7 Ways a Modern Core Administrative Processing System Can Improve Margins & Efficiency 

Health plans are grappling with the challenge of reducing operating costs without sacrificing clinical outcomes. At the heart of this challenge lies the core administrative processing system (CAPS), responsible for claims processing, care coordination, and operational workflows.

Unfortunately, many health plans still rely on legacy CAPS solutions that are rigid, siloed, and incapable of scaling with modern business needs. Modern CAPS solutions, like HealthEdge HealthRules® Payer, are designed to scale alongside payers—helping improve margins, enhance efficiency, and drive innovation.

In this blog, we highlight 7 ways an integrated CAPS is a must-have for health plans aiming to stay competitive in a crowded and ever-changing healthcare landscape.

Limitations of Legacy CAPS Solutions

Legacy administrative systems often come with their own sets of challenges and inefficiencies that can cost payers valuable time and money:

• Reliance on Manual Workflows: Heavy reliance on manual review slows down claims processing and increases the risk of errors.
• Internal Data Silos: Disparate technology systems can fragment critical data, making it difficult to access holistic insights and facilitate coordinated care.
• Scalability Challenges: Adapting legacy systems to meet new demands, such as value-based care models or expanding Medicare & Medicaid lines of business, can require costly and time-consuming updates.
• Compliance Shortfalls: When using legacy CAPS, frequent regulatory changes require time-intensive manual updates and customizations.

Switching to an updated and integrated CAPS can help payers automate manual tasks, scale to meet the needs of new member populations, and stay prepared for changes to regulatory and reporting requirements.

Facilitate Health Plan Growth with a Modern CAPS Solution

Modern CAPS solutions like HealthRules Payer help address the pain points of legacy systems by leveraging cutting-edge technology and workflow automation.

1. Resilience and Enhanced Scalability

Integrated CAPS platforms are designed for adaptation and customization, making it easier for your health plan to stay on top of industry changes. Whether payers are responding to regulatory updates, launching new lines of business, or navigating large-scale population health issues, next-generation CAPS can enable health plans to remain resilient.

Real-World Impact:

• Amid the COVID-19 pandemic, Presbyterian Health Plan leveraged HealthRules Payer to configure new benefit plans within weeks (not months), ensuring members received uninterrupted service.

2. Superior Automation for Increased Efficiency

Automation is a hallmark of modern CAPS. From claims adjudication to retroactive reprocessing, advanced platforms automate repetitive tasks, reducing human error and administrative bottlenecks.

Key Metrics:

• 90%+ Auto-Adjudication Rates: HealthRules Payer uses auto-adjudication to streamline claims processing to achieve up to 99% claims accuracy, drastically cutting down on claim backlogs and administrative costs.
• 800% Increase in Claims Automation: Health plans like Medica reported significant gains in operational efficiency by automating previously manual processes.

3. Faster Time to Market

Launching new products and benefits no longer takes months and excessive IT resources to configure. HealthRules Payer allows business analysts to configure and update benefit plans, provider contracts, and member databases with intuitive, no-code tools.

Benefits:

• Health plans can quickly roll out value-based care models, Medicare & Medicaid expansion programs, and innovative consumer engagement initiatives.

4. Actionable Insights with Real-Time Analytics

Real-time data integration is a game-changer for health plans, facilitating claims processing, member engagement, and care coordination. Modern systems like HealthRules Payer consolidate operational data into one integrated accessible platform, allowing health plans to leverage up-to-date analytics to gain more actionable insights.

Capabilities Include:

• HealthRules Connector: Integrates HealthRules Payer seamlessly with other systems, partner networks and exchanges, to create a digital ecosystem.
• Machine Readable Files:  A cloud-based add-on that improves health plans’ processes for publishing Machine-Readable Files, making meeting regulatory requirements easier, faster, and more accurate than ever.

5. Operational Efficiency That Improves Margins

Efficiency is paramount in improving margins for health plans. By automating processes, eliminating data handoffs, and reducing IT resource dependencies, next-generation CAPS drastically lower operational costs. 

Measurable Outcomes:

• $1.2 Million Savings in the First Year: Medica achieved notable savings by implementing HealthRules Payer, thanks to reduced manual intervention and higher claims accuracy.
• Reduced customer service calls through accurate billing and faster claims resolutions.

6. Enhanced Member and Provider Experiences

With HealthRules Payer, health plans can offer members and providers a more transparent, responsive, and efficient experience.

Industry-Leading Features:

• Transparency Tools: HealthRules Answers provides access to operational data for reporting and analytical dashboards. Users can see and share metrics with stakeholders immediately to enable informed decisions at the point of care.
• Configuration: HealthRules Promote makes it easier for health plans to configure new benefits plans faster to meet the shifting needs of member populations.

7. Regulatory Compliance Without Complexity

Complying with evolving state and federal regulations is often a costly endeavor for health plans using legacy systems. Modern CAPS platforms like HealthRules Payer help ensure compliance through automated updates and flexible configuration tools.

Example:

• HealthRules Payer customers with Medicare and Medicaid lines rely on its built-in compliance functionality to update policy changes rapidly without disrupting operations.

Future-Proof Your Health Plan with HealthRules Payer 

Adopting a modern CAPS is no longer optional for health plans striving to: 

• Drive operational efficiency.
• Improve profit margins.
• Enhance member and provider experiences.
• Scale with agility in competitive markets.

The healthcare industry is evolving rapidly, but your technology doesn’t have to hold you back. Platforms like HealthRules Payer empower health plans to reimagine what’s possible by overcoming the challenges of legacy systems and unlocking future-ready capabilities.

By investing in a next-generation Core Administrative Processing System, you’re preparing your health plan to not just survive, but thrive in an increasingly competitive environment.

Read the brochure to discover how HealthRules Payer can improve resiliency to change, support new business models, enable integrations, and more.