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Payer Software

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Boyd Stewart
VP of Payer/Provider Collaboration
KLAS VP of Payer/Provider Collaboration - Boyd Stewart

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Point of Light
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Points of Light 2025 Case Study 8
13 May 25    |   Aurene Wilford and Boyd Stewart
The payer organizations in this collaboration were struggling to access patient data in a timely manner to determine risk scores and meet quality measures. Historically, the organizations would send requests for medical records to Healthcare Organization 8 at a certain time of year, which overwhelmed that organization. To mitigate these challenges, the stakeholders collaborated with Moxe Health and Cotiviti to automate the release of information (ROI). This led to a more efficient ROI process and time savings for the payer and healthcare organizations.
Performance
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Risk Adjustment 2024
24 September 24    |   Bradley Hunter and Jennifer Hickenlooper
As payers, provider-sponsored health plans, and provider organizations continue to grapple with economic and financial pressures, their need for risk adjustment solutions with both retrospective and prospective capabilities remains high. Solutions that provide a strong ROI and have broad capabilities are top of mind for potential customers, who often want to realize better value and consolidate solutions. To understand what factors are influencing purchase decisions and where organizations are investing, this report examines 52 risk adjustment purchase decisions validated by KLAS between June 2021 and June 2024. Satisfaction data from current customers is also included.
Performance
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CMS Payer Interoperability 2024
21 May 24    |   Ruirui Sun and Tyson Blauer
With the initial goal of meeting CMS requirements (e.g., CMS-9115-F), payer organizations have invested heavily in interoperability solutions to transform data into the FHIR format and provide APIs for member portals and other data exchanges. Still, industry-wide usage among patients for these types of offerings is low, with very few enrolled members asking payers for their medical information. As a result, payers need to determine how to utilize the solutions in a way that maximizes their value, especially as some payers report higher price tags from vendors for the technology to support more use cases. To help payer organizations navigate this field, this report examines the performance of CMS interoperability vendors as well as what current and future use cases are a priority for payers.
Performance
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Customer Relationship Management 2024
24 April 24    |   Adam Cherrington and Jacob Brown
To personalize healthcare and prioritize patient preferences, provider organizations often use customer relationship management (CRM) tools, which can effectively organize and present the details of a patient population. Recently, the CRM market has shifted—vendors have entered the market, sensing the opportunity to address organizations’ growing interest in personalizing care and improving their management of patient data, and some of these newer entrants are now on par with seasoned players. This report examines customers’ experiences with three vendors to see how well they partner with customers and deliver strong technology.
White Paper
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Data Analytics Platforms for Payers
20 March 24    |   Bradley Hunter and Jennifer Hickenlooper
As health plans continually look to reduce costs and improve outcomes for their members, they are utilizing data analytics platforms to bring better visibility to their decisions. This vendor guide is intended to provide a simple starting point for health plans investigating data analytics platforms. The guide focuses on vendors that (1) provide a platform approach to their data analytics solutions, (2) operate across multiple US regions, and (3) provide a variety of use cases. All such vendors known to KLAS as of January 2024 are included in this guide.
Perception
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Patient Engagement 2023
15 November 23    |   Adam Cherrington and Spencer Snyder
In an increasingly digital world, the healthcare industry continues to face increased costs and labor shortages. Patient engagement technology is top of mind for healthcare organizations as they work to improve the overall patient experience, increase volumes, cut costs, and create more provider efficiencies. In collaboration with Bain & Company , KLAS recently identified patient engagement as a top-three priority for healthcare investment. For this report, KLAS engaged with executives from 93 unique healthcare organizations to better understand perceptions of the patient engagement market, including strategies for addressing challenges and goals today, which vendors are most aligned with provider goals, and future plans for investment to improve patient engagement.
First Look
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Onyx SAFHIR 2023
25 October 23    |   Jacob Brown and Joe VanDeGraaff
Patient data sharing has quickly grown much more important for payer organizations, and recent CMS mandates have made it a necessity for all. Recognizing the burden on payers, Onyx has created a platform that transforms healthcare data into a shareable, compliant format requested by the payer. This report presents a first look at the experiences of Onyx payer customers.
Performance
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Payment Accuracy & Integrity Solutions 2023
24 October 23    |   Joe VanDeGraaff and Ruirui Sun
Payers take on financial risk for members and pay for healthcare expenditures based on various plans and reimbursement types. Due to the complexity of reimbursement contracts, many factors (e.g., coding and billing errors, fraud, waste) can contribute to payers sometimes underpaying or overpaying provider organizations. Payment accuracy and integrity solutions help payers make accurate payments and recover losses when overpayments and fraud occur. This report—KLAS’ first on this market—aims to identify the main capabilities these solutions provide and show early findings on customer satisfaction with vendors’ performance. Note: Research in this report is based on feedback from interviewed payer customers. This report is not intended to compare measured vendors’ technological capabilities.
First Look
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Cotiviti Payment Accuracy Solutions
11 October 23    |   Jacob Brown and Joe VanDeGraaff
As healthcare claim volumes grow, payer organizations are working hard to ensure problematic claims do not sneak through the claims process. Cotiviti’s payment accuracy solutions are intended to shoulder the review burden across all major claim types and review stages and to reduce unnecessary spend via improved accuracy. This report offers a first look at customers’ experience with Cotiviti’s payment accuracy suite.
Performance
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Payer Claims & Administration Platforms 2023
15 August 23    |   Joe VanDeGraaff and Ruirui Sun
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, this report provides a comprehensive look at which business lines vendors are focused on, which vendors are gaining or losing market considerations, and how satisfied customers are with their platforms. Note: In this market, vendors that serve only certain types of health plans are designated as component solutions and marked with a [C]. For a complete view of all vendors and their target clients, please see Vendors at a Glance.
First Look
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SKYGEN Core Administration Solutions 2023
02 August 23    |   Jacob Brown and Joe VanDeGraaff
SKYGEN aims to transform benefits management and administration for specialty payers to reduce costs and increase satisfaction for all involved. Currently focused on dental and vision payers, SKYGEN offers a variety of technology to fill all common core administration needs. All solutions are available as a SaaS platform or through SKYGEN’s third-party administrator (TPA) model. This report examines the SKYGEN customer experience.
Performance
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Patient Engagement Ecosystem 2023
13 July 23    |   Adam Cherrington and Dan Czech
Amid the pressures of today’s economic environment, healthcare organizations are investing heavily in patient engagement technology to help reduce costs, alleviate staffing challenges, and consolidate technology in other areas. Both provider and payer organizations seek to understand what patient engagement capabilities vendors offer that can meet their core needs. This study (along with additional deep-dive content that will be published on KLAS’ website) is an update to KLAS’ 2021 report and shows which vendors report the broadest capability sets, which vendors have made the most progress over the last two years, and how the industry as a whole has matured. For reader ease, links to relevant online content are provided where applicable. Note that the data in this study is based primarily on vendor-reported information, accompanied by a limited amount of KLAS performance data.
Emerging Technology
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Viveka Health Benefits Administration Platform 2023
16 June 23    |   Jacob Brown and Joe VanDeGraaff
The complexity of benefits administration can draw focus away from improving health and wellness opportunities for health plan participants. Viveka Health’s benefits administration solution aims to help by integrating all functionality required to administer benefits into one comprehensive platform, allowing payers to communicate, manage claims, and analyze data all in one place. This report explores the experiences of six unique Viveka Health customers and their satisfaction with the platform.
Performance
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Payer Care Management 2023
09 May 23    |   Joe VanDeGraaff and Ruirui Sun
Over time, care management vendors have developed new functionalities that have allowed payer organizations to move beyond traditional use cases (e.g., case management and utilization management) into emerging use cases (e.g., behavioral health, automated prior authorization). Care management solutions are in an already low-performing market with persistent integration and functionality challenges, and with these emerging use cases, customers have a renewed need for strong engagement and support from vendors. This report examines which vendors are providing strong customer relationships, delivering innovative product functionality, and facilitating adoption and long-term customer loyalty.
Point of Light
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Points of Light 2023 Case Study 4
13 April 23    |   Aurene Wilford and Boyd Stewart
Claims data from payer organizations can give providers a more comprehensive view of a patient’s clinical history and thereby improve the quality of care they are able to deliver. Yet incorporating this information at the point of care can be expensive and challenging. To tackle this problem, the collaborators in this project worked to map the payer organization’s claims data so that it could be incorporated into provider workflows in real time at the point of care.
Point of Light
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Points of Light 2023 Case Study 9
13 April 23    |   Aurene Wilford and Boyd Stewart
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.
Point of Light
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Points of Light 2023 Case Study 2
12 April 23    |   Aurene Wilford and Boyd Stewart
Prior authorizations for referrals and clinical procedures are widely acknowledged as a significant pain point for all involved parties—payers, providers, and patients. Using implementation guides from HL7’s Da Vinci Project, the collaborators in this case study created bidirectional data exchange through a FHIR API that enables an automated, in-workflow authorization process. The pilot use cases have been successful, achieving improved efficiency, reduced costs, and—most critically—more timely care and improved patient outcomes.
Emerging Technology
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HealthEdge Source 2023
03 February 23    |   Dallin Seely and Joe VanDeGraaff
Keeping up with Medicare pricing, making edits, and processing claims can be burdensome for healthcare payers. HealthEdge’s Source product (acquired from Burgess in 2020) is intended to ease these burdens by automating important steps in the claims process, providing biweekly updates around Medicare pricing guidelines, and offering first-pass pricing and editing. This report examines HealthEdge customers’ satisfaction and the outcomes they have achieved with the solution.
Perception
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Transitions of Care 2022
29 December 22    |   Bradley Hunter and Paul Warburton
Inefficient care transitions lead to wasted time and energy, increased risk of human error, and potentially poor experiences for both patients and providers. Despite the industry’s attempts to ensure the right information is sent to the right people at the right time, healthcare organizations must often revert to manual processes for data entry, verification, and communication. Some organizations use or want to use technology to streamline their transitions of care (TOC). This report—KLAS’ first to look at TOC—draws from the perspectives of 95 healthcare leaders across multiple care settings to understand their adoption of care transition technology, the challenges they encounter in their care settings, and the vendors they are considering.
White Paper
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Payer Claims & Administration Platforms
08 September 22    |   Joe VanDeGraaff and Ruirui Sun
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.
Perception
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Optum/Change Healthcare Merger
16 August 22    |   Boyd Stewart and Sam Eaquinto
In January 2021, Optum announced their intentions to acquire Change Healthcare. The merger remains unfinalized, however, as the US Department of Justice blocked the deal in February 2022 due to anticompetition concerns—such a merger would give UnitedHealth Group, Optum’s parent company and the nation’s largest insurer, access to rivals’ sensitive data. The legal proceeding is ongoing and scheduled to go to trial August 1, 2022. This report shares Optum and Change Healthcare customers’ reactions to the merger and their perceptions of its impact. Between March 2021 and April 2022, KLAS interviewed 48 individuals from 46 unique organizations; of these respondents, 9% are Optum customers, 56% are Change Healthcare customers, and 35% are customers of both vendors.
White Paper
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CMS Payer Interoperability
04 August 22    |   Joe VanDeGraaff and Ruirui Sun
To enable patients to securely transfer their data from payer to payer as their coverage changes, new mandates dictate that CMS-regulated payers must be able to securely exchange patient data. Several technology vendors are available to help health plans and state agencies comply with these interoperability requirements, providing capabilities such as patient access APIs, provider directory APIs, and payer-to-payer data exchange. This vendor guide is intended to help health plans and TPAs understand the vendor technology options; it includes those vendors known to KLAS as of July 2022.


KLAS VP of Payer/Provider Collaboration - Boyd Stewart
Subject Expert
Boyd Stewart
VP of Payer/Provider Collaboration
KLAS VP of Payer/Provider Collaboration - Boyd Stewart




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