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Claims & Administration Platforms (Payer)
 

Core claims/administration systems used by health plans to process and pay (adjudicate) claims, enroll health plan members, and manage payer product lines (i.e., benefit/plan offerings).

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

Payer Claims & Administration Platforms 2023: Vendor Performance in a Segmented Market) Report Cover Image
Performance
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Payer Claims & Administration Platforms 2023: Vendor Performance in a Segmented Market
15 August 23
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. <br><br> <p style="font-size:.85em; color:#858d96;">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.</p>

Report Abstract

Key Findings:

  1. Cognizant & HealthEdge Are Clear Mindshare Leaders; Support & Delivery Challenges Remain for Customers of Both
  2. Provider-Sponsored Health Plans Frequently Consider Epic; SS&C Health* Continues to Lose Customers
  3. SKYGEN USA & Viveka Health Seen As Solid for Specialty Plans & Small Plans (Respectively); Mphasis (Eldorado)* Still Falling Short of Customer Expectations


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Performance Data

Overall Score by Product

Example Claims & Administration Platforms (Payer) overall score by product image

Products Appearing in Decisions

Example Claims & Administration Platforms (Payer) products appearing in decisions image

Overall Score by Question Topic

Example Claims & Administration Platforms (Payer) overall score by question topic image

Provider Facility Size by Product

Example Claims & Administration Platforms (Payer) provider facility size by product image

Provider Facility Type by Product

Example Claims & Administration Platforms (Payer) provider facility type by product image
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Related Articles
Article
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How Are Payer Organizations Finding Value in Their CMS Interoperability Solutions?
06 June 24    |   Ruirui Sun and Tyson Blauer
Learn how payers are using CMS interoperability solutions, what the market is doing, and the value this technology offers.
Article
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A First Look at CMS Payer Interoperability
01 February 23    |   Ruirui Sun and Joe VanDeGraaff
A new payer interoperability market emerged after CMS announced a mandate on secure patient data exchange, and began enforcing it in July of 2021. Learn more about vendor performance in this follow-up
Article
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KLAS and the Healthcare Payer Market
03 August 21    |   Joe VanDeGraaff
Including payers and payer vendors in our research at KLAS has helped paint a broader picture of healthcare IT and measure healthcare more holistically.
Article
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Payer Core Administration Decision Insights: A First Wave of Change?
10 June 20    |   Joe VanDeGraaff and Sam Eaquinto
Payer Core Administration solutions were born for another time, and health plans and vendors are realizing that these solutions need to be updated, revamped, or replaced for modern value-based care. K
Current Time Inside Cache Tag Helper: 10/30/2024 8:15:38 AM and Model.SegmentId = 315
Related ReportsView All Reports
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.
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.
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.
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.



Reducing Filters

Unlike sizing filters, reducing filters DO NOT recalculate scores based on the evaluations that meet these requirements. They narrow the list of solutions to show the vendors and solutions that can meet a specific need.

This data is based on interviews with a sample of the firms' recent clients. As a result, it is not necessarily comprehensive of all work a firm may do in this segment.

We require a minimum of 2 confirmations of a service performed in the last 3 years for a solution to qualify.

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