Author: Victoria Bucci

Driving Efficiency with AI and Automation: Insights from HealthAxis CTO Chris House on Healthcare IT Today

Artificial intelligence (AI) and automation are transforming healthcare operations, and HealthAxis is at the forefront of this innovation.

In a recent feature with Healthcare IT Today, our CTO, Chris House, shared insights into how AI and Robotic Process Automation (RPA) are driving measurable improvements in healthcare administration. From reducing call handle times to streamlining claims workflows, Chris detailed the real-world applications of these technologies and their impact on efficiency, productivity, and service quality.

The discussion also covered how AI and RPA free up staff from repetitive tasks, enabling them to focus on more complex cases and improving overall service. Chris shared actionable strategies for training teams to adopt these tools effectively and offered his perspective on the future of AI and automation in healthcare.

Watch the full video to explore how AI and automation are driving measurable improvements in healthcare administration and empowering staff across the ecosystem.

At HealthAxis, we are empowering health plans to navigate this transformation with purpose-built solutions tailored to their unique needs. Connect with our experts today to learn how we can help your organization thrive in an increasingly complex healthcare landscape.

HealthAxis InFocus: Health Plan Compliance – Six Key Areas to Prioritize in 2025

Health plans face increasingly complex compliance demands. In this HealthAxis InFocus video, Compliance Officer Milonda Mitchell delves into the six priority areas health plans should focus on to reduce risk and excel in 2025.

Key Compliance Priorities Covered in the Video:

  • Medicare and Medicaid Program Integrity – Steps to prevent fraud and improve quality.
  • Affordable Care Act (ACA) and Commercial Plan Compliance – Navigating the No Surprises Act and billing transparency.
  • Privacy, Cybersecurity, and Interoperability – Ensuring secure data access and meeting HIPAA standards.
  • Health Equity – Addressing social determinants and promoting equitable care.
  • Operational Transparency and Member Communication – Providing clear, timely information to members.
  • CY 2025 Technical Changes – Preparing for upcoming shifts in data reporting and risk adjustment.

Watch the video below for a closer look at each area and find out how health plans can stay ahead of regulatory shifts while building trust with members.

At HealthAxis, compliance is embedded into our technology and services, ensuring health plans can operate with confidence in a complex regulatory landscape. Schedule a call with our experts to learn how we can help fortify your organization against risks and ensure continuous alignment with healthcare regulations.

Top Technology Investments for U.S. Healthcare Payers in 2025: Part 2

In Part 1 of this two-part series, we examined the top five technology areas receiving increased investment from healthcare payers in 2025, according to the 2025 Gartner CIO and Technology Executive Survey. Now, we turn to the next set of high-priority investments aimed at further optimizing payer operations.

Based on Gartner’s survey of healthcare CIOs, Part 2 will cover the following key areas of increasing investment:

    • Data science and machine learning platforms (31%)
    • Analytics tools for payer use cases (27%)
    • Provider data or network management applications (23%)
    • Data management and enrichment tools (20%)
    • Payment integrity tools (18%)
    • Value-based payment and analytics tools (18%)

Each area presents significant opportunities for payers to enhance decision-making, improve data quality, and drive cost savings. Let’s explore these investments and their impact on the healthcare payer industry.

Data Science and Machine Learning (ML) Platforms

Data science and machine learning platforms are becoming a strategic pillar for healthcare payers. These technologies enable payers to build predictive models, gain deeper insights into patient populations, and automate decision-making processes, improving efficiency across multiple operational areas.

Machine learning is particularly valuable for predicting high-risk patients, optimizing care pathways, and detecting fraud. According to Accenture, AI and ML in healthcare could save the U.S. economy $150 billion annually by 2026.1 These platforms enable payers to enhance the accuracy of predictive analytics, improving outcomes while driving down operational costs.

Why This Matters: Payers that leverage data science and machine learning gain a competitive edge through more accurate forecasting, better decision-making, and automation of complex processes—leading to both cost savings and improved patient outcomes.

Analytics Tools for Payer Use Cases

Analytics Advanced analytics tools are becoming increasingly vital for healthcare payers seeking to optimize operations, reduce costs, and improve patient outcomes. These tools allow payers to analyze claims data, perform member segmentation, and conduct financial forecasting, all critical for managing risk and controlling expenditures.

By leveraging real-time analytics, payers can gain insights into trends in member behavior, optimize provider networks, and monitor key performance
indicators to drive organizational performance. According to Clarify Health, business intelligence (BI) tools are key for making data actionable, allowing healthcare organizations to strategically manage revenue cycle operations, reduce claim denials, and enhance patient care.2 This integration of analytics supports better decision-making and ensures payers can stay competitive in a rapidly changing environment.

Why This Matters: Analytics tools equip payers with the actionable insights necessary to streamline operations, identify cost-saving opportunities, and make data-driven decisions that directly impact their bottom line. These tools are essential for navigating the complexities of modern healthcare.

Provider Data or Network Management Applications

Managing provider networks efficiently remains a major challenge for healthcare payers, largely due to complex and often fragmented data management processes. Many payers rely heavily on manual work to maintain accurate, up-to-date provider directories, manage contracts, and ensure compliance with regulatory standards. This manual approach can lead to data inconsistencies and delays, impacting overall network performance.

Improvements in provider data management streamline these processes and enable payers to feed accurate provider data directly into their payment integrity solutions. This integration helps prevent errors and reduces inaccurate payments, aligning with payer goals to enhance data integrity and cost control. By investing in more sophisticated network management applications, payers can improve data accuracy and simplify workflows, building a foundation for more effective provider collaboration and operational efficiency.

Why This Matters: Streamlined provider data management is critical for healthcare payers to reduce manual work and improve data accuracy. These applications not only support regulatory compliance and provider collaboration but also enhance payment integrity by feeding clean, accurate data into downstream systems, ensuring more precise claims processing and cost savings.

Data Management and Enrichment Tools

Data is at the core of payer operations, but ensuring data quality remains a challenge. Data management and enrichment tools are essential for cleaning and organizing payer data to ensure accuracy.

These tools enhance data quality by reducing duplicates, improving interoperability, and enriching member records. Poor data quality remains a widespread issue across healthcare and technology sectors, leading to inefficiencies that stem from data errors, duplicates, and incomplete records. These data challenges drive up operational costs and hinder effective decision-making. For healthcare payers, verifying data accuracy and streamlining data management is critical to reducing fraud, improving claims processing, and enhancing overall operational efficiency.

Why This Matters: High-quality data is the foundation of successful payer strategies. By investing in data management and enrichment tools, payers can increase operational efficiency, reduce errors, and enable better decision-making that drives financial performance.

Payment Integrity Tools

As healthcare payers seek to reduce fraud, waste, and abuse in claims processing, payment integrity tools have become essential. These tools utilize advanced anomaly detection and machine learning algorithms to identify unusual patterns in claims data, allowing payers to prevent improper payments before they occur. Recent advancements in provider coding practices and revenue cycle management (RCM) have led to higher claim severity, adding to the complexity and making accurate detection even more critical.

The National Health Care Anti-Fraud Association (NHCAA) estimates that healthcare fraud costs the U.S. system more than $68 billion annually, underscoring the importance of robust payment integrity solutions.3

To ensure consistency and accuracy in payment integrity, payers are increasingly adopting an enterprise-wide approach, aligning processes and thresholds across different teams. By standardizing these elements, payers can establish a cohesive strategy that enhances fraud detection, improves claim accuracy, and mitigates financial losses.

Why This Matters: An enterprise approach to payment integrity, combined with advanced anomaly detection capabilities, empowers healthcare payers to address the complexities of today’s claims environment. Standardizing payment integrity processes across teams not only reduces financial losses due to fraud but also ensures more accurate and efficient claims processing, providing a stronger, organization-wide defense against fraud, waste, and abuse.

Value-Based Payment and Analytics Tools

As value-based care (VBC) models gain traction, healthcare payers are increasingly investing in value-based payment (VBP) and analytics tools. These tools are designed to align payers and providers around quality metrics, ensuring reimbursements are tied to patient outcomes rather than service volume. However, realizing the full ROI from VBC tools requires prioritizing strong, collaborative relationships between payers and providers. Many providers lack the tools needed to gain actionable insights, making it essential for payers to support these partnerships and bridge technology gaps to foster a people-centered approach.

With relationships as the foundation, streamlined processes come next, providing both payers and providers with workflows that make it easier to monitor performance and manage value-based contracts. Finally, robust data completes the framework, enabling real-time insights and accurate evaluations that support continuous improvement and financial success in VBC models.

Why This Matters: To achieve meaningful ROI from VBC tools, healthcare payers must invest in the pillars of People, Process, and Data. By building strong provider relationships, establishing effective workflows, and leveraging accurate data, payers can support their provider partners in delivering better outcomes, thereby driving success in a value-based healthcare environment.

The Path Forward for Healthcare Payers in 2025

As healthcare payers continue to adapt to an evolving landscape, their investment priorities reflect a growing emphasis on data-driven decision-making, payment integrity, and value-based care. Technologies like machine learning platforms, provider network management applications, and payment integrity tools are becoming essential to building more efficient, cost-effective operations while improving care outcomes.

By strategically investing in these areas, payers not only ensure compliance with regulatory demands but also position themselves competitively in an increasingly complex healthcare market. As healthcare continues to evolve, staying ahead of these technological advancements will be crucial for payers aiming to scale efficiently and deliver better outcomes for members.

Ultimately, the key to success lies in leveraging these technologies to drive operational efficiency while maintaining a strong focus on improving patient care. This balanced approach will enable healthcare payers to thrive amid the challenges and opportunities that 2025 and beyond will present.

With HealthAxis’ forward-thinking technology and expert team by your side, you can confidently navigate this evolving landscape. Schedule a discovery call today to explore how we can help you achieve success in 2025 and beyond.

Author:

Eric Strikowski

Eric Strikowski
Chief Innovation Officer

Sources:

  1. AI: Healthcare’s New Nervous System, Accenture
  2. Why Healthcare Organizations Need Business Intelligence Tools Today, Clarify
  3. FWA Is Increasing. Healthcare Costs Are Spiraling, 4L Data Intelligence

Top Technology Investments for U.S. Healthcare Payers in 2025: Part 1

The healthcare payer industry is at a pivotal moment. 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 the 2025 Gartner CIO and Technology Executive Survey, several key areas are emerging as top investment priorities, all aimed at boosting efficiency, enhancing patient outcomes, and optimizing operations.

In this two-part blog series, we’ll explore the top technology investments healthcare payers are focusing on in 2025. Based on Gartner’s survey of healthcare CIOs, the first part will dive into the top five areas of increased funding, which include:

  • Consumer Experience Capabilities (66%)
  • Core Admin Systems (50%)
  • Interoperability Technologies (36%)
  • Care Management Solutions (36%)
  • Sales Enablement Applications (34%)

Each percentage reflects the proportion of healthcare payers that, according to Gartner’s research, are increasing investments in these areas.

Consumer Experience Capabilities

The drive to enhance consumer experience among healthcare payers stems from a need to influence member behavior, which hinges on building trust—something many payers have struggled to achieve. Unlike other sectors, where consumers can exercise choice, insurance is often non-optional, leaving payers with an added responsibility to cultivate loyalty in a constrained market. According to the Edelman Trust Barometer, trust is a critical factor for long-term brand success, especially in industries like healthcare, where skepticism can significantly impact engagement.1

While consumer expectations for personalized, tech-driven service are growing, many payers are grappling with how to meet these demands effectively. Heavy investments in technology for omnichannel engagement and AI-driven personalization indicate a push toward better consumer experiences, but many of these efforts have yet to translate into tangible gains in trust or loyalty. This illustrates the importance of strategic investments in consumer experience platforms that do more than streamline interactions—they must address deeper relational gaps to foster long-term member retention.

Why This Matters: By investing in cloud-native architectures and AI-driven personalization algorithms, healthcare payers can better align with member expectations, fostering engagement and loyalty in a market where consumer choice is limited. This approach not only enhances satisfaction but also supports long-term retention by addressing relational gaps, building trust, and creating a foundation for a competitive edge in today’s complex healthcare landscape.

Core Admin Processing Systems

Modernizing core administrative systems is another top priority for healthcare payers. A major challenge is the steady retirement of talent skilled in maintaining legacy infrastructure, which, combined with a growing demand for computing power to support AI-driven projects, is driving payers toward cloud-based, scalable solutions. These platforms streamline essential processes like claims management, enrollment, and payment processing while also enabling faster updates and integrations with third-party services.

According to a report by MarketsandMarkets, the global healthcare cloud computing market is estimated to be worth $53.8 billion in 2024, with a projected growth to $120.6 billion by 2029, representing a Compound Annual Growth Rate (CAGR) of 17.5%.2 This shift reflects the broader industry trend of moving away from on-premise infrastructure to more flexible, API-driven systems that allow for greater agility and cost savings.

Why This Matters: Cloud-based platforms allow payers to scale operations seamlessly, reduce infrastructure costs, and future-proof their systems against evolving regulatory requirements. The flexibility of these platforms also makes it easier to integrate new technologies, ensuring long-term operational efficiency.

Interoperability Technologies

As healthcare payers navigate growing regulatory demands, interoperability has become essential. Compliance with standards like FHIR® (Fast Healthcare Interoperability Resources) is now mandated, encouraging payers to adopt solutions that enable accurate, real-time data exchange. While the healthcare industry has yet to reach consensus on a universal data-sharing approach, payers continue investing in a variety of technologies to meet current demands. In the meantime, FHIR®-readiness facilitates smoother data flow with compliant providers, helping payers reduce manual processing and operational bottlenecks.

According to the 2023 CAQH Index, healthcare plans could save $18.3 billion annually by automating transactions like eligibility checks and prior authorizations.3 While compliance remains the primary driver, these savings illustrate an added benefit of interoperability investments. FHIR®’s standardized data structure further establishes a foundation for scalable, future-ready infrastructures.

Why This Matters: Investing in FHIR® and interoperability technologies is essential for healthcare payers to meet regulatory mandates and maintain compliance across a range of platforms. While potential cost savings offer additional value, these technologies support streamlined data exchange, foster stronger provider collaboration, and ensure payers stay aligned with evolving industry standards.

Care Management

With rising healthcare costs and increasing medical loss ratios (MLRs) placing pressure on healthcare payers, the need for advanced care management solutions has become critical. These systems use data-driven approaches to identify high-risk members, coordinate proactive interventions, and manage chronic diseases—ultimately reducing the cost of care and improving patient outcomes. According to a recent analysis by the Kaiser Family Foundation, MLRs have remained high across the individual, group, and Medicare Advantage markets, underscoring the urgency for payers to contain costs through effective care management.4

From a technical perspective, modern care management platforms integrate real-time analytics and predictive modeling tools, allowing payers to intervene early, avoid costly complications, and personalize care. This approach aligns with broader payer goals of implementing scalable solutions that not only drive down costs but also improve the overall quality of care for members.

Why This Matters: Investing in advanced care management platforms allows healthcare payers to manage rising costs effectively while enhancing the patient experience. By leveraging predictive analytics and personalized care pathways, payers can mitigate high-cost events, align with evolving care models, and remain competitive in an increasingly cost-sensitive market.

Sales Enablement Applications

To remain competitive, healthcare payers are increasingly investing in sales enablement tools that align marketing and sales efforts, streamline member acquisition processes, and optimize retention strategies. These tools, especially when integrated with cloud-based platforms, provide real-time insights and facilitate team collaboration, offering a model for efficiency that payers can extend to their core administrative systems.

Salesforce reports that companies using sales enablement platforms see a 15% improvement in their win rates, highlighting the strategic value of these technologies.5 By incorporating data analytics, payers can optimize their go-to-market strategies and improve member retention in an increasingly crowded marketplace.

The success stories seen with cloud-enabled sales tools demonstrate the potential for enhanced agility and scalability. By embracing cloud integration across their tech stack, healthcare payers can drive more effective member engagement while setting a foundation for operational improvements in core admin systems.

Why This Matters: Cloud-enabled sales enablement tools provide healthcare payers with actionable insights and streamlined processes that enhance competitiveness and efficiency. These tools showcase the benefits of cloud adoption, which can be extended to core administrative functions, helping payers sustain an agile, data-driven approach across their operations.

The Path Forward for Healthcare Payers: Laying the Foundation for Long-Term Success

These top five technology investments represent key areas where healthcare payers are dedicating significant resources to meet evolving challenges and seize new opportunities. By focusing on improving consumer experiences, modernizing core systems, ensuring interoperability, enhancing care management, and streamlining sales processes, payers are laying the groundwork for more efficient and effective operations in 2025 and beyond.

Incorporating these advancements not only helps payers meet regulatory and operational demands but also positions them for long-term success in a rapidly evolving healthcare market. The ability to adapt to these trends will be critical for maintaining a competitive edge while delivering better outcomes for members.

Read Part 2 to explore additional strategic investments, including data science platforms, analytics tools, and payment integrity technologies—equally crucial areas that are shaping the future of healthcare administration.

Author:

Eric Strikowski

Eric Strikowski
Chief Innovation Officer

Sources:
1. 2024 Edelman Trust Barometer, Edelman
2. 17.5% CAGR Fueling $120.6B Healthcare Cloud Computing Market by 2029, MarketsandMarkets
3. The CAQH Index Report, CAQH
4. Health Insurer Financial Performance in 2023, Kaiser Family Foundation
5. Everything You Need To Know About Sales Enablement, Alore

HealthAxis Names Suraya Yahaya President and CEO, Building on Strategic Growth

HealthAxis, a leader in healthcare administration technology and business process operations, today announced the appointment of Suraya Yahaya as the company’s new Chief Executive Officer while she continues to serve as President. Suraya has held the role of President and Chief Operating Officer since November 2023, where she played a crucial role in driving strategic growth, operational excellence, and client success. Her promotion to CEO builds on her strong leadership and proven organizational impact.

Suraya has extensive experience scaling business operations and advancing client-centric, technology-driven solutions that empower healthcare payers to optimize their processes and improve member engagement. Under her leadership as President and COO, HealthAxis achieved significant milestones by driving automation and implementing AI-based tools, positioning the company as a leader in healthcare administration technology. As President and CEO, Suraya will continue to lead HealthAxis into its next phase of growth, focusing on innovation, operational excellence, and client outcomes.

“I am honored to step into the role of President and CEO at such a pivotal time for HealthAxis,” said Suraya Yahaya, President and CEO of HealthAxis. “Our mission to transform healthcare administration through forward-thinking technology and client-centered solutions has never been more important. I look forward to leading our talented team as we continue to deliver exceptional results for our clients, foster cutting-edge advancements, and strengthen our impact in the healthcare industry.”

HealthAxis remains committed to providing healthcare payers and third-party administrators with comprehensive, end-to-end healthcare administration solutions that streamline operations, improve efficiency, and drive better healthcare outcomes. Suraya’s leadership will further reinforce the company’s dedication to innovation and operational excellence.

For more information about HealthAxis, please visit HealthAxis.com.

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, visit HealthAxis.com.

Optimizing Medicaid Redetermination: Boosting Member Retention and Recruitment

As states resume verifying Medicaid beneficiaries’ eligibility post-COVID-19, health plans face the daunting task of managing large-scale redeterminations. This process has significant financial implications, from maintaining membership levels to ensuring positive outcomes on key quality measures, such as the Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS). The stakes are high: failure to engage eligible members could lead to a drop in retention and recruitment, directly impacting the bottom line.

In this blog post, we explore these challenges and discuss strategies to optimize Medicaid redetermination while enhancing both member retention and recruitment.

Understanding Medicaid Redetermination

The Importance of Redetermination

Medicaid redetermination is a process where state agencies review beneficiaries’ eligibility to ensure they still qualify for benefits. This process was largely paused during the COVID-19 pandemic due to continuous enrollment policies. In a normal year, about 17 million people lose Medicaid or Children’s Health Insurance Program (CHIP) coverage – some because they’re no longer eligible, but others because of red tape. That means that during the pandemic, more than 50 million Medicaid terminations did not happen.1 With three years of eligibility renewals happening concurrently, it’s more important than ever to help those still eligible maintain coverage and assist others in transitioning to employer-sponsored or ACA Marketplace plans, ensuring health plans avoid a significant drop in membership numbers.

Challenges Faced by Health Plans

The redetermination process brings several challenges for health plans:

  • Member Engagement: Reaching and engaging members who may be unfamiliar with the redetermination process.
  • Difficulty Reaching the Member: Utilizing communication channels that align with member preferences and current contact information.
  • Personalizing Outreach: Ensuring communication is tailored to each member’s specific situation, preferences, and behaviors.
  • Using SDoH Data Meaningfully: Leveraging data on social determinants of health (SDoH) to better understand and address the needs of members.

Strategies for Optimizing Redetermination

1. Invest in Long-Term Engagement Technologies and Services

Health plans should invest in technologies and tech-enabled services that foster long-term engagement and support a comprehensive member experience. Instead of relying on a single tool for one initiative, health plans should adopt a suite of solutions that engage and educate members throughout their relationship with the plan. According to Gartner, leveraging technology to enhance the member experience plays a critical role in improving long-term retention by keeping members engaged and satisfied throughout their journey.2

Examples of Effective Technologies and Services:

  • Communication Platforms: Tools that connect with members through multiple channels—such as text messages, emails, and phone calls—ensure members receive information in their preferred format.
  • Engagement Tools: Platforms that personalize communication-based on member preferences and behaviors can significantly improve engagement rates.
  • Core Administrative Technology: Implementing robust core administrative systems can streamline operations, reduce administrative burdens, and improve data accuracy, thereby enhancing member interactions and support. For example, HealthAxis’s core system is designed to make member engagement more seamless by allowing for fluid data transfer between modules. This design enables more efficient tracking of member interactions and improves data accuracy, which ultimately enhances overall outcomes.
    • Transitioning to a new platform can be time-consuming; therefore, if time is a constraint, consider engaging a consultant to optimize your existing system to streamline processes and enhance member engagement.
  • Business Process as a Service (BPaaS): Leveraging BPaaS solutions can help health plans manage back-office functions more efficiently, allowing them to focus on member-facing activities and ensuring a seamless redetermination process.

By integrating these technologies and services, health plans can create a more responsive and engaging environment, leading to higher member retention and recruitment.

2. Leverage Trusted Providers and Community Resources for Communication

Members tend to trust healthcare providers and community organizations more than health plans. According to a study by the American Board of Internal Medicine Foundation, 84% of people trust doctors, while only 33% trust health insurance companies.3 Health plans can leverage this trust by collaborating with healthcare providers, pharmacies, local public agencies, and community-based organizations to communicate redetermination requirements.

Strategies for Leveraging Provider and Community Trust:

  • Integrated Messaging: Include redetermination reminders in provider communications, such as appointment notifications and care management updates.
  • Partnerships with Community Resources: Collaborate with community organizations and pharmacies that members regularly engage with, especially for members who may not have consistent healthcare interactions or stable residence.
  • Incentives for Providers: Offer value-based payment incentives to providers who assist members with the redetermination process.

3. Personalize Member Communication

Tailored communication is crucial for meeting the diverse needs of Medicaid members. Members come from various backgrounds and have different levels of digital literacy, making personalization key to boosting engagement and compliance.

Health plans can capitalize on the data they already collect to drive personalization efforts. Specific data cleansing and management techniques employed by HealthAxis ensure that this data is reliable and actionable, allowing for more targeted outreach.

Personalization Techniques:

  • Customized Content: Use data to tailor messages for individual members, addressing their specific circumstances and needs.
  • Multiple Communication Channels: Ensure members can receive information through their preferred channels, such as text, email, phone calls, or mail.

4. Address Social Determinants of Health (SDoH)
SDoH—such as housing, food security, and employment—play a crucial role in members’ ability to engage with the redetermination process. Health plans should integrate SDoH data into their strategies to provide meaningful support for members facing such barriers.

Incorporating SDoH into Member Support:

  • Comprehensive Support Services: Offer resources and referrals for housing, food assistance, and other social services.
  • Partnerships with Community Organizations: Collaborate with trusted community agencies to provide holistic support for members and address their broader needs.

Real-World Success: California’s Medi-Cal Program

California’s Medi-Cal program provides an excellent example of effective redetermination strategies. Starting in April 2023, California implemented 17 federal waivers and flexibilities to streamline the redetermination process. These included income-based and administrative waivers that significantly eased the process for Medi-Cal members. For example, California automated income-based waivers in eligibility and enrollment systems, increasing the ex parte renewal rate from an average of 34% to 66% by December 2023.4

Additionally, California’s efforts to partner with the United States Digital Services (USDS) to automate these waivers resulted in a dramatic reduction in Medi-Cal disenrollments, dropping from 19-21% to 9% in December 2023.4 These measures not only streamlined the redetermination process but also significantly improved member retention and satisfaction

Navigating the Redetermination Challenge

Optimizing Medicaid redetermination is a complex but essential task for health plans. By focusing on enhancing the member experience through long-term engagement technologies, leveraging trusted providers, personalizing communication, and addressing social determinants of health, health plans can navigate this challenging process effectively.

At HealthAxis, we are committed to supporting health plans 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 health plan.

Author:

Nick Hutchins

Nick Hutchins
Chief Growth Officer

Sources:
1. CMS Fact Sheet: Keeping People Covered As States Restart Routine Medicaid Renewals, CMS
2. Quick Answer: How Can Medicaid Redetermination Optimize the End-to-End Member Experience?, Gartner
3. Surveys of Trust in the U.S. Healthcare System, The American Board of Internal Medicine Foundation.
4. California’s Journey with Medi-Cal Redeterminations, DHCS

HealthAxis and COPE Health Solutions Announce Strategic Partnership to Drive Value-Based Care and Operational Efficiency Across Health Plans and Providers

HealthAxis, a leader in healthcare administration technology and business process operations, and COPE Health Solutions (CHS), a national expert in value-based care and population health management, are pleased to announce a strategic partnership aimed at delivering comprehensive, end-to-end solutions for health plans and for providers in value-based payment arrangements, including employee health plans. This collaboration brings together HealthAxis and COPE Health Solutions scalable CAPS and ARC platforms and business process operations with CHS’ expertise in, value-based payment models, medical management, and analytics to drive operational efficiency and clinical excellence across the healthcare industry.

The partnership will be focused on supporting payers and risk-bearing providers—to streamline operations, reduce costs, and optimize clinical and quality performance.

“Our partnership with COPE Health Solutions underscores our shared vision of empowering healthcare organizations to thrive in a rapidly evolving industry. By combining HealthAxis’ healthcare administration services with COPE Health Solutions’ population health management technology solutions and value-based payment expertise, we are uniquely positioned to deliver comprehensive, high-impact solutions that address both operational efficiency and clinical excellence.”

Scott Martin

Scott Martin
CEO
HealthAxis

“Collaborating with HealthAxis enables us to bring a truly comprehensive and high-quality solution set to our clients nationally who are regional health plans, providers sponsored health plans, self-insured employers, delegated IPAs and other providers in advanced risk arrangements. Meeting clients where they are, we can provide a full TPA or MSO solution enabled by our co-source model or more targeted solutions in areas such as medical management, care management, network build and management, analytics and others.”

Allen Miller, Principal & Chief Executive Officer, COPE Health Solutions

Allen Miller
Principal & Chief Executive Officer
COPE Health Solutions

For more information about HealthAxis and COPE Health Solutions, please visit HealthAxis.com and COPEHealthSolutions.com.

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, visit HealthAxis.com.

About COPE Health Solutions
COPE Health Solutions (CHS) is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers. For more information, visit COPEHealthSolutions.com.

Cybersecurity in Healthcare: Four Essential Practices to Protect Health Plans and TPAs

Every October, organizations across the public and private sectors come together to observe Cybersecurity Awareness Month. Established in 2004 by a joint declaration from the President of the United States and Congress, this month serves as a critical reminder of the importance of cybersecurity in an increasingly digital world. What began as a U.S. initiative has grown into a global movement, with governments and industries collaborating to raise awareness about the ever-evolving landscape of cyber threats.

Now in its 21st year, Cybersecurity Awareness Month encourages organizations to adopt proactive measures to safeguard personal, financial, and operational data. This year’s focus on best practices serves as a vital guide for healthcare organizations looking to strengthen their defenses.

Protecting sensitive information is paramount in the complex and data-heavy world of healthcare. Health plans and Third-Party Administrators (TPAs) handle large volumes of patient health data, making them prime targets for cyberattacks. As healthcare organizations rely heavily on technology for managing claims, enrollments, and billing, the risk of a breach grows, making cybersecurity not just a priority but a necessity.

In this blog, we will explore four essential practices that healthcare organizations can adopt to enhance their cybersecurity strategies. Building upon guidance from the Cybersecurity & Infrastructure Security Agency (CISA), we have tailored these practices specifically for health plans and TPAs:

  • Recognize and Report Phishing
  • Use Strong Passwords
  • Enable Multi-Factor Authentication (MFA)
  • Keep Software Updated

These tips are designed to help healthcare organizations protect their data and maintain trust with their members, ensuring operational stability and regulatory compliance.

1. Recognize and Report Phishing: Identifying the First Line of Attack

Phishing

Phishing attacks remain one of the most common and dangerous forms of cyber threats. According to the Verizon 2024 Data Breach Investigations Report, phishing remains a significant issue, with the human element involved in 68% of all breaches.1 Furthermore, phishing simulations revealed that 20% of users reported phishing attempts, though the median time for a user to click on a phishing link was alarmingly fast—just 21 seconds.

In healthcare administration, where multiple touchpoints exist between patients, providers, and administrators, phishing schemes are particularly disruptive. Health plans and TPAs must train employees to detect suspicious emails or messages that appear to come from trusted sources but are, in fact, designed to steal sensitive information. Proper reporting channels ensure that phishing attempts are caught and neutralized quickly, reducing the risk of further compromise.

What to Do:

  • Educate employees to recognize telltale signs of phishing, such as unfamiliar senders, incorrect domains, or unexpected attachments.
  • Establish a streamlined reporting process to alert the IT team to suspicious emails and potential phishing attempts.

2. Use Strong Passwords: Fortifying the Gateway to Sensitive Data

Password

Weak passwords remain one of the easiest ways for cybercriminals to access critical systems. According to the CrowdStrike 2024 Global Threat Report, credential-based attacks continue to be a preferred entry method for cyber adversaries, with a 60% year-over-year increase in the number of interactive intrusion campaigns.2 These attacks typically involve the use of stolen or weak credentials to gain access to critical systems, emphasizing the importance of strong, unique passwords to protect healthcare administration systems.

For health plans and TPAs, password policies need to go beyond the basics, ensuring that passwords are not only strong but also unique and regularly updated. Utilizing password management tools can help reduce the risk of using weak or reused credentials.

What to Do:

  • Mandate that passwords be at least 12 characters, incorporating numbers, symbols, and a mix of upper- and lower-case letters.
  • Provide employees with password management tools to ensure they use unique and strong passwords across systems.

The CrowdStrike report emphasizes that password-related vulnerabilities remain a leading cause of system breaches, underscoring the necessity of password security in any comprehensive cybersecurity strategy.

3. Enable Multi-Factor Authentication (MFA): Adding an Extra Layer of Security

Multi-Factor Authentication (MFA)

Multi-Factor Authentication (MFA) is a crucial security measure that goes beyond the use of passwords. According to Microsoft, enabling MFA can block 99.9% of automated cyberattacks.3 With over 300 million fraudulent sign-in attempts to Microsoft’s cloud services daily, MFA has proven to be a powerful tool in preventing unauthorized access.

For health plans and TPAs, MFA can dramatically reduce the risk of unauthorized access to systems containing sensitive personal and financial data. MFA requires users to provide an additional form of verification—such as a one-time code sent to their phone or email—before accessing systems. Even if a password is compromised, MFA provides a critical second layer of defense.

What to Do:

  • Require MFA for all platforms that handle sensitive data, including client portals, health plan administrative systems, and billing platforms.
  • Ensure vendors and partners also use MFA to protect shared systems.

By implementing MFA, organizations can significantly decrease the chances of account compromise, making it a vital part of a robust security strategy.

4. Update Software: Staying Ahead of Vulnerabilities

Update Software

Outdated software continues to be one of the most significant vulnerabilities in healthcare systems. According to the 2023 Ponemon Institute Cost of Insider Risks Report, organizations that experienced insider-related incidents attributed a significant percentage of breaches to employee negligence, which includes failing to update or patch software. In fact, non-malicious insider incidents—often caused by oversight such as missing software updates—represented 55% of all insider incidents, costing organizations an average of $505,113 per incident.4

Health plans and TPAs rely on numerous systems to handle sensitive data, and failure to keep these systems updated leaves them vulnerable to both insider threats and external attacks. Regular software updates ensure that known vulnerabilities are patched, reducing the likelihood of successful cyberattacks.

What to Do:

  • Implement a routine schedule for system audits and software updates, prioritizing critical patches for known security vulnerabilities.
  • Partner with vendors who proactively deliver security updates for their software solutions.

By staying on top of software updates, healthcare organizations can significantly reduce the risk of insider incidents and potential breaches, keeping sensitive data secure.

Commitment to Cybersecurity Beyond October

National Cybersecurity Awareness Month serves as an annual reminder to evaluate and strengthen your organization’s security posture. For health plans and TPAs, securing sensitive health data is about more than compliance—it’s about trust, reputation, and operational stability. By adopting best practices like recognizing phishing, using strong passwords, enabling MFA, and keeping software updated, your organization can mitigate risk and better protect your data from cyber threats.

At HealthAxis, our commitment to cybersecurity extends beyond mere observance of this month. It’s woven into our daily operations and solutions to ensure that we provide the highest standards of security for our clients. Cybersecurity is a shared responsibility, and with the right tools and practices in place, we can all contribute to building a safer healthcare administration ecosystem.

Author:

Ralph Pugh

Ralph Pugh
Information Security Analyst III

Sources:

  1. 2024 Data Breach Investigations Report, Verizon
  2. 2024 Global Threat Report, CrowdStrike
  3. One Simple Action You Can Take to Prevent 99.9 Percent of Attacks on Your Accounts, Microsoft
  4. 2023 Cost of Insider Risks Global Report, Ponemon Institute | DTEX

HealthAxis InFocus: Claims Efficiency – Lower Costs, Higher Retention

In this installment of HealthAxis InFocus, Dawn Pardee, Director of Claims Operations, shares valuable insights into how healthcare payers can improve claims processing efficiency to reduce costs and enhance member retention.

With the increasing complexity of healthcare claims, leveraging solutions like Robotic Process Automation (RPA) is becoming essential for streamlining operations. Dawn explains how automating repetitive tasks not only speeds up processing times but also reduces errors, allowing payers to focus on higher-priority claims and ultimately improve the member experience.

Ready to transform your operations? Connect with our experts to learn how HealthAxis can help you leverage cutting-edge technology for your health plan.

Open Enrollment Readiness: Expert Insights from HealthAxis – Call Center Edition

Welcome to the third edition of our blog series, Open Enrollment Readiness: Expert Insights from HealthAxis. This series is designed to provide health plans with actionable insights and expert advice to navigate the complexities of the open enrollment period successfully.

In our first two editions, we covered critical areas of compliance with insights from our Compliance Officer, Milonda Mitchell, and explored best practices for enrollment processes with Rosalie Torres, our Associate Director of Enrollment and Fulfillment Operations.

In this edition, we’re turning our focus to the heart of member engagement during open enrollment: call center operations. To guide us through this vital topic, we’re featuring Jason Master, Vice President of BPO Operations at HealthAxis. With a robust background in healthcare operations and a passion for innovation, Jason will share his expert insights on managing increased call volumes, tracking performance metrics, and leveraging technology to enhance call center efficiency during open enrollment.

How can health plans effectively manage increased call volumes during open enrollment while maintaining high levels of customer satisfaction?

Jason Masters

Jason Master

Vice President of BPO Operations

Managing the surge in call volumes during open enrollment is a significant challenge, but it’s also an opportunity to reinforce member trust through exceptional service. To effectively handle the influx, health plans should implement a multifaceted approach focused on strategic staffing, advanced call center technology, and a strong emphasis on customer service excellence.

First, it’s crucial to have a well-prepared staffing plan in place. This means hiring additional temporary staff to manage the increased volume and investing in thorough training programs well before open enrollment begins. Agents should be fully equipped with the knowledge and tools they need to resolve member inquiries efficiently, reducing the need for call transfers and ensuring first-call resolution.

Additionally, utilizing intelligent call routing systems can significantly enhance efficiency. By directing calls to the most appropriate agents based on their expertise, health plans can minimize wait times and ensure that members receive the right answers promptly. This, coupled with self-service options such as interactive voice response (IVR) systems and online FAQs, can help deflect routine inquiries, allowing agents to focus on more complex issues.

Lastly, maintaining high levels of customer satisfaction requires a culture of empathy and active listening. Agents should be trained to handle stressful situations calmly and to communicate clearly and compassionately. Providing regular feedback and support to agents during this peak period can help maintain morale and, in turn, improve the overall member experience.

What key metrics should health plans track to measure call center performance during open enrollment, and how can these metrics be used to improve operations?

Tracking the right metrics is essential for health plans to assess call center performance and identify areas for improvement during the busy open enrollment period. The key performance indicators (KPIs) that should be monitored include:

  • Service Level:
    • The percentage of calls answered within a specific time frame (e.g., 80% of calls answered within 30 seconds).
    • Reflects the responsiveness of the call center and impacts customer satisfaction.
  • Average Hold Time (AHT)
    • This is the amount of time a caller spends on hold before speaking to a representative.
    • The goal is to balance efficiency with quality—short calls are not always better if they leave issues unresolved.
    • Monitoring AHT alongside First Call Resolution (FCR) helps ensure that efficiency does not compromise customer satisfaction.
  • Call Abandonment Rate
    • Reflects the percentage of callers who hang up before speaking to an agent.
    • A high abandonment rate often signals long wait times or inadequate staffing levels.
    • Tracking this metric in real-time allows for necessary adjustments, such as reallocating resources or activating overflow teams, to better manage call volume and reduce wait times.
  • First Call Resolution (FCR)
    • Measures the percentage of calls resolved without the need for follow-up.
    • A high FCR indicates that agents are well-trained and empowered to handle a variety of inquiries on the spot.
    • Improving FCR can reduce overall call volume and enhance member satisfaction by addressing issues promptly.
  • Customer Satisfaction Score (CSAT)
    • Provides direct feedback from members about their experience.
    • Regular post-call surveys offer insights into service effectiveness and help identify areas for improvement.
    • Dips in CSAT can prompt immediate corrective actions to address service quality issues before they impact overall member satisfaction.

By closely monitoring these metrics, health plans can make data-driven decisions to optimize call center operations. For instance, if AHT or call abandonment rates are rising, it may indicate a need for additional training or a reevaluation of call routing strategies. Similarly, dips in CSAT can prompt immediate corrective actions to address service quality issues before they affect overall member satisfaction.

How can health plans leverage technology and automation to streamline call center operations and improve agent productivity during open enrollment?

Health Technology and automation are powerful tools that can transform call center operations, especially during the intense period of open enrollment. By integrating advanced solutions, health plans can streamline processes, reduce the burden on agents, and ultimately improve the quality of service provided to members.

One of the most impactful technologies is intelligent call routing, which uses algorithms to direct calls to the most suitable agent based on the caller’s needs and the agent’s expertise. This reduces the time spent transferring calls between departments and ensures that members receive accurate and timely assistance, leading to higher satisfaction rates.

Automation can also play a significant role in handling routine inquiries, such as account balance checks or basic plan information. By utilizing AI-driven chatbots and interactive voice response (IVR) systems, health plans can provide members with instant answers to common questions without requiring human intervention. This not only frees up agents to focus on more complex issues but also reduces wait times for members.

Workforce management tools are also crucial during open enrollment, as they allow health plans to forecast call volumes and adjust staffing levels accordingly. These tools can schedule shifts, monitor agent performance, and ensure that the call center operates at optimal efficiency throughout the enrollment period.

By leveraging these technologies, health plans can not only handle the increased demand during open enrollment but also deliver a superior member experience. The result is a more efficient operation that supports both the plan’s objectives and the needs of its members.

If you need immediate support or have questions about how HealthAxis can assist in your open enrollment readiness, connect with our experts today. We’re here to help ensure your success during this pivotal time.