Is Your Health Plan Getting Full Value From Its Core Systems?

Health plans today are under increasing pressure to improve operational efficiency, reduce administrative burden, and respond more quickly to changing business and regulatory demands. At the same time, many organizations are still working within highly customized legacy environments that have evolved over years, even decades.

We recently sat down with Tegria managing director Gary Mirka to discuss a question many payer organizations are beginning to ask:

How can payer leaders tell if they’re getting full value from their core systems and operational workflows? 

Below are a few highlights from that conversation.

Q: When you talk with health plans, what are the most common signs that an organization may not be getting full value from its core systems?

One of the biggest indicators is operational friction.

That might show up as claims payment accuracy issues, long turnaround times for configuration changes, or manual workflows that require significant staff intervention. In many organizations, even relatively routine changes—like implementing a new employer group or updating benefit configurations—can take far longer than leadership expects.

Another common sign is that organizations are maintaining extensive customizations while newer capabilities within their platform go largely unused.

“Many health plans have continued to maintain custom workflows or custom functionality because that’s what their teams know,” said Mirka. “Over time, organizations may not fully adopt newer features and functions that are already available within the platform.”

Q: Why does this happen so frequently in payer organizations?

In many cases, it’s not because teams are doing something wrong. It’s often the result of years of competing priorities, staffing changes, regulatory demands, and platform evolution happening incrementally over time.

Platform upgrades can also be expensive and disruptive, which means organizations tend to focus first on maintaining operational continuity rather than fully evaluating every new feature or workflow enhancement available to them.

“In many environments, the technology is technically current from a version standpoint,” Mirka explained, “but the business teams haven’t always had the time or resources to fully operationalize the newer capabilities.”

As a result, organizations often end up with a mix of:

Q: Are there particular operational areas where these issues tend to surface first?

Claims operations are often an early indicator because the downstream impact is so visible.

Organizations may see:

• Increased pended claims  
• Inconsistent pricing outcomes  
• Slower adjudication times  
• Challenges onboarding new business efficiently  
• Higher manual review volume  

But the broader issue is usually workflow governance and operational visibility.

“One of the first questions I typically ask is: What metrics are you using to manage configuration operations?” said Mirka. “A lot of organizations don’t necessarily have consistent metrics around turnaround time, defect rates, testing quality, or operational performance.”

Without that visibility, it becomes difficult to identify where inefficiencies exist or where improvements could deliver measurable value.

Q: Does optimization always require a large transformation initiative?

Not necessarily.

In fact, Mirka believes organizations often see better results when they focus on smaller, targeted operational improvements rather than broad enterprise-wide initiatives.

“I generally like to start with a specific workflow or operational domain,” he said. “Something like prior authorization, coordination of benefits, or a specific configuration process. When you focus more narrowly, it becomes easier to measure outcomes, build momentum, and help teams adopt changes successfully.”

This type of focused approach can also make it easier to engage the right operational stakeholders and demonstrate measurable improvement early in the process.

Q: What should payer leaders be thinking about right now?

Mirka believes health plans should start by evaluating operational performance and governance maturity before assuming they need major platform replacement or transformation efforts.

“There’s often significant opportunity to improve performance using capabilities organizations already have,” he said. “The key is understanding where operational friction exists, what metrics matter most, and where targeted improvements can create meaningful impact.”

For many payer organizations, the opportunity is about getting more value from the systems, workflows, and teams already in place, rather than starting over.

Looking Ahead 

As payer organizations continue balancing operational efficiency, modernization, and growing business demands, optimization conversations are becoming increasingly important, particularly around claims operations, workflow governance, and platform adoption.

In our next Q&A with Gary Mirka, we’ll explore how health plans can approach optimization initiatives without overwhelming operational teams or disrupting day-to-day performance.