Expand to New Markets Using a Next-Generation Core Administrative Processing System (CAPS)

The healthcare industry is evolving at a rapid pace. Regulatory demands, shifting consumer expectations, and the need for data-driven decision-making are placing unprecedented pressure on health plans. The challenge is clear—how can payers remain competitive while meeting the growing complexities of modern healthcare?

This is where a next-generation Core Administrative Processing System (CAPS) like HealthRules Payer comes in. Designed to empower health plans with real-time data and unparalleled flexibility, this innovative system enables organizations to expand offerings and serve new member markets with ease.

How Health Plans Can Expand to New Markets with Modern CAPS

Health plans operate in an increasingly demanding environment. The traditional, hard-coded administrative systems of the past are ill-equipped to keep up with today’s healthcare landscape. A next-generation CAPS solution does more than process claims and manage benefits—it becomes the foundation for achieving strategic growth, operational efficiency, and superior member experiences.

With a next-generation solution like HealthRules® Payer, health plans can:

• Understand diverse member populations with real-time data and analytics.
• Quickly configure and launch new benefits offerings.
• Expand into new markets to capture valuable growth opportunities.

By leveraging a modern CAPS, health plans can move faster, adapt smarter, and make better-informed decisions—all while lowering administrative costs.

Real-World Transformations with HealthRules Payer

Health plans of all sizes have chosen HealthRules Payer as a technology partner for its ability to scale, adapt, and transform payer operations. See an overview of how three different health plans leveraged the HealthRules Payer CAPS solution to configure new offerings and expand to new markets.

Medica Health Plan

Medica, a regional health plan managing over 1 million lives, partnered with HealthEdge to streamline existing lines of business and expand its benefit offerings by reducing time to market.

Key Achievements:

• Configured 81 benefit plans in just 10 days using only four resources.
• Responded to new market opportunities in real time, leveraging accurate and actionable data.
• Automated manual processes across existing business lines, significantly reducing administrative costs.

“Data is the most valuable asset that health plans have.”

-VP of Business Transformation at Medica.

McLaren Health Plan

McLaren faced mounting inefficiencies with its outdated legacy system, including a low auto-adjudication rate. With the integrated CAPS solution from HealthRules Payer enabled McLaren to modernize their operations and respond to industry changes faster—which better positions the organization for long-term growth.

Key Achievements:

• Achieved a 90% auto-adjudication rate, reducing reliance on manual claims processing.
• Increased operational efficiency, allowing staff to reallocate resources toward innovation.
• Seamlessly expanded membership to 620,000 lives, bolstering business performance.

“HealthRules Payer has made reporting better and quicker, enabling us to operate with greater efficiency as we scale.”

-VP of Business Information & Operations at McLaren Health Plan.

Presbyterian Health Plan

Processing over 9 million claims annually, Presbyterian Health Plan required a flexible CAPS to manage growing complexities and maintain compliance. They leveraged the HealthRules Payer solution to automate claims processing, improve responsiveness, and adapt to shifting industry demands.

Key Achievements:

• Reduced claims turnaround time to under 5 days, ensuring prompt provider payments.
• Increased staff productivity by 30%, measured by the number of claims processed per hour.
• Enhanced benefits configuration efficiency by 40%, enabling rapid product launches.

“The configuration capabilities within HealthRules Payer are phenomenal. We’ve been able to make changes in half the time it took us previously.”

-VP of Claims Operations at Presbyterian Health Plan

What Sets HealthRules Payer Apart from other CAPS solutions

HealthRules Payer offers distinct advantages that make it a go-to choice for health plans seeking to modernize their administrative systems. Here’s what differentiates it:

1. Flexibility, Scalability, and Resilience

The HealthRules Payer CAPS is designed for flexibility and scalability, allowing payers to adapt to regulatory shifts, market trends, and emerging member needs for long-term viability.

• Real-Time Data Insights: Access accurate data instantly to make informed decisions and respond to opportunities ahead of competitors.
• Regulatory Compliance: Easily modify rules, produce auditable information, and adapt to regulatory requirements without disrupting operations.
• Faster Time-to-Market: Configure, review, and deploy new benefit offerings with unmatched speed and precision.

For McLaren Health Plan, this adaptability enabled rapid adaptation to industry changes, providing a significant edge in a competitive market.

2. Adaptability to New Business Models

The healthcare landscape is shifting from fee-for-service to value-based care (VBC), requiring payers to adopt more complex reimbursement structures. HealthRules Payer excels in enabling value-based reimbursement by:

• Designing and implementing benefit plans in less time and at lower costs than traditional systems.
• Sharing critical insights from data analytics with providers, improving performance metrics and creating stronger partner relationships.

For example, HealthRules Payer’s natural language capabilities have improved first-call resolutions at Presbyterian Health Plan, building trust and reducing callbacks—a direct reflection of enhanced service and data transparency.

3. Automation and Efficiency

Move away from manual workarounds and legacy inefficiencies. HealthRules Payer automates major processes, driving seamless operations that save both time and money. From claims processing to reporting, automation fosters:

• Higher accuracy
• Reduced operational costs
• Scalable business expansion

For example, Medica’s adoption of HealthRules Payer eliminated costly manual processes, improving productivity across Individual & Family, Medicare, and Commercial Group business lines.

The Competitive Edge for Health Plans

By implementing HealthRules Payer, health plans gain more than just operational efficiency—they secure a competitive advantage. Some key benefits include:

• Faster Response Times: Adapt to regulatory changes and industry demands in record time.
• Cost Efficiency: Lower administrative costs with streamlined, automated operations.
• Market Growth: Launch differentiated offerings ahead of competitors, capturing new members and revenue streams.
• Superior Member Experience: Deliver accurate, personalized service with easy-to-access data and insights.

With health plans increasingly vying for consumer loyalty, having a robust CAPS solution provides the tools needed to stand out in a crowded marketplace.

Do you want to learn more about how the next-generation CAPS from HealthRules Payer can empower your health plan to expand to new markets? See how a regional health plan achieved a 90% auto-adjudication rate, opened new lines of business, and expanded to new states. Read the case study.