en.Wedoany.com Reported - HealthEdge CEO Kevin Adams recently gave an industry media interview, elaborating on his company's unique model of bypassing health plan Chief Information Officers (CIOs) to directly collaborate with Chief Financial Officers (CFOs) and Chief Operating Officers (COOs) on business process transformation. He pointed out that currently, 95% of artificial intelligence (AI) applications in the health plan sector fail to deliver measurable results.
Adams founded UST HealthProof in 2015. The company focuses on serving community and regional health plans, operating claims processing through a "technology plus services" model and offering guaranteed prices 20% to 40% lower than competitors. In ten years, it grew from zero to $520 million in revenue and 5,000 employees. In 2025, Bain Capital acquired UST HealthProof for $1.3 billion and merged it with portfolio company HealthEdge. Adams stated that UST HealthProof was once HealthEdge's largest customer, and the combined company has adopted a model called "Business Process as a Service," promising health plans to process claims accurately, compliantly, and 30% to 40% cheaper than the plans could handle themselves.
Discussing the health plan market, Adams noted that HealthEdge and Cognizant's Trizetto division each hold about 20% market share, totaling approximately 40%, while the remaining 60% of the market uses traditional, often in-house mainframe solutions. He revealed that the company has completed validation with Amazon Web Services (AWS) and expanded its product to support 35 million members. Regarding the current migration of large-scale users from mainframes, he mentioned that the Centers for Medicare & Medicaid Services (CMS) has issued a Request for Proposal (RFP) to migrate all fee-for-service Medicare within the next six months, affecting 34 million Americans. Adams emphasized that the company's business model involves minimal interaction with CIOs, instead directly targeting COOs and CFOs by outsourcing business processes and guaranteeing price points, significantly reducing health plan costs.
On AI applications, Adams believes that 95% of AI on the market today is essentially glorified Robotic Process Automation (RPA) and does not change fundamental issues. He advocates embedding AI directly into the core processing engine rather than adding wrapper layers externally. He estimates that by deeply integrating AI into products, the company could reduce claims processing staff by 50% over the next two to three years. Adams also mentioned that as providers and payers compete using AI in prior authorization and claims denial, the government needs to establish clearer rules at the Medicare level to lower overall costs and simplify the issue.
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