KLAS: Payers Want Efficient Claims and Administration Platforms

Payers prefer to utilize claims and administration platforms from vendors that are efficient, manage multiple business lines, and can meet their complex needs, according to a KLAS report.

The Payer Claims & Administration Platforms 2023 report includes KLAS Decision Insights data and KLAS performance data, which reflects information about vendors and feedback from healthcare organizations.

Among 28 payer organizations, 14 considered using HealthEdge’s claims and administration solutions. The vendor received an overall performance score of 76.5 on a 100-point scale. Twelve organizations considered using Cognizant, which received a score of 74.7.

HealthEdge users noted the solution’s advanced technology and modern user interface. They also said the platform improves automated adjudication rates, drives operational efficiency, and offers solid capabilities for benefit configuration and processing claims.

However, some users want better billing functionalities and more vendor engagement, while others reported experiencing defects after upgrades and insufficient project management during implementations.

Cognizant received similar reviews, with payers of all sizes reporting satisfaction with the vendor’s ability to manage multiple business lines. Users also noted that functionality and efficiency have improved over the years. But some respondents indicated a lack of timely vendor support and issues with over-customization.

Epic was a common vendor across provider-sponsored health plans due to its integration capabilities and customer loyalty. Payers tend to use the vendor for both utilization management and claims and administration functionality. Some respondents said Epic’s health plan implementation team is less experienced than the clinical team, leading to poor usability. The vendor received a 79.0 for overall performance.

athenahealth and SS&C Health had limited data but received respective performance scores of 92.2 and 72.8. athenahealth customers praised the vendor’s EMR integration and smooth upgrade experiences but said the system’s ease of use could be better.

Payers typically work with SS&C Health for accountable care organization (ACO) contracts. User satisfaction was low, with respondents feeling uncertain about the vendor’s roadmap and citing old technology and lacking innovation and scalability.

SKYGEN USA was popular among specialty and Medicaid health plans. Users generally found the product easy to use and said the vendor was willing to adapt it to their needs. Others indicated the vendor does not proactively alert users about bugs, explain customization choices, or provide training.

Smaller health plans used Viveka Health and said the vendor is easy to work with, proactive, and innovative with technology. Customers highlighted the member-facing mobile app and the provider and patient communication feature.

Plans typically used Advantasure’s solutions for Medicare Advantage plans. With limited data, customers said the solution was effective at checking Medicare Advantage eligibility in real-time but said it cannot manage multiple business lines. Respondents also noted inefficient workflow due to separate billing and enrollment functionalities.

Similarly, limited data on Mphasis showed that users are disappointed in platform quality and implementations, with no payers planning to use the vendor again.