In this era of disruptive transformations, businesses cannot bear to sit back and let the progressions make them obsolete; more so if you are a health payer in the ever-so-complex US healthcare ecosystem. With every new regulation and every new development in the industry comes the implacable need to upgrade and modernize your core administrative systems. A core administrative processing system of healthcare payers should be robust, versatile, adaptable, modular, easy-to-use, and above all, help the company concentrate on their business without worrying much about IT. If you are a health payer in the midst of choosing a core administrative solution or if you are embarking on a journey to build one from scratch, here are the 11 crucial architectural and design considerations to keep in mind:

• Compliance: The primary need for a payer organization is to abide by the legislatures and reforms. The business predilection is to have a well-researched design and architectural framework that is fully compliant. All Healthcare solutions should be at least HIPAA (Health Insurance Portability and Accountability Act) and PCI DSS (Payment Card Industry Data Security Standard) compliant.

• Line of Business: The success of a product or a service lies in its ability to be customized as per the changes in lines of business (LOBs). The need of the hour is the product’s ability to accommodate multiple rules, have configurable field formats and labels. It needs to have a strong capacity to bolster numerous lines of business and support both private and government insurance programs including medical, dental, vision, Medicare and Medicaid.

• Modularity: A plug and play solution can support multiple business requirements. It is cost-effective and can get easily integrated with the existing IT systems. For example, if a payer is looking for just an Individual Billing System or an Agent Portal then a pluggable modular solution that can seamlessly integrate with the rest of their systems is preferred over buying a full product suite. It is, hence, highly desirable to have a payer suite that is completely modular to support future business requirements.

• Configurability: This is another major component of an ideal payer solution as the business requirements of the payers are unique and diverse. A configurable payer solution consists of a Centralized Rule Engine with the ability to turn rules on/off, create new rules, and configure different parameters pertaining to plans, rates, products, eligibility, etc. The flexibility to configure the system as per the business need improves the time for implementation, reduces the dependency on IT and eases maintenance.

• Integration: Most healthcare payer solutions use legacy systems. The requirement for shifting from a legacy/existing system to a current solution either fully or partially is a big task in itself. Therefore, an ideal solution should be able to read/provide the data that the legacy system understands to provide smooth transitioning and integration capabilities. For example, adding multiple interfaces and secured web APIs reduces implementation time, thereby making the solution winsome.

• Scalability: A scalable solution keeps in mind the evolving needs of the business. A malleable solution enhances itself with minimal coding efforts while maintaining the performance benchmarks. For example, accommodating large business houses with more than 1 million+ enrollments by adding multiple nodes with existing ones makes the solution easily scalable.

• Multi-File Format: The ability of the platform to upload/download and map different types of files is a vital feature that an ideal health payer solution should have. The formats that a healthcare system might require to process on a daily basis are – EDI, PDF, XLSX, XML, DOCX, etc.

• Workflow System: Fully automated fail-safe and standard operating protocols should be inbuilt. This acts as an auto-correction mechanism in case of system errors and improves productivity by many notches. E.g. in case of business rule failures or data entry error in application processing, pre-defined standard operating procedures for error handling of every possible scenario is a good-to-have feature. It significantly reduces the internal user’s manual work and expedites the process.

• Customer Handling: Categorical tracking mechanism helps in managing grievances and appeals formulated by the customers in a timely manner. A proper escalation protocol with robust user-management and a self-service member portal to accelerate member requests are two must-have features of an ideal health payer solution.

• Usability: The system should provide simple navigation and intuitive screens where the user should be able to perform required actions without putting in much effort to understand it. For example, the user should be able to navigate to the required page within 2 clicks. Also, it should have keyboard shortcuts to complete actions without using a mouse.

• Inbuilt Reporting: Core administration systems of payers should come with inbuilt features for reporting and analytics. An ideal solution will help you visualize your data, intuitively explore and discover the hidden patterns, democratize the data in order to drive better business decisions.

Conclusion

Every need to upgrade or modernize the core systems is an opportunity to enhance the user experience, improve efficiencies and gain a competitive advantage in a dynamic market. While this is not a comprehensive guide to choose the best core administrative system for payers, it does nonetheless give you a headstart in choosing the right solution. As the needs can change from payer to payer, there can never be a one-size-fits-all solution, and every selection has to be carefully assessed. A thorough pre-assessment of the solution followed by a detailed live demonstration can accelerate the process and get you closer to your ideal solution.