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Payer Core Claims and Administration 2017

Payer Core Claims and Administration 2017
The Future Suggests a Bumpy Road

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Many health plans today are faced with rapidly changing regulations combined with middle-of-the-road performance from their core claims and administration vendors. Citing poor service and support, old technology, and nickel-and-diming, these health plans are looking for improved innovation and the ability to quickly adapt to industry changes.


1. Cognizant Invests in TriZetto; Innovation from Smaller Vendor Health Solutions Plus (HSP) Looks Promising

Used in every business line in this report, Cognizant (TriZetto) has unrivaled market share and offers a wide variety of modules outside of core claims. Clients say there is significant room for improvement in integration, ease of use, implementation and training, and proactive customer service. They view Cognizant's investment in TriZetto as positive and expect it to result in improved innovation and products. HSP's client feedback comes from a small sample but represents a quarter of the client base. Viewed as visionary and progressive, HSP receives high praise for innovation. Development of their flexible, user-friendly product is often driven by client input, and a high percent of interviewed customers use more than just core claims and administrative functions. Some customer complaints are noted, the most frequent involving contracting and pricing—about 30% of respondents say HSP nickel-and-dimes.


innovation in core claims space




2. Many DST and Eldorado Customers Headed for the Exit

DST Health Solutions has one of the largest, most dissatisfied client bases in the market. Though some clients see the system as configurable and stable, nearly one-third of those interviewed plan to leave, citing poor support, nickel-and-diming, aging products, and disappointment in new offerings. Eldorado clients report similar levels of frustration; their concerns include poor implementations and system bugs that negatively impact claims processing. With average support and technology, almost all interviewed Cognizant (TriZetto) clients plan to stay, due in part to improving innovation and the prospect of more integration beyond the core. Aldera has attentive support and a quality core claims product; however, their other products are viewed as antiquated and buggy.

performance and the future of payer core claims market




3. Cognizant and HSP More Adaptable to Industry Changes

Most vendors have struggled to keep up with state/federal regulations, payment models, government-sponsored health plans, and the individual insurance exchange. Highly configurable, the Cognizant (TriZetto) and HSP systems are more easily adapted. In addition, Cognizant has a dedicated staff for meeting state/federal regulations, though clients say more expertise is needed for some states. DST Health Solutions clients feel they are behind in meeting requirements due to slow product development. Eldorado doesn't offer business lines for government-sponsored health plans, and the product's instability hinders its capacity to meet needs. Aldera clients report that their vendor is knowledgeable and has a specific department for meeting industry requirements.

what impact has your vendor had on your ability to adapt to evolving industry requirements




vendor landscape market presence and core capabilities

Key Topics

  1. Cognizant Invests in TriZetto; Innovation from Smaller Vendor Health Solutions Plus (HSP) Looks Promising
  2. Many DST and Eldorado Customers Headed for the Exit
  3. Cognizant and HSP More Adaptable to Industry Changes
  4. HealthEdge and Other Smaller Vendors Garnering New Market Energy

The vendor landscape, market presence, core capabilities, and performance ratings from the experience of health plans are included.

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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. © 2019 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.