2022 Best In KLAS Payer Claims & Administration Platforms

Submitting and following up on requests for prior authorization is often a manual, time-consuming process, creating administrative burden for both payer and provider organizations and potentially delaying needed care for patients. The stakeholders in this collaboration worked to streamline the process by automating the submission and follow-up for authorization requests, enabling providers to complete these tasks from within their EMR workflow. Results include faster turnaround times, reduced administrative workload, and fewer denials.

Performance

CMS Payer Interoperability 2022

13 September 22 | Joe VanDeGraaff and Ruirui Sun

CMS recently issued a new regulation stipulating that CMS-regulated payers must be able to securely store and share patient data under the HL7 FHIR standard. To achieve this, organizations use CMS payer interoperability products, which usually provide capabilities such as patient access APIs, provider directory APIs, and payer-to-payer data exchange. Health plans and state agencies are evaluating how well technology vendors’ existing or newly developed solutions can help them stay compliant with the new CMS requirements. This report is KLAS’ first to validate the purchase decisions and customer experience of some of the vendors in this area.

Value-based care models have created widespread recognition among health plans that flexible technology is a must, while the need to be more member-centric and digitally focused is driving a desire for better integration between claims platforms and other payer HIT applications. This vendor guide is intended as a simple starting point for health plans and TPAs investigating payer claims and administration platforms. The guide is limited only to vendors with commercial software solutions (services firms are not covered) and includes all vendors known to KLAS as of July 2022.

Though core administration platforms are essential for payer organizations, many of the products in the market are perceived as outdated, complex, and low performing (the market has one of the lowest average performance scores of any KLAS measures). However, HealthEdge has recently seen increased attention from both small and large health plans, who view the vendor’s technology as innovative and who have been asking KLAS for vendor insights. This report examines the experience of HealthEdge customers and how the HealthEdge technology stands out from competitors’.

Company/solution	Overall score	Total evaluations	Trend (2021-2022)	Culture	Loyalty	Operations	Product	Relationship	Value	Censinet assessment

HealthEdge HealthRules Payor	78.1	n=17	+2%	C-	B+	C+	C+	B-	C

Cognizant Trizetto Core Claims/Administration Solutions	70.8	n=28	-9%	C-	C	C+	C	C-	D
	50.0	100.0		*Limited Data

Company/solution	Trend (2021-2022)	Culture	Loyalty	Operations	Product	Relationship	Value

HealthEdge HealthRules Payor 78.1 n=17 COMMENTS	+2%	C-	B+	C+	C+	B-	C
Cognizant Trizetto Core Claims/Administration Solutions 70.8 n=28 COMMENTS	-9%	C-	C	C+	C	C-	D

Company/solution	Overall performance score	Total evaluations	Culture	Loyalty	Operations	Product	Relationship	Value	Censinet assessment

Advantasure Core Administration Solutions * L C	66.3	n=11	D-	C	D	D	C-	D

Conduent HSP (MediTrac) * L	90.3	n=6	A	A+	A-	B+	A-	B+

Epic Tapestry [C] C	83.4	n=20	B	B+	B	B-	B+	B-

SS&C Health DST Health Solutions Core Claims/Administration Solutions * L	0	n=0	Error getting product's grades

Company/solution	Overall performance score	Total evaluations

Advantasure Core Administration Solutions * L C culture D- loyalty C operations D product D relationship C- value D	66.3	n=11

Conduent HSP (MediTrac) * L culture A loyalty A+ operations A- product B+ relationship A- value B+	90.3	n=6

Epic Tapestry [C] C culture B loyalty B+ operations B product B- relationship B+ value B-	83.4	n=20

SS&C Health DST Health Solutions Core Claims/Administration Solutions * L Error getting product's grades	0	n=0

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