Modernizing the Claims Adjudication Process for Healthcare Payers

The COVID-19 pandemic has accelerated the digital transformation journey for many industries and healthcare is no exception. While great strides have been made over the past few years, healthcare payers have only started to tap into the digital opportunities that exist in other industries. One of the greatest opportunities for innovation and strategic differentiation is the claims management process, which is at the core of every healthcare payer’s business model.

Payer Challenges

Healthcare payers face some unique challenges when it comes to digital transformation. The costs and complexity of claims management continues to grow. As the population ages and cases of chronic diseases increase, the number of claims that payers must process continues to grow exponentially. Petabyte-scale data growth is an issue for Payers and the cost of storage continues to impact their bottom line.

Consumer expectations have also continued to rise. Today’s consumers expect the same omnichannel digital experiences that they receive in other industries, such as retail. They expect accurate, real-time data to be available at the click of a mouse. Many legacy claims processing systems operate in batch mode which causes stale and inconsistent data across business units. Often times this leads to a negative member experience because a member may be viewing information that’s inaccurate and inconsistent with what a claims customer service representative may be telling them.

Benefits to Modernization

To respond to these demands, many payers have focused on modernizing their claims management systems. Reduced claims processing time results in higher member satisfaction, which ultimately impacts their NPS (Net Promoter Score) scores. As many payers invest in modernizing their claims systems, they have similar goals:

  • Real-time adjudication capabilities
  • Increase automation to reduce human intervention when possible
  • Leverage AI/ML for risk stratification, fraud detection, and prior authorizations
  • Improve data transparency
  • Lower total processing cost per claim
  • Data interoperability

Lessons Learned

Most claims systems are monolithic mainframe applications that were built years ago so modernizing these systems is no small task. Claims systems are part of a complex web of upstream and downstream processes. Many organizations find their biggest challenge is figuring out where to start. VMware has helped many of their payer customers on this journey and learned important lessons along the way:

  • Ensure that you have the right people and processes in place before you begin the modernization process. Determining how you will upskill your people is extremely important. Even if you bring in outside talent to help with the modernization, having a skilled internal team to support the application is crucial.
  • Similarly, processes will likely need to be changed to support your new claims system. Often technology is the easiest element of these transformations. It’s making sure that you have the right people and processes in place that adds complexity.
  • Create a detailed plan for how you will support your legacy system and modernized application in parallel. In order to mitigate the risk associated with this type of deployment, running your systems in parallel for some length of time is recommended. Developers are often “building the plane while flying it” and unfortunately there is no margin for error when it comes to claims processing.
  • Break down your monolithic application into loosely coupled microservices. An event-driven architecture will enable your services to scale and fail independently. So, if one service fails, the remaining services are not impacted. This resilience is a huge improvement over the monolithic applications of the past. This type of architecture also promotes agility. Since each microservice is completely independent, new features can easily be added without impacting the other services.
  • Listen, learn, and iterate. Engage employees, members, and providers frequently and use their feedback to help you build your product roadmap. Customer service teams are a great source for feedback because they are engaging with members daily. Simple productivity enhancements for customer service teams can result in significant call time reduction and exponential ROI. Look for these “quick wins” as the broader modernization efforts progresses. Utilize an Agile methodology such as SAFe (Scaled Agile Framework) to build incrementally with rapid learning cycles.

Contact Us

If you are interested in learning more about how VMware can support your business on its claims modernization journey or other healthcare initiatives, explore our solutions.



Leave a Reply

Your email address will not be published. Required fields are marked *