For Healthcare Payers, Enrollment and Billing Technology can Power Growth and Profitability

Srini Venkatasanthanam, GVP Insurance Product Development, Oracle Financial Services | May 1, 2023

Agility, automation, and insight—from enrollment to renewal—are more critical than ever for health insurance providers as they navigate several significant market developments:

  • Healthcare payers are experiencing rising healthcare and prescription drug costs that outpace inflation. From July 2021 to July 2022, more than 1,200 products posted price increases that exceeded the 8.5 percent inflation rate. The average increase was 31.6 percent.
  • Market competition continues to grow. In the last five years, the average number of Medicare Advantage plans available to beneficiaries has more than doubled from 20 health plans per beneficiary in 2018 to 43 plans per beneficiary in 2023. And, customers are measuring their healthcare payer experience against the frictionless and immediate transactions they enjoy elsewhere in their daily lives. Payers continue to work to meet these expectations. According to OpsDog, the median number of members receiving their ID cards on or before the policy’s effective date is 46.7 percent.
  • The regulatory environment continues to grow more complex, specifically around pricing transparency. These requirements have wide-reaching billing and revenue optimization ramifications, and many organizations struggle to achieve compliance using their inflexible legacy systems.

In this environment, healthcare payers seek opportunities to boost their bottom line by improving operational efficiency, achieving faster time to market for new products, elevating the customer experience, and facilitating regulatory compliance. This requires technology modernization at scale, and two of the most critical junctures in the customer and policy lifecycle—enrollment and billing—are especially ripe targets.

Legacy processes and technology limit opportunities

The insurance industry is, by nature, risk-averse. This mindset extends to process and technology modernization. For many years, insurers bet on the risk of change, outweighing the efficiency, customer experience, security, and business opportunity gains that modernization could afford.

That’s no longer the case as healthcare insurers seek to address longstanding obstacles to agility, efficiency, insight, and growth, including:

  • Fractured data flows—Payers struggle with duplicative data stores and inefficient integration across the entire enrollment and billing lifecycle. Rigid legacy applications and incompatible technologies prevent seamless data exchange and a single view of the customer across all lines of business. This translates to missed opportunities to create exceptional value early in the customer acquisition process and throughout the relationship.
  • Inefficient processes—Disjointed point systems, which lack API compatibility, and legacy manual processes lead to inefficiency that drives up costs and makes it difficult to launch new products rapidly, offer flexible billing, and bill for all contracted charges. E-mail-dependent workflows and approvals delay processes across the lifecycle, including launching new offerings, calculating pricing, providing customer information updates, and delivering a seamless billing experience.
  • Slow systems and limited scale—Most legacy systems, which require hardcoding and extensive IT team intervention for even the simplest updates, cannot pivot rapidly to meet changing business needs. Further, many continue to rely on batch processing that does not deliver the real-time information and decisions that the market demands. And, many organizations struggle to scale their infrastructures, which complicates their ability to add lines of business, expand geographically, and grow through acquisition.
  • Security and privacy complexity—Security threats and requirements continue to escalate. Legacy infrastructures typically contain multiple data stores that fuel dozens of point solutions and often lack adequate preventative controls and audit trails. This reality complicates compliance with internal controls as well as regulatory requirements and elevates overall risk.

Essential capabilities to solve these four challenges

Six core administration capabilities are essential to empowering payers to overcome these persistent challenges, unlock new opportunities, and build stronger relationships. They include:

  • A central golden member record and automate end-to-end processes
  • A microservices architecture that enables progressive transformation, flexibility, and performance
  • Rules-based and highly configurable applications
  • API-rich approach to enable real-time processing and data access
  • Multiple consumption models—functional components, end-to-end solution, calculation engine
  • Security with preventable controls and extensive audit trails

Oracle’s answer

Oracle Health Insurance Core Administrative Solution, a leading SaaS solution, which includes Policy Administration, Revenue Management and Billing for Healthcare Payers—is purpose-built to help healthcare payers compete agilely in a constantly changing landscape, delivering the essential capabilities identified previously and many more. Our solution drives frictionless onboarding, creates a central golden member record, enables efficient member management, and ensures accurate, efficient, and flexible billing. It also supports both commercial and government health insurance and billing from a single platform.

Read our eBook to learn more about Oracle Health Insurance Core Administrative Solution for enrollment and billing (PDF).

Oracle’s component-based solution spans the complete lifecycle—and payers can begin their enrollment-to-billing modernization journey where they want and proceed at their own pace.