps in compliance with privacy laws but also minimizes the risk of data misuse in the event of a data breach. 

Tony:  

  • Employee Training Programs: Comprehensive training ensures our teams are equipped to identify and mitigate security risks effectively. Not only is it vital to have an internal training program in place, but utilizing third-party training programs is a great way to keep your team up to date on the latest cybersecurity trends. According to KeepNet, cyber security awareness training leads to a 70% reduction in security-related risks.4 
  • Zero Trust Framework: We limit access to sensitive systems based on strict authentication and continuous verification protocols. Imprivata came out with a study that shows 65% of cyberattacks could have been prevented with 2FA.5 
  • System and Application Updates: Regularly updating systems and applications is essential for maintaining data security. Software vendors frequently release patches to address newly discovered vulnerabilities that cyber attackers could exploit. Keeping operating systems, applications, and security software up to date ensures protection against known threats, minimizes the risk of breaches, and enhances overall system performance. Automated update mechanisms and patch management policies should be implemented to ensure timely updates without disrupting business operations. 

 

In closing, what is the long-term importance of data privacy for healthcare insurers?  

Ralph: Data privacy is an ongoing commitment, not a one-time effort. For healthcare payers, it is about more than avoiding breaches and fines. It’s about protecting the trust and well-being of members. Investing in robust data privacy measures builds brand trust and helps build a safer, more secure future.  

Strong data privacy practices reduce the risk of costly breaches, legal penalties, and reputational damage. Moreover, as the industry moves toward personalized medicine and data-driven healthcare solutions, maintaining robust privacy standards will enable insurers to harness data’s potential responsibly and ethically. Ensuring data privacy is not just a regulatory requirement but a moral imperative for fostering innovation. 

Tony: Data privacy is foundational to healthcare companies’ long-term success and sustainability. Beyond ensuring compliance with regulations, safeguarding data builds trust with members, which is critical for maintaining retention. Strong privacy practices not only protect against legal and reputational risks but also enhance member experiences and provide a competitive edge. By prioritizing data security, healthcare organizations can foster trust, drive innovation, and ensure long-term growth in an increasingly digital landscape. 

Join us for the second part of the Q&A next time with Milonda Mitchell, Compliance Officer at HealthAxis.  

At HealthAxis, we are committed to supporting health payers in these efforts. Our solutions are designed to improve member engagement, streamline communication, and ensure compliance, ultimately enhancing the overall member experience. Connect with our experts for more detailed insights and practical strategies on how we can support your healthcare organization.  

Authors: 

Ralph Pugh
Information Security Analyst III

Tony Gambino
Cyber Security Engineer

 

Sources:
1 Data Privacy Day, U.S. Department of Energy
2 The 40% Rise of Phishing Attacks: How New Domain Extensions Are Fueling Cyber Crime, KnowBe4
3 Credential Phishing Increased by 703% in H2 2024, KnowBe4
4 2024 Security Awareness Training Statistics, keepnet
5 Why two-factor authentication is critical for healthcare organizations, Imprivata

Cloud Computing: Transforming Healthcare Administration for a Smarter Future

As the healthcare landscape becomes increasingly complex, organizations such as health plans, risk-bearing providers, and third-party administrators (TPAs) face mounting challenges. These include navigating regulatory shifts, reducing operational costs, and improving member and patient experiences. Cloud computing has emerged as a transformative solution, enabling organizations to scale operations, enhance compliance, and achieve cost-efficiency goals while addressing these critical pain points. 

In this blog, we’ll cover: 

  • The current state of cloud computing in healthcare. 
  • Key benefits driving cloud adoption, including scalability, security, and cost efficiency. 
  • Emerging trends that healthcare organizations must prepare for, such as interoperability and artificial intelligence (AI) integration. 

 

The State of Cloud Computing in Healthcare 

Cloud computing is driving a significant transformation in healthcare, offering organizations the ability to modernize operations and adapt to evolving industry demands. According to a 2024 report by MarketsandMarkets, the global healthcare cloud computing market is projected to grow from $53.8 billion in 2024 to $120.6 billion by 2029, at an impressive compound annual growth rate (CAGR) of 17.5%.1 

This rapid growth is fueled by several key factors, including: 

  • Rising use of big data analytics, wearable devices, and IoT. 
  • Enhanced data storage, flexibility, and scalability provided by cloud computing. 
  • Emergence of new payment models and cost-efficient cloud solutions. 
  • Evolving health benefit plan designs requiring adaptable IT infrastructure. 

Cloud computing presents an unparalleled opportunity for healthcare stakeholders to address challenges such as legacy system inefficiencies, growing data demands, and greater interoperability. With cloud platforms, these organizations can seamlessly integrate diverse systems, improve data-sharing capabilities, and achieve greater operational agility. 

As healthcare organizations continue to adopt cloud technologies, they are better equipped to navigate regulatory complexities, reduce administrative burdens, and deliver improved member experiences. The shift to cloud computing is no longer a forward-looking strategy; it’s a necessity for those aiming to remain competitive and future-ready in an increasingly digital healthcare landscape. 

 

Key Benefits Driving Cloud Adoption 

Cloud computing offers transformative benefits for healthcare organizations, enabling them to address persistent challenges and stay competitive in a rapidly evolving industry. Among these benefits, scalability, enhanced security, and cost efficiency stand out as critical drivers for adoption. 

  1. Scalability and Flexibility

Health plans, risk-bearing providers, and TPAs need systems that can scale with their organizational needs, particularly during high-demand periods like open enrollment or during contract expansions. Cloud computing allows for the elimination of the burden of large CAPEX spend, long lead times from HW vendors, and physical capacity limitations that owning data centers brings.  

A HIMSS report highlights how cloud platforms provide seamless data storage and access, enabling organizations to manage large datasets effectively and adapt quickly to operational needs.2 This scalability ensures that healthcare entities can remain agile in addressing complex administrative and member requirements. 

  1. Enhanced Security and Compliance

According to a study done on healthcare cyber security by Ponemon Institute in 2024, ransomware attacks are on the rise, while the compromise on cloud-based user accounts is down year over year.3

Maintaining security and compliance with evolving healthcare regulations is a top priority. Cloud platforms provide advanced security features such as encryption, real-time monitoring, and automatic updates to help organizations stay compliant with frameworks like HIPAA and HITECH. 

Microsoft’s Azure for Healthcare, for instance, incorporates built-in tools to enhance data security and compliance, enabling risk-bearing providers and plans to collaborate securely across platforms while safeguarding sensitive information. At HealthAxis, we leverage Azure as the foundation for our core administrative processing system (CAPS) platform, ensuring that our clients benefit from these advanced security features while meeting industry-specific compliance requirements. 

  1. Cost Efficiency and Operational Savings

The high maintenance costs of legacy systems, coupled with limited scalability, often strain healthcare organizations’ budgets. Cloud computing operates on a subscription-based model, allowing organizations to pay for only what they use while reducing the need for expensive hardware upgrades. 

These cost efficiencies, in the form of both real cash out the door (upfront CAPEX), as well as sometimes large opportunity costs and time to market, enable healthcare organizations to reallocate savings toward other important projects and initiatives, such as improving member services or focusing on growing their provider network.  

  1. Disaster Recovery and Backup Capabilities

Cloud adoption offers significant benefits in the area of disaster recovery and business continuity. By leveraging cloud computing, healthcare organizations can ensure data integrity and availability during emergencies, such as natural disasters or communication outages. Cloud platforms provide reliable data backup and recovery systems, which are vital for maintaining business operations and accurate communication. This capability allows organizations to quickly restore critical data and services, minimizing the downtime and ensuring continuity of care.  

Additionally, cloud-based disaster recovery solutions are often more cost-effective and scalable compared to traditional on-premises systems, enabling healthcare entities to adapt to changing needs and protect their data without significant upfront investments. 

 

Emerging Trends in Cloud Computing for Healthcare 

As healthcare organizations continue to embrace digital transformation, several emerging trends in cloud computing are shaping the industry’s future. 

  1. Interoperability and Data Integration

Interoperability remains a pressing challenge across healthcare. Advanced cloud platforms are adopting standards like Fast Healthcare Interoperability Resources (FHIR®) to enable seamless data sharing between systems. This is crucial for risk-bearing providers collaborating with plans or TPAs managing multi-client environments. 

The CMS regulation requiring FHIR support is part of the CMS Interoperability and Prior Authorization Final Rule. This rule aims to improve the electronic exchange of healthcare data and streamline prior authorization processes. It includes several key provisions that must be complied with by January 1, 2027.4 

  • Patient Access API: Allows members to access claims, encounter information and clinical data.  
  • Provider Access API: Allows providers with access to current member data from plans.  
  • Payer-to-Payer API: Facilitates member data exchange between plans.  
  • Prior Authorization API: Enables providers to determine prior authorization needs and submit new requests.  
  1. Artificial Intelligence (AI) and Machine Learning (ML)

Cloud platforms are increasingly utilized to run AI and machine learning models, enabling predictive analytics, personalized treatment plans, and improved diagnostic accuracy. These integrations allow healthcare providers to leverage vast amounts of data to enhance member outcomes and operational efficiency.  

  1. Edge Computing and Real-Time Analytics

Edge computing allows real-time data processing by storing data closer to the source (e.g., hospital equipment or wearable devices), offering healthcare organizations faster and often real-time insights. For example, healthcare plans using edge computing for claims processing can reduce latency and accelerate decision-making, improving both speed and accuracy. 

  1. Blockchain Integration with Cloud Platforms for Enhanced Security

Cloud platforms are increasingly integrating blockchain technology to bolster data security and transparency in healthcare. By leveraging blockchain’s decentralized and immutable ledger capabilities within cloud environments, healthcare organizations can securely share data while ensuring compliance with privacy regulations such as HIPAA. This integration addresses security concerns and fosters trust among stakeholders. 

A World Economic Forum article highlighted how blockchain-powered data storage can enhance the security of healthcare data and minimize risks associated with cybersecurity breaches.5 

Unlocking the Future with Cloud Computing 

Cloud computing represents a critical opportunity for healthcare organizations to modernize their operations and better serve members, patients, and stakeholders. From scalability to compliance and operational savings, the advantages are undeniable. By staying ahead of emerging trends such as interoperability and AI integration, health plans, risk-bearing providers, and TPAs can achieve new levels of efficiency and innovation.  

The adoption of cloud computing has increased significantly in recent years, with an estimated 70% of healthcare organizations having migrated to the cloud as of 2023.6 This indicates a few things, starting with growing confidence. The high adoption rate suggests that healthcare organizations have gained confidence in the security, reliability and scalability of cloud computing. In the past, the healthcare industry has been slow to adopt some technologies, historically relying on legacy systems due to the effort it would take to transfer data, but with cloud computing, we are seeing accelerated adoption. 

At HealthAxis, we are committed to empowering healthcare payers with innovative, cloud-powered solutions to streamline operations, improve scalability, and drive efficiency. Our CAPS platform, AxisCore™,  leverages the power of the cloud to deliver unparalleled performance, adaptability, and security—helping organizations navigate today’s challenges and prepare for tomorrow’s opportunities. 

Ready to see how AxisCore™ can transform your operations? Schedule a demo today!

Sources:
1Healthcare Cloud Computing Market: Growth, Size, Share, and Trends, MarketsandMarkets
2Empowered by the cloud: How cross-border health data flows can create value for patients and boost health system efficiency, HIMSS
3The 2024 Study on Cyber Insecurity in Healthcare: The Cost and Impact on Patient Safety and Care, Ponemon Institute, ProofPoint
4CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), CMS.gov
5How blockchain can improve data security in healthcare, World Economic Forum
6How Cloud Computing in Healthcare is Revolutionizing Patient Care? NetGuru

HealthAxis Names Norah Brennan as Vice President of Product Management

HealthAxis, a leader in healthcare administration technology solutions and business process operations, is proud to announce the appointment of Norah Brennan as Vice President of Product Management. With over 20 years of experience working with health plans across the country, Norah’s leadership will play a pivotal role in driving transformation, market expansion, and client success. 

“Norah’s extensive expertise in healthcare IT and proven ability to lead and design high-growth solutions will be instrumental as we continue to evolve our technology platform and services,” said Suraya Yahaya, President and CEO, HealthAxis. “Her collaborative approach and commitment to bridging operational and technology challenges perfectly align with our mission to deliver exceptional value and outcomes for our clients.” 

As Vice President of Product Management, Norah will lead the strategic direction of HealthAxis’ core administrative processing solution, AxisCore™, ensuring it continues to meet the evolving needs of healthcare payers and third-party administrators. Her previous leadership roles, including Senior Director at Cognizant Technology Solutions, highlight her track record of delivering innovative solutions that address industry-critical challenges such as interoperability and price transparency.  

“Joining HealthAxis is an incredible opportunity to work with a team that is dedicated to transforming healthcare administration,” said Brennan. “I am excited to help advance our product offerings, optimize operations, and strengthen our client relationships as we enter 2025 with a focus on growth and innovation.” 

Norah’s depth of experience includes leading teams to implement scalable solutions, modernizing legacy systems, and ensuring compliance with federal health plan regulations. Her strategic insights and client-centered focus will further elevate HealthAxis’ ability to deliver impactful solutions that empower payers and enhance member engagement. 

 

About HealthAxis
HealthAxis is at the forefront of transforming healthcare delivery in the United States, blending state-of-the-art technological solutions with unmatched expertise. Our offerings include AxisCore™, which delivers advanced core administrative processing system (CAPS) technology, and AxisConnect™, which encompasses a broad spectrum of services, including business process as a service (BPaaS), business process outsourcing (BPO), consulting, and staff augmentation. These solutions collectively empower payers, risk-bearing providers, and third-party administrators to optimize their operations, elevate efficiency, and enhance member engagement. Committed to addressing the critical challenges faced by payers, HealthAxis is dedicated to improving the experiences of members and providers, fostering positive outcomes, and contributing to the advancement of a healthier future. For more information, explore HealthAxis.com. 

Advancing Healthcare Processes with Innovative Technologies: Streamlining Operations to Focus the Human Touch

In today’s dynamic healthcare landscape, operational efficiency and member retention are more interconnected than ever. The challenge lies in finding the right balance between automation and the human touch—leveraging innovative technology to manage routine tasks while reserving human expertise for meaningful interactions. According to MarketsandMarkets, the global artificial intelligence in healthcare market is projected to grow from $14.9 billion in 2024 to $164.2 billion by 2030, highlighting the increasing reliance on technology to drive improvements across the industry.¹ 

By investing in tools like artificial intelligence (AI), machine learning (ML), and robotic process automation (RPA), healthcare payers and third-party administrators (TPAs) can streamline operations, reduce errors, and free up their teams to focus on what truly matters: serving members with empathy and precision. 

In this blog, we’ll explore three key areas where strategic investments in technology are driving healthcare operations towards the future: 

  • Reducing Cost and Errors in Claims Adjudication with AI and ML
  • Advancing Workflow Efficiency with Robotic Process Automation (RPA)
  • Redefining Call Center Operations with AI-Powered Tools 

By focusing on these innovations, we will show how healthcare payers and TPAs can streamline repetitive processes, reduce costs, and free their teams to focus on delivering exceptional member experiences. 

Taking Claims Adjudication to the Future with Reduced Processing Times, Lowered Costs 

Investing in machine learning (ML) and artificial intelligence (AI) is transforming claims adjudication, streamlining processes, and improving outcomes for healthcare payers. Predictive models and intelligent algorithms are enabling organizations to achieve higher auto-adjudication (AA) rates, reduce processing times, and minimize disputes. By automating repetitive claims tasks, payers can decrease manual errors and labor costs while increasing accuracy. 

For example, leveraging AI to identify discrepancies early in the process prevents costly errors and reduces downstream disputes with providers or suppliers. We anticipate a decline in disputes over time, particularly those related to settlement accuracy and appropriate reimbursement. These advancements allow human resources to focus on complex cases that require critical thinking and problem-solving—ensuring that when the human touch is needed, it truly makes an impact. 

Reducing Manual Tasks to Improve Time and Accuracy 

Robotic process automation (RPA) is revolutionizing how healthcare payers handle repetitive and manual tasks, creating opportunities for greater efficiency and accuracy. By deploying RPA bots, organizations can automate processes like managing 843 rejects, loading provider rosters, and matching authorizations on HCFA claims—tasks that previously consumed significant time and resources. 

This shift reduces reliance on manual labor, lowers administrative costs, and minimizes the risk of human error. For example, automating 834 recheck management ensures consistency and accuracy while freeing staff to focus on high-value activities like solving complex member issues or improving operational workflows. The result is a more streamlined operation where resources are allocated to tasks that truly benefit from human expertise. 

By utilizing RPA, HealthAxis more efficiently helps clients minimize costs and enhance administrative efficiency. For instance, automating claims processing significantly reduces manual intervention, ensuring near-perfect accuracy and faster reimbursements. This not only strengthens provider relationships but also lowers administrative labor costs. 

Scaling the Call Center 

Healthcare call centers handle an average of 2,000 calls daily. According to Dialog Health, peak staffing levels often meet only 60% of required coverage, creating a significant operational gap.² This shortfall can result in delays, frustration, and decreased satisfaction for patients seeking timely assistance. Addressing these challenges requires innovative solutions that optimize resources while maintaining high service standards. 

AI is stepping in to bridge the gap by automating routine tasks and enhancing workforce management. AI-powered chatbots and digital assistants now handle common inquiries quickly and accurately, alleviating the burden on staff and ensuring members receive prompt, reliable information. Workforce management (WFM) tools further enhance efficiency by optimizing staff scheduling and improving agent performance. 

HealthAxis is currently utilizing AI-driven voice technology built on voice large language model (LLM) infrastructure purpose-built for contact centers. This allows the interaction to be immediate, while still maintaining the conversational aspect. This system is designed to handle repetitive tasks such as checking claim status, providing coverage details, and scheduling appointments.  

By automating repetitive interactions, healthcare organizations free their human representatives to focus on complex and emotionally sensitive member issues—tasks that truly benefit from empathy and critical thinking. This strategic use of AI ensures that operational efficiency does not come at the cost of personalized service, resulting in higher member retention and better resource utilization. 

Reimagining Healthcare Through Innovation 

Investing in AI, machine learning, and automation is more than just a strategy for improving efficiency—it’s a way to reimagine operations in healthcare. By automating routine tasks, payers can reduce costs, enhance accuracy, and free their teams to focus on what matters most: delivering meaningful, human-centered care to their members. 

When organizations embrace forward-thinking technologies, they not only improve operational workflows but also create the space to build stronger, more empathetic connections with the people they serve. This is the future of healthcare—one where innovation and the human touch work hand in hand. 

Connect with our experts to learn how HealthAxis is leveraging these innovations to transform healthcare operations and deliver exceptional results for our clients.  

Author:

Nick Hutchins

Nick Hutchins
Chief Growth Officer

 

Sources:

¹Markets and Markets, Artificial Intelligence (AI) in Healthcare Market, Growth, Size, Share and Trends 

²Dialog Health, Latest Healthcare Call Center Statistics: Must-Know for 2025 

 

Looking Back at Our Most Viewed Blogs from 2024

As 2024 unfolded, healthcare organizations faced a rapidly shifting landscape—embracing advanced technologies, navigating regulatory complexities, and doubling down on member retention strategies. Throughout the year, HealthAxis delved into these challenges and opportunities, sharing insights that resonated across the industry. 

From strategies for retaining members to preparing for CMS audits and ethical AI implementation, these posts highlighted critical trends shaping healthcare. As we look to 2025, these topics remain as relevant as ever, guiding payers and third-party administrators to tackle rising operational costs, compliance pressures, and evolving member expectations. 

Here is a look back at the blogs that captured your attention in 2024. 

Achieving Member Retention Excellence: Strategies for Healthcare Payers | April 2024 

In today’s competitive healthcare landscape, retaining existing members is more cost-effective than acquiring new ones. Achieving high retention rates requires balancing member satisfaction, operational efficiency, and cost control. 

This blog brings to light the key factors healthcare payers need to consider when prioritizing member satisfaction. We will explore how identifying operational gaps can illuminate areas for improvement, ultimately leading to a more engaged and loyal membership base. Read more on member retention here. 

The Impact of Non-Compliance for Healthcare Organizations | August 2024 

In the intricate realm of healthcare, healthcare organizations confront the daunting challenge of adhering to stringent regulations. Non-compliance can precipitate severe financial penalties, erode trust, and impair operational efficacy.  

Striking a balance between regulatory adherence, operational efficiency, and financial stability is essential to safeguarding the organization’s reputation and ensuring its long-term success in a highly scrutinized and competitive industry. Read more here.  

Top Technology Investments for U.S. Healthcare Payers in 2025: Part 1 | Eric Strikowski, Chief Innovation Officer | November 2024
As operational costs rise, consumer expectations evolve, and technology rapidly advances, payers are compelled to reassess their technology priorities to stay competitive and ensure they can scale efficiently while addressing complex regulatory and operational demands. According to several sources, a few specific key areas are emerging as top investment priorities, all aimed at boosting efficiency, enhancing patient outcomes, and optimizing operations. Discover the top technology investments here.  

Ethics, Equity, & Data: The Core of Artificial Intelligence in Healthcare | Chris House, Chief Technology Officer | May 2024
While artificial intelligence (AI) has the potential to revolutionize healthcare by enhancing efficiency and accuracy, its success depends on upholding ethics, equity, and data quality. Ethical AI requires transparency and accountability to prevent perpetuating biases present in historical data. Ensuring equity involves designing AI systems that address and correct these biases to serve all demographics fairly.  

High-quality data is essential, as the effectiveness of AI models is directly tied to the integrity of the input data. HealthAxis is committed to integrating these principles to drive responsible AI innovation in healthcare. Read more about ethical AI here. 

5 Signs You’re Not Ready for Your CMS Part C and Part D Program Audit Now | Milonda Mitchell, Compliance Officer | February 2024
In the complex landscape of healthcare administration, being prepared for a CMS (Centers for Medicare & Medicaid Services) Parts C and Part D Program Audit is paramount for healthcare payers. These audits are critical for ensuring compliance with federal regulations and maintaining the integrity of healthcare services. However, several indicators can suggest an organization may not be fully prepared for such scrutiny. Find out what those signs are here. 

In 2025, HealthAxis remains focused on empowering healthcare payers and third-party administrators with forward-thinking solutions to streamline operations, improve member retention, and deliver measurable results. Schedule a discovery call to learn how HealthAxis can help your organization succeed this year and beyond. 

Interoperability: A Strategic Imperative for Healthcare Payers

Interoperability has long been a critical challenge for the healthcare industry, but for payers, it has become a strategic imperative. As regulatory mandates grow more stringent and the pressure to optimize quality and risk programs intensifies, healthcare payers must embrace interoperability to remain competitive.

Beyond compliance, interoperability presents opportunities to improve operational efficiency, enhance member experience, and realize better financial outcomes.

In this blog, we will explore:

  • How compliance serves as the foundation for strategic interoperability.
  • The challenges payers face in achieving ROI.
  • The strategic priorities driving interoperability adoption in 2025.

Compliance: The Foundation for Strategic Interoperability

Regulatory compliance remains the primary driver of interoperability initiatives for healthcare payers. According to the “2024 Gartner U.S. Healthcare Payer Interoperability Benchmarks” report, which surveyed 32 U.S. healthcare payer leaders, compliance use cases were ranked three times higher than any other interoperability priority. Regulations such as the 21st Century Cures Act and the CMS Interoperability and Patient Access Final Rule (CMS-9115-F) have compelled payers to exchange clinical and administrative data seamlessly with providers and other stakeholders.

The stakes for compliance are high. Non-compliance can result in financial penalties and damage to payer reputation. Moreover, regulatory mandates have evolved to include more granular requirements, such as support for Fast Healthcare Interoperability Resources (FHIR®) standards and transparency in coverage. While these requirements are crucial for fostering a connected healthcare ecosystem, they also pose significant technical and operational challenges for payers.

Beyond Compliance: The Strategic Value of Interoperability

While compliance is the starting point, the strategic benefits of interoperability extend far beyond meeting regulatory mandates. Gartner’s research highlights that payers increasingly view interoperability as a way to:

  • Enhance Quality and Risk Programs: By closing care gaps and improving data accuracy, payers can optimize risk adjustment and quality measure performance.
  • Improve Member Engagement: Seamless data exchange enables personalized member experiences, from proactive health interventions to streamlined claims processes.
  • Drive Cost Efficiencies: Interoperability reduces administrative redundancies and accelerates workflows, creating operational savings.

ROI Challenges: Bridging the Expectation Gap

Despite its potential, interoperability has yet to deliver consistent returns on investment (ROI) for many healthcare payers. Gartner’s survey reveals that nearly two-thirds of interoperability initiatives have not met ROI performance expectations.1 This aligns with broader industry trends, where the initial costs of technology implementation and the complexity of scaling data exchange efforts often outweigh short-term benefits.

Key Barriers to ROI

Several factors contribute to the ROI challenges of interoperability initiatives:

  • Legacy Systems: Many payers operate on outdated core systems that are not natively designed for standards-based data exchange. Integrating these systems with modern platforms can be costly and time-consuming.
  • Talent Shortages: Less than half of surveyed payers have HL7/FHIR® programmers on staff, relying instead on third-party vendors to fill the gap.
  • Provider Resistance: Interoperability requires robust collaboration with providers, many of whom are hesitant to invest in interfaces or share data due to competing priorities.

To bridge the gap between expectations and outcomes, payers must set realistic goals and invest in scalable, long-term solutions. For example, Gartner recommends incentivizing providers to participate in data exchange by subsidizing interfaces or offering financial rewards for data-sharing compliance. Additionally, updating data usage agreements and exploring innovative prepayment reimbursement models can further align payer-provider priorities.

HealthAxis plays a crucial role in helping healthcare payers address these challenges. Our core administrative processing system (CAPS) platform is designed as a modern solution, built to seamlessly support interoperability efforts without the limitations of legacy systems. Combined with our integrated business services, HealthAxis enables payers to streamline data exchange processes, achieve scalable ROI, and foster more collaborative relationships with providers—all while maintaining compliance and improving operational efficiency.

Strategic Priorities for Interoperability in 2025

Interoperability is not a one-size-fits-all initiative. Successful payers adopt a strategic approach that aligns with their organizational goals. Based on Gartner’s findings and broader industry insights, the following priorities are shaping interoperability efforts in 2025:

1. Adopting Standards-Based Frameworks
Standards such as HL7/FHIR® have become the backbone of interoperability. In 2024, the number of payers using HL7/FHIR®-based data exchange increased significantly, reflecting the industry’s shift toward more consistent and scalable frameworks. Certified electronic health records (EHRs) and health information exchanges (HIEs) are key enablers, but payers must also ensure their own systems are equipped to handle these standards.

2. Scaling Data Exchange Capabilities
Expanding the scale of data exchange is essential for achieving meaningful ROI. This includes connecting with a broader network of providers and ensuring active submission of HL7/FHIR data. Payers should prioritize investments in technology platforms that support seamless integration and real-time data exchange.

3. Fostering Provider Collaboration
Collaboration with providers is critical for scaling interoperability. According to the Gartner report, resistant providers and funding constraints are among the top barriers to success. Payers can address these challenges by building stronger partnerships and offering value-based incentives for participation in interoperability initiatives.

4. Enhancing Data Governance
Effective data governance is the foundation of interoperability. Payers must establish clear policies for data usage, privacy, and security while ensuring compliance with regulations. Leveraging advanced analytics tools can also help extract actionable insights from shared data.

5. Integrating Interoperability with Strategic Goals
To maximize impact, interoperability initiatives should align with broader strategic objectives such as member retention, cost reduction, and competitive differentiation. For example, interoperability can support care management programs that improve health outcomes while reducing costs.

Real-World Implications and Next Steps

As the healthcare landscape evolves, interoperability will continue to play a pivotal role in driving payer success. Organizations that invest strategically in interoperability—balancing compliance with innovation—will be better positioned to meet regulatory demands, enhance member experiences, and achieve sustainable growth.

HealthAxis is committed to helping healthcare payers navigate these challenges and opportunities. With expertise in core administrative platforms and integrated business services, we offer solutions that empower payers to achieve their interoperability goals efficiently and effectively.

To learn how HealthAxis can empower your interoperability strategy, connect with our experts today.

 

Sources:
1. 2024 Gartner U.S. Healthcare Payer Interoperability Benchmarks