Cognizant & HealthEdge Leads Marker for Payer Claims & Administration Platforms –

What You Ought to Know:

  • Lately, the complicated payer claims and administration market has seen a number of adjustments. Traditionally, payers have used a number of know-how distributors and homegrown instruments to satisfy their broad performance wants. Now, payers want to consolidate platforms to enhance effectivity and their means to handle a number of enterprise traces.
  • As discovering a platform that meets payers’ complicated wants could be difficult, a new report by KLAS gives a complete take a look at which enterprise traces distributors are targeted on, which distributors are gaining or dropping market cons.

Key Insights into Payer Claims and Administration Platforms 2023

  1. Cognizant & HealthEdge Are Clear Mindshare Leaders; Assist & Supply Challenges Stay for Each: Cognizant is a distinguished participant out there, usually a best choice in buying selections. Their options, reminiscent of TriZetto Sides and QNXT, provide complete options utilized by payers of all sizes. Customers usually belief the software program’s means to deal with varied enterprise facets. Satisfaction is excessive, with customers noting improved performance and effectivity over time. Some points embrace delayed assist and extreme customization, which may scale back effectivity and stability, prompting a couple of dissatisfied customers to hunt alternate options. Nonetheless, most Cognizant customers plan to stay with the seller. HealthEdge is gaining traction amongst payers contemplating options. Their superior know-how and fashionable person interface entice consumers. Present customers discover the answer enhances operational effectivity, automates adjudication successfully, and excels in profit configuration and claims processing. Some need higher billing functionalities and extra engagement from the seller, together with coaching and well timed assist. Challenges reported embrace post-upgrade defects and insufficient mission administration throughout implementations.
  2. Supplier-Sponsored Well being Plans Often Think about Epic; SS&C Well being* Continues to Lose Clients: Epic is a well-liked selection for provider-sponsored well being plans utilizing their EMR in scientific settings, pushed by consolidation, integration advantages, and powerful current relationships. Nonetheless, challenges come up from much less skilled well being plan implementation groups resulting in usability issues. Athenahealth’s stable product high quality, EMR integration, and improve processes are praised by their clients, although usability enhancements are desired, and restricted consideration in buying selections is famous resulting from possession adjustments and uncertainty. SS&C Well being clients make the most of the system for ACO contracts however categorical dissatisfaction with gradual know-how improvement, uncertainty in regards to the roadmap, and replacements being pushed by outdated know-how and perceived lack of innovation and scalability. KLAS has not just lately validated wins for athenahealth and SS&C Well being.
  3. SKYGEN USA & Viveka Well being Seen As Strong for Specialty Plans & Small Plans (Respectively); Mphasis (Eldorado)* Nonetheless Falling Wanting Buyer Expectations: SKYGEN USA’s product is taken into account user-friendly and versatile, supporting specialty enterprise traces like dental, imaginative and prescient, and Medicaid. Whereas some clients discover SKYGEN adaptable and attentive to customization wants, others spotlight issues about missing proactive bug alerts, coaching, and customization explanations. A necessity for enhanced customization and performance assist for particular industrial plans can be expressed. KLAS validated two well being plans choosing SKYGEN resulting from its sturdy configurations and integration capabilities with clearinghouses and cybersecurity instruments. Viveka Well being caters largely to smaller well being plans and TPAs, appreciated for its govt engagement, user-friendly strategy, and revolutionary member-facing cellular app. Advantasure* primarily serves Medicare Benefit enrollment, with its current acquisition by UST HealthProof casting uncertainty on buyer satisfaction. The answer is praised for real-time MA eligibility checks however criticized for fighting a number of enterprise traces and an inefficient workflow resulting from segregated billing and enrollment features. Clients demand improved subject decision timeliness, and a few take into account leaving resulting from unsatisfactory vendor relations. Restricted information on Mphasis (Eldorado)* suggests disappointment amongst largely TPAs, citing platform high quality points and sluggish implementations.
  4. Distributors Who Are Thought-about however Not KLAS Rated: Along with distributors assessed by KLAS, payers making buying selections additionally take into account different choices. enGen (previously HM Well being Options) focuses on serving Blues plans and presents BPaaS companies. Flume Well being has skilled current progress, partaking with newer payer sorts like start-ups, nontraditional plans, and self-insured employers. This vendor is seen as technologically revolutionary, notably in community administration options. Oracle is steadily thought-about resulting from its established work with giant payers and scalability, though its adoption is extra distinguished in non-US markets, elevating issues amongst US payers about its means to deal with US enterprise traces. PLEXIS Healthcare Techniques has gained traction resulting from superior know-how of their newer product model, regardless of being changed by two organizations. VBA garners a couple of issues, primarily specializing in the TPA market, and is famous for its optimistic repute in that area. For details about different non-rated distributors’ claims and administration choices, seek the advice of KLAS’ 2022 vendor information.