How to Modernize Health Plan Core Administrative Processing Systems
The ever-changing healthcare landscape requires health plans to have access to the insights and agility necessary to control costs, embrace change, and move quickly to take advantage of new opportunities. For many payers, upgrading to modernized health plan core administrative processing systems (CAPS) is a key strategy to remain flexible and competitive in the market.
To stay ahead of industry changes, many health plans are transitioning to cloud-based solutions. Doing so makes it easier for payers to consolidate their applications, reducing reliance on third-party point solutions and outdated proprietary systems. This forward-thinking approach streamlines operational efficiencies and meets the growing demand for agility in the ever-shifting healthcare regulatory environment.
Payers increasingly recognize that investing in modern health plan core administrative processing systems is essential to improving both member and provider experiences— needs that remain largely unmet by legacy systems. Leveraging cloud-based CAPS solutions make it easier for health plans to embrace the industry shift toward data accessibility and real-time claim adjudication while empowering them to react swiftly to stakeholder demands.
6 Key Trends Driving Investment in Health Plan Core Administrative Processing Systems
Healthcare payers must navigate a complex landscape of demands and opportunities to succeed. Several trends have emerged that are shaping payers’ decisions to reinvest in their existing CAPS solutions. An industry-wide shift toward a value-based care model is compelling executives to reevaluate their organizational workflows and internal processes. As a result, payers are more closely evaluating which CAPS partners will be ideal for long-term partnership in the dynamic healthcare environment.
1. Claims Processing for Non-Medical Services
One significant trend is the integration of claims processing for non-medical services. To support members holistically, payers are addressing social determinants of health (SDOH) by facilitating claims for services beyond traditional medical care. Examples of covered SDOH services include community-based programs—such as housing stabilization and emergency food access—as well as transportation to and from appointments. These offerings help support broader member needs, leading to better clinical outcomes, lower long-term care costs, and greater member satisfaction.
2. Low-Friction Support for Price Transparency and Interoperability
A regulatory focus on pricing transparency is driving payers to adopt integrated CAPS solutions that support low-friction access to updated pricing information. Delivering accurate pricing information not only satisfies compliance mandates but also empowers members to make more informed healthcare choices, fostering trust and improving satisfaction. Interoperability is the cornerstone of compliance for payers working across technology systems and disparate data sources, helping ensure seamless information sharing between stakeholders and across platforms.
3. Adoption of API & FHIR Capabilities
Data integration is vital for delivering accurate pricing information, enhancing the provider and member experience. The adoption of Application Programming Interface (API) and Fast Healthcare Interoperability Resources (FHIR) capabilities is a critical aspect of this strategy. These standards enable the efficient exchange of healthcare data between systems, empowering payers with the most accurate and up-to-date information available.
4. Transition to Commercial Cloud Hosting
An industry-wide shift toward commercial cloud hosting demonstrates a significant increase in health plans’ agility and scalability in the market. By leveraging cloud services, payers can reduce IT overhead costs by reducing or eliminating the need for on-site hardware and servers. Cloud-based solutions also make it easier to increase data security and deploy updates more quickly—which are vital to earning and maintaining trust in the rapidly evolving healthcare industry.
5. Self-Serve Member & Provider Portals
When it comes to member engagement and support, healthcare consumers have high expectations. They’re looking for personalized, digital experiences that they can access when it’s convenient for them.
Investing in easy-to-navigate self-service portals can be valuable tools for improving member engagement and delivering more personalized support. Member care management apps or resource portals serve as hubs for provider communication, personalized resources, coverage information, and other valuable services. Solutions like these can empower members with the information they need at the right time, helping them make more informed health decisions while fostering trust in their health plan.
6. Value-Based Care Administration
Value-based care models have gained prominence in the healthcare industry and are redefining health plan operations. To take full advantage of the outcomes-based care model, health plans must shift their focus to prioritize care quality over service volume. If payers invest in CAPS solutions with robust analytics and performance tracking, they will be well-positioned in the evolving market.
Trends across the healthcare industry are pushing payers to invest (or reinvest) in CAPS solutions that facilitate data integration, transparency, and high care quality. Effectively leveraging capabilities like these can enhance operational efficiency and position health plans as trusted partners within the healthcare ecosystem. For leaders willing to adapt and embrace modern CAPS solution, there is no shortage of potential.
HealthRules® Payer is more than a health plan core administrative processing system—it is a revolutionary tool tailored to meet the demands of the modern healthcare industry. By leveraging cutting-edge technologies, including artificial intelligence (AI), HealthRules Payer provides payers with the efficiency, agility, and competitive advantage necessary to stay ahead of the market.
Not sure what to expect when it comes to a CAPS implementation? Check out our eBook, “5 Steps to a Successful CAPS Implementation”.
