Core administrative processing systems (CAPS) serve as the center of the healthcare payer architecture and are essential for efficient business operations. These systems are needed to support administrative and transactional processing and are a significant investment in technology. Selecting a CAPS system isn’t a single purchase, but rather an ongoing partnership that requires maintenance to ensure the system remains up to date to support industry and regulatory changes. Last year, 99% of surveyed health IT leaders said they had plans to evaluate their CAPS systems within the next two years, with key drivers being the speed of creating benefits plans, seamless integration with other solutions, better support of value-based arrangements, and lower administrative and operational costs. Recently, health leaders reported managing costs as one of the top challenges they’re currently facing, with operational efficiencies ranking as the second greatest challenge. Why are cost management and operational efficiencies most important this year? There are a variety of factors to consider, but outdated systems requiring manual intervention have proven to be a hefty investment to meet today’s industry demands.
Operational efficiencies have always been a challenge for health plan leaders, but as workforce shortages continue to cause difficulty within the industry, health plan leaders are seeking new ways to accomplish more with fewer resources. Too many payers are still operating on decades-old CAPS systems built on legacy technologies, which have been sufficient in the past but are no longer enough to meet today’s needs. While legacy technologies are suitable to accomplish basic functions, digitization in healthcare continues to build momentum and payers will need to build a digital foundation that both eliminates manual processes that eat up valuable time and enables greater access to real-time data. To meet the demands of the changing landscape, health plans must evolve.
The following are some of the top factors health plan decision-makers should consider before implementing a CAPS system to address market opportunities, innovate and remain competitive.
1. Evaluate Experience and Expertise Level
When it comes to making a significant long-term investment in a system, selecting a partner who is well-versed in the insurance software marketplace is critical. Your team of decision-makers should ask themselves, “How long have they been in business?” and “What is their level of expertise?” before selecting a partner. You want to ensure the partner you choose is well-equipped to guide you through the process and provide the proper training in order to ensure a successful implementation. By choosing a partner who is experienced in the planning and development stage with client-tested software, you can ensure your goals will be properly met. Unsure where to start? Every year, KLAS Research recognizes companies that excel at helping healthcare professionals improve patient care.
2. Establish Goals for Functional Capabilities
Before you make a significant investment in a next-generation CAPS system, consider your company’s ideal state and long-term goals for success. Ask yourself, “Where do we want to be?” and “What restrictions do we no longer want to have?” Having clearly established business goals ensures you’re selecting a CAPS system that checks all the boxes aligned with these goals. Take a step back and create a long-term strategic plan that highlights how you’d like to operate moving forward. Doing so can help identify which tasks could and should be automated and align those requirements with the technology you choose to implement. Skilled partners should have the capability to assist you in identifying goals to suit your individual business needs.
3. Optimize Business Practices with Real-Time Data Access
Changes to the healthcare industry have been occurring very quickly, impacting the requirements for payers’ CAPS systems. There are new and changing regulatory requirements payers must follow to remain compliant. Still, many times, legacy technologies aren’t well suited to keep up with today’s needs, as access to real-time data directly impacts a health plan’s ability to keep up with regulatory changes.
CMS interoperability mandates require health plans to offer access to data via FHIR-enabled application programming interfaces (APIs). The new Transparency in Coverage Rule requires health plans to make available Machine Readable Files (MRFs), and the No Surprises Act requires health plans to maintain accurate provider data in their systems within 48 hours. Legacy systems simply weren’t built to open and share the data that is locked within them. As this new wave of compliance requirements progresses and the consequences for non-compliance continue to grow, modern and next-generation platforms are doing more to help address these challenges.
4. Ensure Proper Training is Provided
One of the biggest mistakes you can make when implementing a CAPS system is underestimating the level of training required and the ongoing support that will be needed from the initial bid to after the final implementation of the CAPS system. Shifting to an interoperable system requires an understanding of how each piece of the puzzle works together and, most importantly, how they impact each other. It can be more productive to have an implementation team that includes people within different departments, paired with external project management and implementation support, to ensure success in moving forward with a new system across the organization. You can’t evolve by using the same processes or the same train of thought, so it’s essential to incorporate new, non-traditional roles and mindsets to ensure your goals are properly met.
5. Remember, It’s a Marathon, Not a Sprint
Have patience with both the new technology, as well as your internal team as they learn how to use it. It’s not just about implementing a new platform but rather a process of adapting to a more connected and interoperable approach to satisfy modern-day needs. The length of time any new software implementation process takes can vary greatly, and as unexpected challenges may arise, it’s important to keep your end goal in mind. Every organization is different, which is why finding a partner who can customize your approach is invaluable to a successful implementation.
There are a variety of technologies and tools for automation, but selecting a CAPS system platform that also proactively helps you understand where and how you can continuously improve your level of value can improve processes while supporting overall business goals. Value realization is critical. It is imperative to move the needle not only on cost management but care management as well. Before making your selection, keep in mind that you are not merely implementing a system but instead selecting a partner to help you to bridge the gap between understanding the business need and maximizing how technology is configured and implemented to support your goals and objectives.
About Michele Oliveto
Michele Oliveto serves as SVP and General Manager of our Global Professional Services division at HealthEdge. Leveraging nearly thirty years of experience in the healthcare payer business, technology operations, implementation planning, execution, application functionality, and information management, Michele directs our professional services teams. She oversees over 100 concurrent consulting engagements across the HealthEdge customer portfolio. Michele is passionate in her commitment to ensuring that our customers realize optimal value from our suite of product solutions.
