Change is never easy, but replacing a claims system is often in a health plan's best overall interests
By Emily Rafferty and Michael Miller
For health plans, breaking up with a core administrative partner is, well, hard to do. Whether it's the comfort of sticking with something you know, the hope that your partner will adapt to change, or resistance to undertaking the long process of finding and then migrating to a new IT platform, there are myriad reasons not to make a switch.
Yet, there are times when it undoubtedly makes sense to seek out other options. Markets change. Plans grow. They take on new business lines and payment models. The more plans aspire to achieve, the greater the demands become on their core administrative platform to support those goals. Even if the current platform runs smoothly today, it might not be built for tomorrow's ambition.
Here are seven triggers that may make you reconsider whether your health plan's relationship with its administrative platform is built to weather change and guide you to success.
You've lost trust—in claims accuracy.
You entered the honeymoon period with great hopes. It felt like a true partnership. But as time has gone by, you have become increasingly disillusioned. Fewer claims are paid correctly and on time. Provider directories are out of sync. Administrative loss ratio is climbing. Meanwhile, your plan is trapped by contract limitations. Buyer's remorse can set in. Getting the platform to meet your needs requires IT changes that consume all the time and money that was promised you would save by choosing your vendor. It should not be this hard, and you want out.
You're ready to take things to the next level—such as true value-based care—but your system is not.
Your plan wants to build value-based arrangements with providers in your network. Unfortunately, your administrative platform's infrastructure either does not support those capabilities or you resort to inefficient workarounds. For example, your system cannot process capitated rates or partial capitation. Immature analytics limit your ability to produce scorecards informing you how well providers are performing. You have tremendous amounts of data, but it is not informing your care management outreach, and the highest-need members aren't being supported.
Your claims system can't or won't change—to open a new business line.
You are starting a new plan in Medicaid, Medicare Advantage or Exchange. You need a partner with deep experience supporting that line's unique requirements. That means not only having a platform that can be readily configured for claims in that new business, but also deep experience supporting that population. Does your existing plan have the clinical capabilities to start supporting, for example, a Medicaid managed care organization? Without tools to leverage social determinants of health, member clinical data and other sources to target care management efforts, you may have trouble finding value in a business with margins that are already incredibly tight.
You cannot get it to open up—with actionable insights.
Despite all the data in your platform, you are getting limited insights about your actual performance. Where are you losing value? Which providers and practices are bleeding money from a network efficiency perspective? How well are providers managing populations? For these and other questions, your system is tight-lipped. You need a solution that provides robust analytics that you can act on.
You're ready to settle down—with a unified platform.
Saying "It's not you, it's me" is cliché, but it's also true. Over the years, you have assembled a tangle of point solutions. Now you see the pitfalls of juggling relationships with different vendors with different systems. Minor changes or upgrades to one have a domino effect on the others. Trying to make them work together is expensive and hinders the performance of all the solutions. Meanwhile, it is difficult to get a true, comprehensive picture of your members' health. You realize it's time to commit to a more unified and integrated platform.
You have big plans—but your current solution doesn't.
Artificial intelligence, automation, bots—the world is teeming with technologies that could help your plan run more efficiently and profitably, and better support a whole-person approach to care. But your vendor is plopped on the couch, either unwilling or unsure (or both) how to leverage such tools. You want a true partner with ambition—who is constantly thinking about where health plan administration will be next year, and five years from now, and is on the leading edge of that change.
Times are tough—and your partner hasn't been there for you.
Just as COVID-19 magnified the shortcomings of our health care system, it has proven an effective test of your relationship with your administrative platform. You’ve heard stories about health plans with full-service administrative partners who are truly "all-in" with them on the response. They're providing guidance so the plan can rise to new challenges, such as identifying members at high-risk for serious COVID-19 complications, or helping to mitigate impacts on risk adjustment programs, as Evolent has done. Your administrative vendor, on the other hand, has been missing, content to process claims in the background. You want a more committed partner.
Do any of these scenarios sound familiar? If so, contact Evolent Health Services to discuss your health plan's needs and determine if Evolent's approach to health plan administration is a change for the better.
About the Authors
Emily Rafferty, as president of Evolent Health Services (EHS), is responsible for the overall partner life-cycle—supporting new and existing partner growth strategy, implementation and ongoing market operations. Emily also has direct accountability for the EHS Pharmacy Services team. She has been with Evolent for almost five years and previously led the Advisory Services team, working closely with provider organizations to define their value-based strategy, as well as designing and building the capabilities required to successfully manage value-based contracts.
Michael Miller, chief sales officer for Evolent Health Services, has more than 27 years of experience in the health care industry. He is responsible for driving short- and long-term growth through business development, marketing, strategy and product innovation. Before joining Evolent, Michael held various leadership positions at GE Medical Systems, TriZetto/Cognizant and WebMD.