What You Should Know:
- In recent years, the complex payer claims and administration market has seen several changes. Historically, payers have used multiple technology vendors and homegrown tools to meet their broad functionality needs. Now, payers are looking to consolidate platforms to improve efficiency and their ability to manage multiple business lines.
- As finding a platform that meets payers’ complex needs can be challenging, a new report by KLAS provides a comprehensive look at which business lines vendors are focused on, which vendors are gaining or losing market cons.
Key Insights into Payer Claims and Administration Platforms 2023
- Cognizant & HealthEdge Are Clear Mindshare Leaders; Support & Delivery Challenges Remain for Both: Cognizant is a prominent player in the market, often a top choice in purchasing decisions. Their solutions, such as TriZetto Facets and QNXT, offer comprehensive features used by payers of all sizes. Users generally trust the software’s ability to handle various business aspects. Satisfaction is high, with users noting improved functionality and efficiency over time. Some issues include delayed support and excessive customization, which can reduce efficiency and stability, prompting a few dissatisfied users to seek alternatives. Still, most Cognizant users plan to stick with the vendor. HealthEdge is gaining traction among payers considering solutions. Their advanced technology and modern user interface attract buyers. Current users find the solution enhances operational efficiency, automates adjudication effectively, and excels in benefit configuration and claims processing. Some want better billing functionalities and more engagement from the vendor, including training and timely support. Challenges reported include post-upgrade defects and inadequate project management during implementations.
- Provider-Sponsored Health Plans Frequently Consider Epic; SS&C Health* Continues to Lose Customers: Epic is a favored choice for provider-sponsored health plans using their EMR in clinical settings, driven by consolidation, integration benefits, and strong existing relationships. However, challenges arise from less experienced health plan implementation teams leading to usability problems. Athenahealth’s solid product quality, EMR integration, and upgrade processes are praised by their customers, though usability improvements are desired, and limited consideration in purchasing decisions is noted due to ownership changes and uncertainty. SS&C Health customers utilize the system for ACO contracts but express dissatisfaction with slow technology development, uncertainty about the roadmap, and replacements being driven by outdated technology and perceived lack of innovation and scalability. KLAS has not recently validated wins for athenahealth and SS&C Health.
- SKYGEN USA & Viveka Health Seen As Solid for Specialty Plans & Small Plans (Respectively); Mphasis (Eldorado)* Still Falling Short of Customer Expectations: SKYGEN USA’s product is considered user-friendly and versatile, supporting specialty business lines like dental, vision, and Medicaid. While some customers find SKYGEN adaptable and responsive to customization needs, others highlight concerns about lacking proactive bug alerts, training, and customization explanations. A need for enhanced customization and functionality support for specific commercial plans is also expressed. KLAS validated two health plans opting for SKYGEN due to its robust configurations and integration capabilities with clearinghouses and cybersecurity tools. Viveka Health caters mostly to smaller health plans and TPAs, appreciated for its executive engagement, user-friendly approach, and innovative member-facing mobile app. Advantasure* primarily serves Medicare Advantage enrollment, with its recent acquisition by UST HealthProof casting uncertainty on customer satisfaction. The solution is praised for real-time MA eligibility checks but criticized for struggling with multiple business lines and an inefficient workflow due to segregated billing and enrollment functions. Customers demand improved issue resolution timeliness, and some consider leaving due to unsatisfactory vendor relations. Limited data on Mphasis (Eldorado)* suggests disappointment among mostly TPAs, citing platform quality issues and sluggish implementations.
- Vendors Who Are Considered but Not KLAS Rated: In addition to vendors assessed by KLAS, payers making purchasing decisions also consider other options. enGen (formerly HM Health Solutions) specializes in serving Blues plans and offers BPaaS services. Flume Health has experienced recent growth, engaging with newer payer types like start-ups, nontraditional plans, and self-insured employers. This vendor is seen as technologically innovative, particularly in network management features. Oracle is frequently considered due to its established work with large payers and scalability, although its adoption is more prominent in non-US markets, raising concerns among US payers about its ability to handle US business lines. PLEXIS Healthcare Systems has gained traction due to advanced technology in their newer product version, despite being replaced by two organizations. VBA garners a few considerations, primarily focusing on the TPA market, and is noted for its positive reputation in that space. For information about other non-rated vendors’ claims and administration offerings, consult KLAS’ 2022 vendor guide.