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HealthEdge Core Payer Administration Platform 2021 HealthEdge Core Payer Administration Platform 2021
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HealthEdge Core Payer Administration Platform 2021
Newfound Energy in a Stagnant Market

author - Joe VanDeGraaff
Joe VanDeGraaff
author - Jennifer Hickenlooper
Jennifer Hickenlooper
October 26, 2021 | Read Time: 9  minutes

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administration platforms are essential for payer organizations, many of the products in the market are perceived as outdated, complex, and low performing (the market has one of the lowest average performance scores of any KLAS measures).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’.

HealthEdge Leads the Market in New Wins

In the last two years, payer organizations purchasing a new core administration platform have most often selected HealthEdge. The vendor is typically selected by small and midsize health plans, and KLAS has also recently validated some larger customers. Organizations that consider HealthEdge are excited about HealthRules Payor’s new features, which they view as more modern than other solutions’. Those who end up selecting HealthEdge highlight the platform’s configurability, which enables users to create benefit plans that meet value-based care requirements. Both current and prospective customers wonder whether HealthEdge’s rapid growth will stretch them thin and create scalability issues in the future.

core payer administration purchase decisions

quotation“We looked at the players in the core platform space, and our decision came down to HealthEdge and one other vendor. We thought HealthEdge had a better platform because of its rules capabilities. Their product had more flexibility and was less costly. One thing that is important for other people to know is that they need to find a good systems integrator for HealthEdge’s system. They need someone who is experienced with the platform and who will be a good partner. I like the look of HealthEdge’s system.” —Manager

Technology’s Robust Flexibility Creates New Efficiencies—and Some Complications

The majority of live customers view HealthRules Payor’s flexibility and configuration as market differentiators, even if they haven’t fully implemented all of the system’s capabilities. The most successful users mention that HealthRules Payor is user friendly and has helped increase efficiency (e.g., increased automatic adjudication). A director shared, “HealthRules Payor is a newer product on the market but has grown very popular in the last few years. It is pretty sophisticated and highly configurable. It is very user friendly and intuitive. For a one-source system, it is pretty high functioning. It manages eligibility, enrollment premiums, billing, accounting, capitation, claims processing, and payments.” Some health plans mention the high configurability can have its downsides—upgrades sometimes break system customizations, and there can be a lack of governance around customizability and system resources. Additionally, about one-third of respondents feel nickel-and-dimed for some system enhancements.

how would you rate healthedge's configuration & flexibility across different lines of business

quotation“Flexibility is both a blessing and a curse in HealthRules Payor. People always say that a person’s greatest asset can also be their Achilles’ heel. The system is highly configurable, and that is fabulous. I don’t think there is anything from a claims and benefits perspective that we can’t figure out how to do in HealthRules Payor. Our ability to configure HealthRules Payor leads to challenges in upgrades. But the way that we have mitigated that at our health plan is to have all configurations centralized under one team.” —VP

HealthEdge Has Improved Engagement & Delivery; Frustration Persists in a Few Areas

Though some customers report issues, overall, the HealthEdge customer base is more satisfied than users of other core payer administration platforms. Citing recent improvements to the product and the vendor’s executive engagement, respondents are more likely than before to recommend HealthEdge and to remain with the vendor long term. One VP explained, I view HealthEdge as a key strategic partner. I enjoy working with them. They are very responsive. They want to do the best work that they can and do the right thing. So from a foundational perspective, the vendor’s bar is already really high. Over the years, I would say that the service and support have been the areas that have caused the most frustration. HealthEdge started as a software company, and they didn’t even value service. Now they do. The new customer success executive understands what HealthEdge customers want and need in the service space. And so does the product person, who owns not only the technology product but also the professional services product. We are seeing lots of improvement.” 

Most customer frustrations center around HealthEdge’s support delivery and follow-through. Frequent frustrations include long, difficult-to-customize implementations and team members who aren’t proactive or available, often because HealthEdge’s resources are stretched thin. A few respondents say the vendor can be slow to address issues and provide needed fixes. Additionally, some customers view HealthEdge’s healthcare expertise as lacking, though they report the vendor has added more-experienced people to their team over the last year.

healthedge overall satisfaction vs market average overall satisfaction healthedge satisfaction distribution

quotation“HealthEdge is a company where the people are nice, well meaning, and positive. I like the people that work there. Getting support can be challenging at times, not because people don’t want to support us but because they seem overwhelmed. HealthEdge has a lot of work and probably doesn’t have enough trained support staff. Sometimes, the process to get help is slow because HealthEdge is supporting a lot of different health plans. HealthEdge’s ability to fix issues is sometimes limited. Sometimes, we get consulting or help from HealthEdge, and the issue just never gets resolved. Often, I tell my teams not to rely on HealthEdge and to just fix the issues ourselves. The vendor is not reliable when we need an outcome. Other health plans have said the same thing about HealthEdge to me.” —Director

HealthEdge Viewed as Best Technology Option; Ability to Consistently Deliver Not Yet Proven 

Looking to the future, respondents are excited about HealthEdge’s potential while remaining somewhat cautious about the vendor’s ability to consistently deliver, especially as the vendor continues to expand. A director shared, “HealthEdge has changed a lot of their leadership in the last year, and we are seeing things trend in the right direction. So even though we had a rocky start, HealthEdge is really showing good intentions.” Unlike most vendors, whose products have been acquired, HealthEdge offers a natively built core payer platform. Respondents expect HealthEdge to fully integrate their two newest acquired products—Altruista (care management) and Burgess (payment integrity)—into the payer platform. HealthEdge has made recent progress with upgrades and implementations, though a few customers still experience ongoing challenges (e.g., new functionality not delivered in a timely manner). Ultimately, HealthEdge customers believe the vendor’s customizable technology has an edge over other vendors’ platforms.

part of long-term plans and would you buy again

quotation“HealthRules Payor is our future state claims and enrollment platform. It is a much more intuitive system than our legacy system. If we were to go out to bid for a solution again, I would still recommend HealthRules Payor. I am satisfied with the platform and its resources. The solution is open source and API enabled. Our decision to move to HealthRules Payor also triggered a decision for us to move to a more modern technology stack that had web services and cloud-based APIs. Indirectly, the vendor has caused us to modernize.” —VP

System Information Provided by HealthEdge

The information below was provided by HealthEdge.

How would customers describe your product?

HealthEdge customers talk about the product’s innovation and integration capabilities and cite how configurable and flexible the system is. These capabilities allow customers to adjust quickly to new and ever-changing market requirements. Below are some comments from our customers (collected by HealthEdge):

“HealthEdge allows us to achieve speed to market with our products in the rapidly changing healthcare environment, with the capability to configure and implement products quickly and on the fly.”

“Our ability to grow depends on HealthRules Payor.”

“HealthRules Payor has allowed us to continue to grow amidst the fluidity of our industry. HealthEdge will lead the next-generation payer platform market because of the decisions and investments they are making, the suite of solutions they are putting together, and how well they integrate.”

What are HealthEdge’s biggest differentiators?

  1. New business models—Adopt the full spectrum of VBR models. Bring benefit plans to market. Implement provider contracts. Remain compliant.
  2. Operational efficiency—Automation, speed, claims accuracy, auto-reprocessing, payment resolution & matching authorizations.
  3. Resiliency to change—Embrace change created by market dynamics.
  4. Flexibility of configuration—Quickly, accurately configure any benefit, provider contract, or other core business process using HealthRules Language.
  5. Easy integration—Integrate best-of-breed systems in real time.
  6. Insights—Leverage actionable insights; improve patient outcomes, lower costs, and enable transparency.
  7. Reimagined upgrades—Consume the latest technology innovations at low cost with ease. Incorporate standard new functionality & innovation.

Solution Technical Specifications (provided by HealthEdge)

Cloud environment: Private cloud—uses two geographically separated Tier-4 data centers; each data center will failover to the other site, and clients can self-host
Development platform: Java, C#, and secure web services
Database environment: Two Oracle databases—an operational database and a user-facing data warehouse
Mobile application environment: HealthRules Connector provides real-time and batch access to all HealthRules data and functionality, allowing HealthRules to easily integrate
Security platform: Role-based security model restricts user access and grants permission to specific system actions; permissions manage user access and may be granted at a granular level
Confidentiality: HealthEdge abides by national and state-level member confidentiality requirements
Data encryption: Connect with HTTPS over IPsec-based VPN using FIPS 140-2 validated encryption methods and algorithms. Storage encrypted on our EMC VMAX SAN using Symmetrix Data Encryption at AES 256
Integration approach: Enterprise-class integration layer HealthRules Connector, which provides real-time and batch access to all HealthRules data and functionality
HITRUST certification: Yes

About This Report

Data for this report comes from two sources: (1) KLAS Decision Insights and (2) KLAS performance data.

KLAS Decision Insights Data

All references in this report to organizations’ purchasing motivations come from KLAS’ Decision Insights data. Since 2017, KLAS has been gathering information as to which vendors are being replaced, considered, and purchased and what factors drive these decisions. KLAS Decision Insights data does not represent a comprehensive census or win/loss market share study. Rather, it is intended to help payer and provider organizations understand which vendors have market energy and why. The data set in this report comes from 26 organizations that are making or have recently made a core payer administration purchase decision validated by KLAS between September 2019 and September 2021.

KLAS Performance Data

Each year, KLAS interviews thousands of healthcare professionals about the IT solutions and services their organizations use. For this report, interviews were conducted over the last 18 months using KLAS’ standard quantitative evaluation for healthcare software, which is composed of 16 numeric ratings questions and 4 yes/no questions, all weighted equally. Combined, the ratings for these questions make up the overall performance score, which is measured on a 100-point scale. The questions are organized into six customer experience pillars—culture, loyalty, operations, product, relationship, and value.

customer experience pillars software

To supplement the customer satisfaction data gathered with the standard evaluation, KLAS also created a supplemental evaluation to delve deeper into several questions specific to the core payer administration market. This evaluation asked customer respondents (1) how they see HealthEdge as different from other vendors in the market, (2) how they would rate HealthEdge’s configuration and flexibility across different lines of business, (3) what impact HealthEdge (i.e., their service/support, technology, and company culture) has had on the organization over the last two years, and (4) what their future outlook is for HealthEdge as they bring together different companies and products.

Sample Sizes

Unless otherwise noted, sample sizes displayed throughout this report (e.g., n=16) represent the total number of unique customer organizations interviewed for a given vendor or solution. However, it should be noted that to allow for the representation of differing perspectives within any one customer organization, samples may include surveys from different individuals at the same organization. Ratings from these individuals are aggregated in order to prevent any one organization’s feedback from disproportionately impacting a solution’s score. The table below shows the total number of unique organizations interviewed for each vendor or solution as well as the total number of individual respondents.

Some respondents choose not to answer particular questions, meaning the sample size for any given vendor or solution can change from question to question. When the number of unique organization responses for a particular question is less than 10, the score for that question is marked with an asterisk (*) or otherwise designated as “limited data.” If the sample size is less than 5, no score is shown. Note that when a vendor has a low number of reporting sites, the possibility exists for KLAS scores to change significantly as new surveys are collected.

about this report
author - Sarah Hanson
Sarah Hanson
author - Jess Wallace-Simpson
Jess Wallace-Simpson
author - Robert Ellis
Project Manager
Robert Ellis
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This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2024 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.