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11 Things to consider while choosing a Health Payer Suite

March 28, 2017

by Aditya Jhunjhunwala

   In this era of disruptive transformations, corporates 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 them 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, these are the 11 important architectural and design considerations to keep in mind:

  • Compliance: The primary need for a payer organization is to abide by the legislatures & reforms. The business predilection is to have a well-researched design & 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 business lines (LOBs). The need of the hour is the product’s ability to accommodate multiple rules, have configurable field formats & labels. It needs 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 just for 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: Configurability is another major component of an ideal payer solution as the business requirements of the payers are unique & diverse. A configurable payer solution consists of a Centralized Rule Engine with the ability to turning rules on/off, creating new rules, configuring 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 the maintenance.
  • Integration: Most Healthcare Payer solutions use legacy systems. The requirement for shifting from legacy/existing system to current solution either fully or partially is an errand in itself. Therefore, an ideal solution should provide smooth transitioning and integration capabilities where it can read/provide the data that the legacy system understands.  For example, adding multiple interfaces and secured web APIs reduces implementation time, thus embodies the solution as winsome.
  • Scalability: An ascendable solution keeps in mind the cultivating needs of the business. A malleable solution enhances itself with minimal coding efforts while maintaining the performance benchmarks. g. Accommodating large business houses with more than 1 million+ enrollments by adding multiple nodes with existing ones entitles a solution as easily scalable.
  • Multi File Format: The ability of the platform to upload/download and map different types of files is a feature that an ideal health payer solution should have. The formats that Health Care System might require to process in daily basis are: EDI, PDF, XLSX, XML, DOCX etc.
  • Workflow System: Fully automated fail-safe & 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, a pre-defined standard operating procedures for error handling of every possible scenario is a good to have feature. It tapers the internal user’s manual work and expedite the process.
  • Customer Handling: Categorical tracking mechanism helps in managing grievances & 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 the required actions without spending much effort to understand. For example, the user should be able to navigate to required page within 2 clicks. Also it should have the keyboard short cuts to complete the action thereby avoiding mouse usage.
  • In built 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.


Every need to upgrade or modernize the core systems is an opportunity to enhance user experience, improve efficiencies and gain competitive advantage in a dynamic market. While this is not a comprehensive guide to choose the best core administrative system for payers, this however gives you the head start in choosing a right solution. As the needs of the payers are diverse and unique there can never be 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.