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Challenges with Integrating Multiple Claims Software Systems on a Single Technology Platform

By Michelle Spencer

SKYGENUSA Powering Healthcare for the Digital Age


For most payers, having more than one claims software system is a fact of life. At least if they’re offering dental. Because while most of the benefits they offer – medical, vision, physical therapy, long-term care, etc. – can run on their core systems since they share coding and other characteristics, as a general rule dental claims cannot.

Dental claims processing requires special considerations, such as tooth charts, dental business rules, and edit capabilities, that are not found in typical medical claims software. As a result, most payers must run dental claims through a separate system that they must then interconnect to their core system.

This is a problem for a couple of reasons. One is that when members log onto web portals or contact the call center, their expectation is they will receive answers to all their questions immediately. Another is the impact one system, or one part of the body, can have on others.

For example, dental wellness has been shown to have a direct effect on the mother and baby during pregnancy as well as people with certain chronic diseases such as diabetes and heart disease. Without a comprehensive view of ALL of a member’s health information, issues that could be easily caught and corrected when they are small can grow to become much more serious. In an age where we’re moving quickly toward value-based care, that’s not good for anyone. Especially the members.

It’s difficult for payers to gain that 360 degree view, however, when medical data is held in one system and dental data is held in another. Legacy systems built in the pre-Internet days aren’t designed to aggregate data from different systems with that sort of speed; the interconnections between systems are normally complex.

This situation is exacerbated by offerings that have cross-product benefit accumulation. Members who have combined total benefits for, say, dental and vision, need to know how much they’ve spent to date on both.

So how can payers resolve this difference between their systems’ capabilities and their members’ health needs and expectations?

The best approach would be to replace your core technology platform with claims management software designed for the realities of the 21st century. This software would be flexible, agile, and designed for use with the Internet. It would also already have taken the future into consideration.

A good example is the Wonderbox Technologies Enterprise System. Although it was originally designed for dental claims processing, we anticipated that it might one day also be used for various medical claims and thus built that functionality into it from the start. As a result, we were able to remove the potential points of failure that usually accompany attempts to bolt two completely different systems together.

In today’s world, where reimbursement is increasingly tied to value and outcomes, customer satisfaction is critical, and members can change payers with the click of a mouse, managing benefits on multiple, separate technology platforms simply won’t cut it. You either meet member expectations for a single view or watch as they move on to a payer who can.

What steps have you taken to consolidate benefits onto a single platform? Has it been quick and agile or slow or painful? What alternative approaches have you looked into?

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Michelle Spencer

Michelle Spencer

As Chief Innovation Officer, Michelle Spencer leads the team responsible for driving market innovations and increasing SKYGEN USA’s speed in launching new products and services in the marketplace. Ms. Spencer oversees efforts to identify, test, and launch new business opportunities with charter clients. She and her team also ensure new solutions are effectively transitioned more broadly into the SKYGEN USA organization.

Ms. Spencer brings a wealth of experience in the health benefits industry to SKYGEN USA. Previously employed by Andersen Consulting (now Accenture) and a leading national managed care company, she gained invaluable experience in the areas of system conversions and financial audits. With her knowledge of computer systems and finance, Ms. Spencer has proven to be a strong and versatile team leader.

Ms. Spencer holds a Bachelor's Degree in Business with majors in Accounting and Management Information Systems from the University of Wisconsin-Milwaukee. As a Certified Public Accountant, she also holds an MBA with an emphasis in Healthcare Administration from the University of Wisconsin-Milwaukee.

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