A health insurance model built for yesterday won’t meet the demands of today’s consumers. Expectations for seamless, intuitive experiences are accelerating, while fragmented systems continue to drive up costs, create blind spots, and erode trust.
Addressing these challenges takes more than incremental fixes. The path forward requires breaking down silos and creating synergy across plans, while aligning technology, strategy, and teams to deliver human-centered experiences at scale. This is more than operational; it’s strategic. It’s how health insurers build resilience, move with speed and purpose, and stay ahead of evolving demands.
Reflecting on recent industry conversations, we’re proud to have sponsored LeadersIgnite and the 2025 Inter-Plan Solutions Forum. As Hari Madamalla shared:
“When insurers share insights, build solutions together, and scale what works, they can cut costs, streamline prior authorization and pricing, and deliver the experiences members expect.”– Hari Madamalla, Senior Vice President, Healthcare + Life Sciences
To dig deeper into these challenges, we spoke with healthcare leaders Hari Madamalla, senior vice president, and directors Pavan Madhira and Priyal Patel about how health insurers can create a competitive edge by leveraging digital innovation with inter-plan collaboration.
The Complexity Challenge Health Insurers Can’t Ignore
Health insurance faces strain from every angle: slow authorizations, confusing pricing, fragmented data, and widening care gaps. The reality is, manual fixes won’t solve these challenges. Plans need smarter systems that deliver clarity and speed at scale. AI and automation make it possible to turn data into insight, reduce fragmentation, and meet mandates without adding complexity.
“Healthcare has long struggled with inefficiencies and slow tech adoption—but the AI revolution is changing that. We’re at a pivotal moment, similar to the digital shift of the 1990s, where AI is poised to disrupt outdated processes and drive real transformation.” – Pavan Madhira, Director, Healthcare + Life Sciences
But healthcare organizations face unique constraints, including HIPAA, PHI, and PII regulations that limit the utility of plug-and-play AI solutions. To meet these challenges, we apply our PACE framework—Policies, Advocacy, Controls, and Enablement—to ensure AI is not only innovative but also rooted in trust. This approach ensures AI is deployed with purpose, aligned to business goals, and embedded with safeguards that protect consumers and organizations.
Still, technology alone isn’t enough though. Staying relevant means designing human-centered experiences that reduce friction and build trust. Perficient’s award-winning Access to Care research study reveals that friction in the care journey directly impacts consumer loyalty and revenue.
More than 45% of consumers aged 18–64 have used digital-first care instead of their regular provider, and 92% of them believe the quality is equal to—or better.
That’s a signal leaders can’t afford to ignore. It tells us when experiences fall short, consumers go elsewhere, and they won’t always come back.
For health insurers, that shift creates issues. When members seek care outside your ecosystem, you risk losing visibility into care journeys, creating gaps in data and blind spots in member health management. The result? Higher costs, duplicative services, and missed opportunities for proactive coordination. Fragmented care journeys also undermine efforts to deliver a true 360-degree view of the member.
For leaders, the solution lies in intuitive digital transformation that turns complexity into clarity.
Explore More: Empathy, Resilience, Innovation, and Speed: The Blueprint for Intelligent Healthcare Transformation
Where Inter-Plan Collaboration Creates Real Momentum
When health plans work together, the payoff is significant. Collaboration moves the industry from silos to synergy, enabling human-centered experiences across networks that keep members engaged and revenue intact.
Building resilience is key to that success. Leaders need systems that anticipate member needs and remove barriers before they impact access to care. That means reducing friction in scheduling and follow-up, enabling seamless coordination across networks, and delivering digital experiences that feel as simple and intuitive as consumer platforms like Amazon or Uber. Resilience also means preparing for the unexpected and being able to pivot quickly.
When plans take this approach, the impact is clear:
- Higher Quality Scores and Star Ratings: Shared strategies for closing gaps and improving provider data can help lift HEDIS scores and Star Ratings, unlocking higher reimbursement and bonus pools.
- Faster Prior Authorizations: Coordinated rules and automation help reduce delays and meet new regulatory requirements like CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).
- True Price Transparency: Consistent, easy-to-understand cost and quality information across plans helps consumers make confident choices and stay in-network.
- Stronger Member Loyalty: Unified digital experiences across plans help improve satisfaction and engagement.
- Lower Administrative Overhead: Cleaner member data means fewer errors, less duplication, and lower compliance risk.
“When plans work together, they can better serve their vulnerable populations, reduce disparities, and really drive to value based care. It’s about building trust, sharing responsibility, and innovating with empathy.” – Priyal Patel, Director, Healthcare + Life Sciences
Resilience and speed go hand in hand though. Our experts help health insurers deliver both by:
- Designing for agility with composable architectures, MVP+ delivery models, and intelligent automation that accelerates time-to-value while maintaining regulatory integrity.
- Aligning digital transformation with value-based care goals, enabling organizations to shift from volume to value through strategic investments that integrate cloud platforms, interoperable systems, and advanced analytics.
- Operationalizing AI responsibly to support equitable, secure, compliant, and scalable AI adoption.
This approach supports the Quintuple Aim: better outcomes, lower costs, improved experiences, clinician well-being, and health equity. It also ensures that innovation is not just fast, but focused, ethical, and sustainable.
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Accelerating Impact With Digital Innovation and Inter-Plan Collaboration
Beyond these outcomes, collaboration paired with digital innovation unlocks even greater opportunities to build a smarter, more connected future of healthcare. It starts with aligning consumer expectations, digital infrastructure, and data governance to strategic business goals.
Here’s how plans can accelerate impact:
- Real-Time Data Sharing and Interoperability: Shared learning ensures insights aren’t siloed. By pooling knowledge across plans, leaders can identify patterns, anticipate emerging trends, and act faster on what works. Real-time interoperability, like FHIR-enabled solutions, gives plans the visibility needed for accurate risk adjustment and timely quality reporting. AI enhances this by predicting gaps and surface actionable insights, helping plans act faster and reduce costs.
- Managing Coding Intensity in the AI Era: As provider AI tools capture more diagnoses, insurers can see risk scores and costs rise, creating audit risk and financial exposure. This challenge requires proactive oversight. Collaboration helps by establishing shared standards and applying predictive analytics to detect anomalies early, turning a potential cost driver into a managed risk.
- Prior Authorization Modernization: Prior authorization delays drive up costs and erode member experience. Aligning on streamlined processes and leveraging intelligent automation can help meet mandates like CMS-0057-F, while predicting approval likelihood, flagging exceptions early, and accelerating turnaround times.
- Joint Innovation Pilots: Co-development of innovation means plans can shape technology together. This approach balances unique needs with shared goals, creating solutions that cut costs, accelerate time to value, and ensure compliance stays front and center.
- Engaging Member Experience Frameworks: Scaling proven approaches across plans amplifies impact. When plans collaborate on digital experience standards and successful capabilities are replicated, members enjoy seamless interactions across networks. Building these experiences on solid foundations with purpose-driven AI is key to delivering stronger engagement and loyalty at scale.
- Shared Governance and Policy Alignment: Joint governance establishes accountability, aligns incentives for value-based care, and reduces compliance risk while protecting revenue.
Success in Action: Empowering Healthcare Consumers and Their Care Ecosystems With Interoperable Data
Make Inter-Plan Collaboration Your Strategic Advantage
Ready to move from insight to impact? Our healthcare expertise equips leaders to modernize, personalize, and scale care. We drive resilient, AI-powered transformation to shape the experiences and engagement of healthcare consumers, streamline operations, and improve the cost, quality, and equity of care.
- Business Transformation: Activate strategy for transformative outcomes and health experiences.
- Modernization: Maximize technology to drive health innovation, efficiency, and interoperability.
- Data + Analytics: Power enterprise agility and accelerate healthcare insights.
- Consumer Experience: Connect, ease, and elevate impactful health journeys.
We have been trusted by the 10 largest health systems and the 10 largest health insurers in the U.S., and Modern Healthcare consistently ranks us as one of the largest healthcare consulting firms.
