Best Vendors for Healthcare Payer Services, Software Needs

February 17, 2023 - As the US enters a post-pandemic era with the end of the public health emergency, healthcare payers will want to choose the right partners to take them into the next stage. They might locate new partners in the Best in KLAS Software & Services 2023 report, which highlighted the highest-performing vendors from 2022 based on customer responses.

“To sustainably maintain momentum, both healthcare organizations and vendors must fortify themselves and evaluate what is and what isn’t helping,” said Adam Gale, chief executive officer of KLAS Research.

“Healthcare organizations can’t revert to old, pre-pandemic workflows. Vendors can’t stretch themselves to meet customer needs only to let their performance slip shortly thereafter. As an industry, we have to keep improving patient care by utilizing new tools and partnering with patients.”

KLAS covered the top vendors for payers in care management, claims and administration, CMS payer interoperability, quality analytics, risk adjustment, IT consulting services, and employer-sponsored healthcare services.

Care management

The top care management solution of 2023 was ZeOmega which scored 82.9 points out of 100. This score is 8.1 points above the average care management solutions overall performance score.

Jiva, ZeOmega’s care management software, scored highest on consumer loyalty. The software achieved an A- for loyalty. Feedback from individual clients highlighted the tool’s integration of various functions from utilization management to pharmacy, medical, or quality management.

The vendor was the only competitor in the care management category that received a B- or above in almost every customer experience pillar except value, in which the vendor achieved a C+. The tool received a B- for culture, B- for operations, and B+ for relationship.

All 18 respondents said they planned to incorporate ZeOmega Jiva into their long-term plans. And 15 out of 15 respondents agreed that they would repurchase ZeOmega Jiva.

“Being distinguished by KLAS as a top performer in our market is a testament to ZeOmega’s revolutionary developments in population health management and ongoing customer satisfaction,” Sam Rangaswamy, chief executive officer of ZeOmega, said in a press release.

“It directly reflects health plans’ confidence in Jiva as the go-to tool for all aspects of care management, and we look forward to optimizing our offerings even more in the future as we continue our mission of helping plans ensure their members receive the right care at the right time.”

At the opposite end of the spectrum, Medecision’s Aerial for payer care management scored 49.7 points with an overall value of a D- and four out of five scores were an F.

Claims and administration

HealthEdge’s HealthRules Payor platform achieved the highest rating for claims and administration software.

The platform received 76.6 points, largely due to its customer loyalty which received a B grade. Its operations, product, and relationship scores were all a C+. It received a D+ for customer loyalty. These points contributed to an overall value of C-.

Individual respondents highlighted the software’s configurable nature and the use of APIs to integrate solutions within the platform better. Additionally, the company’s collaborative and proactive culture became clear in users’ comments.

All 20 respondents said they planned to integrate HealthEdge as part of their long-term plans.

KLAS ranked only two solutions for this segment: HealthEdge and Cognizant. Cognizant’s Trizetto Core Claims/Administration Solutions received a score of 66.0. The platform received a C- for operations and product, a D+ for loyalty and relationship, a D for culture, and an F for value.

CMS payer interoperability

Edifecs’s XEngine Server for FHIR had the highest score for CMS payer interoperability software. KLAS gave the software 87.9 out of 100 points. The tool received an A- in almost every customer experience pillar—culture, loyalty, product, and value. Only operations and relationships received lower scores of a B.

Edifecs executives indicated that the company’s long history in interoperability and data transactions was critical to its success.

“Our customers serve more than 290 million people, as a result, we have a wealth of experience with customer data and processes,” Venkat Kavarthapu, chief executive officer of Edifecs, said in a press release.

“This deep expertise has helped make our platform the proven choice to future-proof capabilities and ease the adoption of new compliance mandates. We’ve continued to leverage our industry know-how to provide business solutions that accelerate value-based payment adoption, obtain complete and accurate funding, and fully automate prior authorizations. Together, these solutions help replace the pervasive friction between payers, providers, and members with collaboration.”

All eight respondents indicated that Edifecs did not charge “for every little thing.” Customers from 1upHealth and InterSystems gave the same feedback for those platforms.

Edifecs outperformed three other ranked solutions from 1upHealth, Smile Digital Health, and InterSystems. While these platforms did not receive as many points as Edifecs’s XEngine Server for FHIR, they stood out in different ways. For example, 12 out of 12 respondents said that they intended to integrate Smile Digital Health into their long-term plans and 14 out of 14 respondents said they would repurchase 1upHealth’s FHIR Platform.

Quality analytics

Milliman MedInsight had the highest ranking on quality analytics for its Quality Analytics platform. KLAS gave MedInsight’s Quality Analytics platform a score of 84.7 points out of 100.

Milliman MedInsight’s relationship score was its strongest customer experience pillar, receiving an A. The platform achieved a B+ in loyalty and value, Bs in culture and operations, and a B- in product.

In its press release, the company noted that this is the fifth year in a row that the platform has achieved a top ranking for quality analytics in the KLAS report.

While MedInsight took the highest ranking, Cotiviti showed strong improvement in this space. Closest to the quality analytics platform average score at 81.3 points, the platform increased eight percent over its 2022 score. Its grades were in the B range across every customer experience pillar.

Risk adjustment

KLAS ranked 15 companies’ platforms for risk adjustment and Vatica Health’s Risk Adjustment and Quality of Care Solution came out on top. The platform achieved a score of 92.5 out of 100 points. This was the highest score that any payer solution received for the Best in KLAS 2023 report.

Vatica received an A-range ranking in almost every category. The solution achieved an A+ for loyalty and relationship, an A for culture and value, an A- for product, and a B+ for operations. Its score was 9.6 points above the average score among risk adjustment software.

The solution received accolades in every additional performance question. All 12 respondents said that the company did not charge “for every little thing” and all 13 respondents said that Vatica Health kept its promises, would be part of the company’s long-term plans, and that the respondents would purchase this tool again.

“We are thrilled to be ranked as the leading risk adjustment solution and appreciate the extensive research done by KLAS in making this determination,” Steve Zuckerman, co-founder and chief strategy officer at Vatica, said in the press release. “We also greatly appreciate our clients’ partnerships that have enabled us to achieve this distinction. This award validates Vatica’s innovative model that produces better and more compliant risk adjustment results for health plans, providers and patients.”

Other ranking risk adjustment software included EXL’s Clarity, Apixio’s HCC Identifier, Perot Intelligence’s Risk Solutions, Advantmed’s ELEVATE Risk Adjustment Insights, Talix’s Risk Adjustment and Analytics Solutions, Episource’s Risk Adjustment and Analytics, Veradigm’s Illumin8 Risk Analytics, MedInsight’s Risk Analytics, and Arcadia’s Risk Navigator Plus, along with five other solutions.

Clients agreed that Arcadia, Pareto Intelligence, and Talix did not charge for every single thing. EXL customers said that the company kept its promises. Advantmed, Arcadia, and Talix customers planned to keep these risk adjustment tools as part of their long-term plans. Additionally, Advantmed and Pareto Intelligence respondents said that they would repurchase these tools.

Different tools excelled in different areas. Apixio and EXL came out strong in their analytics functions. Episource performed well in analytics, chart retrieval, and chart review or coding services. Vatica Health performed well in chart view or coding services and health assessments, including retrospective, telehealth, and home-based.

IT consulting services

EMIDS achieved the highest score in IT consulting services, scoring 86.1 points out of 100.

The solution received an A for customer loyalty, an A- for relationship, B for services, and B- for operations and value. All of the respondents said that they would repurchase EMIDS. Although it achieved the highest ranking, EMIDS’s score did not exceed the overall performance score average of 86.4 points, and it saw a downward trend of five percent in 2023.

Employer-sponsored healthcare services

Marathon Health achieved the highest score for employer-sponsored healthcare services. The company received a score of 91.2 points out of 100, exceeding the average in this segment by 4.4 points.

Marathon Health trended upward by two percent in 2023. The company received an A for customer loyalty, an A- for relationship, and a B+ for operations, services, and value. All of the respondents said that they would buy Marathon Health again.

One client reported that Marathon Health excelled in its flexibility, according to the company’s press release.

The platform’s score exceeded four other competitors’ solutions: QuadMed, Premise Health, Everside Health, and Oracle Health. All of the QuadMed respondents said that they would purchase the services again.