When I came into the industry, we worked on green screen mainframes, where each function was its own application compartmentalized into silos. For an operations person, claims, eligibility, billing, and benefits were all in separate systems.
Eventually, organizations realized that the older technology was costly to maintain and began to move to the modern core system that encompasses multiple health plan operation functions in one application. The core system was less expensive and easier to use—no longer did someone need to exit one system and enter another system to gather information.
Over the years, the siloed approach comes up occasionally. Sometimes it may be an ambitious startup, companies that want to be disruptors in the market. However, it can also be large organizations as well. Regardless, this viewpoint of searching for a utopian IT state with each function to be a separate solution is something that persists and continues to cycle and come up from time to time.
Developing a claims system is not easy. It takes five to ten years of solid development and battle-proven, customer-tested processing (accumulating millions of transactions and scenarios over time) to get to a semi-mature state of a claims adjudication engine.
So, when an organization feels they can build a claims engine with individual components, i.e., eligibility, capitation, pricing, claims, benefits, etc., they tend to underestimate how complex it is and neglect to consider its impact on the end-user.
Logistically, plans need to consider all the integration an organization would need to create to connect and those separate systems. Often the integration effort turns into a ball of spaghetti code that becomes increasingly complex and costly to implement and maintain.
In my industry experience, the sought-after solution these organizations are a mirage and do not exist successfully. As it is not just the TCO associated with implementing and maintaining all the different systems; however, it is the end-user who suffers the most because they need to navigate across the separate applications in their daily course of work. Additionally, from an operations perspective, if a health plan wants to introduce one change—whether it is regulatory or market-driven—they must coordinate the change now across many systems, which is incredibly difficult and leaves a significant risk of error.
While data replication for members and providers becomes increasingly common today, based on my experience, I would argue that a core system’s minimum viable product (MVP) provides benefit configuration and claims adjudication in the same container. Additional required pieces of adjudication can be replicated with comprehensive APIs for the core system provided as a standard by today’s measures. The reconciliation of transactions between systems and remediation of fallout are the bigger pain points that usually need to be addressed.
Nonetheless, on top of the MVP by adding flagship pricing (Burgess Source) and care management (GudingCare) capabilities complementing HealthRules Payer’s open integration, business empowered automation, configuration, and provider capabilities shape the unified vision of the HealthEdge solution into a best-in-class approach that provides the maximum value to our customers.