Is Your Health Plan Ready for Touchless Claims Processing?

The pace of change in healthcare continues to accelerate. Don’t let outdated technology keep your organization from seizing new opportunities to expand business offerings and stay competitive.

Relying on legacy core administrative processing systems (CAPS) means relying on rigid manual workflows and data trapped in silos, drastically limiting efficiency and scalability. To keep up with shifting regulatory demands and new industry norms, payers must understand their current technological capabilities and operational bottlenecks.

This is exactly why we created the next generation CAPS readiness assessment. By evaluating your organization’s current position on the automation continuum, you can uncover strategic opportunities to reduce member healthcare expenses, boost regulatory compliance scores, and unify the member experience.

Key Takeaways

• Legacy CAPS solutions rely on manual workflows and data silos that limit efficiency and scalability
• Health plans can reduce member healthcare expenses, boost regulatory compliance scores and unify the member experience by modernizing their CAPS
• HealthEdge’s five-question readiness assessment helps organizations identify where they fall on the automation continuum
• McLaren Health Plan operated at a 0% auto-adjudication rate before implementing HealthRules Payer
• Continuing to rely on outdated technology poses a greater risk than transitioning to an integrated solution

What Are the 3 Hidden Costs of Relying on Legacy Claims Processing?

Managing a health plan on a legacy or outdated CAPS solution can create significant operational barriers. These systems lack the integration and flexibility required to adapt to modern healthcare demands.

1. Manual IT Requirements

When state or federal regulatory changes occur, legacy systems require time-intensive IT intervention and manual workarounds. Manual interventions also increase the risk of payment errors, driving up administrative costs and requiring rework.

2. Internal Data Silos

Legacy platforms heavily depend on batch processing. This creates data silos that prevent health plans from seeing and leveraging real-time insights. Without a unified view of population health data and claims information, predicting chronic disease trends or optimizing cost management becomes nearly impossible.

3. Member Satisfaction

Relying on manual claims reviews can lead to operational bottlenecks, strained provider relations, and member dissatisfaction. To keep processing times low and reduce abrasion with members and providers, payers need an integrated solution with advanced automation.

Why Take a Readiness Assessment for a CAPS Solution?

Transitioning to a modern, automated system requires strategic planning. Our readiness assessment is a targeted, five-question evaluation designed to help you determine exactly where your organization falls on the automation continuum.

Three Benefits of Taking a Readiness Assessment

1. Immediate clarity on your current operational maturity
2. Help identify critical gaps in your claims processing workflows
3. Highlights specific areas where advanced automation can drive return on investment

By analyzing your readiness for touchless claims processing, you can prioritize technology investments that directly impact your key success indicators. Whether your primary goal is reducing manual overrides, improving compliance scores, or enhancing member engagement metrics, the assessment serves as your baseline for strategic transformation.

Realizing the Benefits: A Client Success Story

Understanding the benefits of automated claims process is important, but seeing its practical application proves its value. Consider McLaren Health Plan: Operating on a 30-year-old legacy technology system, they relied entirely on manual claims processing review, with a 0% auto-adjudication rate.

McLaren’s legacy CAPS solution was notoriously difficult to configure, not user-friendly, and severely lacked scalability. Relying on this outdated infrastructure resulted in massive inefficiencies, poor data accessibility, and high administrative overhead.

By implementing HealthRules Payer, McLaren Health Plan was able to:

• “Drastically improve” reporting capabilities
• Automated data entry and review
• Reduce administrative costs

Take the Next Step Toward Transformation

Traditionally, healthcare is a risk-averse industry—but continuing to rely on outdated technology poses a greater risk than leaning into integrated solutions.

Are you ready to optimize claims processing, control costs, and reallocate resources to high-impact initiatives? Evaluate your infrastructure and embrace the future of core administration.

Take the five-question HealthRules Payer readiness assessment today to discover how you can improve efficiency, reduce administrative costs, and achieve regulatory excellence.

Take the Assessment

Not ready to take a full assessment? See 5 signs your health plan has outgrown its legacy CAPS platform. Download the brochure.

Frequently Asked Questions

What are the hidden costs of legacy claims processing? The three primary costs are: time-intensive manual IT intervention when regulatory changes occur, internal data silos created by batch processing that prevent real-time insights, and operational bottlenecks from manual claims review that strain provider relations and member satisfaction.

Why do legacy CAPS systems have low auto-adjudication rates? Legacy CAPS platforms rely on rigid, manually maintained rules that cannot adapt quickly to regulatory changes or new benefit configurations. Their dependence on batch processing — rather than real-time data — prevents the continuous validation needed for high auto-adjudication rates.