Payer Front Office Assessment

Welcome to the Assessment!

Please proceed through the following **seven sections** to evaluate your organization's Front Office capabilities. Select all options that apply to your current situation within each category.

Click "Start Assessment" to begin.

1. Product Development & Benefit Design: The Loss of the Standard Package

Q1: How would you describe your current product offerings and benefit design? (Select all that apply)

Primarily fixed PPO/HMO bundles with limited customization. Ancillary services are typically separate carve-outs. We offer Level-Funded plans as a defensive strategy and package a few preferred digital health solutions. We offer ancillary services and digital health services as an offering based on population analytics. Benefits are highly modular and customized via a central product catalog. Plans are designed with a clear ROI focus for TCOC management. We offer outcome-based, performance-guaranteed plans with dynamic, AI-driven personalized benefits.

2. Sales & Distribution: The Broker/Consultant Challenge

Q2: How does your sales team currently engage with employers and brokers/consultants? (Select all that apply)

Sales focus is on network size and premium. Broker channel is primarily transactional. Product, Benefit and Rate information are integrated with selling tools for underwriting, quoting and enrollment. Sales documentation is auto-generated with very little manual intervention. Our sales team is segmented, and we provide materials to counter alternative funding (Captive/RBP) pitches. We have deep engagement with top consultants on risk pooling and custom solutions. Sales act as TCOC consultants for employers. Our direct-to-employer teams win on integrated value-based care models. The sales process is fully digital with no paper forms.

3. Underwriting & Actuarial: Risk in a Custom World

Q3: Describe your approach to underwriting and risk management for employer groups. (Select all that apply)

We use legacy data and broad averages. Minimal ability to price Level-Funded risk accurately. We incorporate specialty pharmacy risk modeling and use detailed stop-loss data for plan pricing. Rating & Underwriting tools are integrated into the sales process with auto-ingestion and referencing of product and benefit data. We integrate clinical, pharmacy, and SDOH data for granular risk prediction, pricing based on proactive health management ROI. We own and manage custom reinsurance/captive structures for large clients, using AI for real-time risk-pool adjustments.

4. Account Onboarding and Operational Experience

Q4: How efficient is your process from sales order to member enrollment and data flow? (Select all that apply)

Sales orders are captured manually, requiring re-keying into eligibility and claims systems. High enrollment error rates. We use APIs for basic data exchange between CRM and eligibility, and RPA for simple enrollment tasks. We have a seamless, automated data flow from quote-to-card. Digital self-service tools for brokers/employers manage eligibility. We have real-time integration with digital partner ecosystems and achieve zero-defect eligibility driven by a single system of record.

5. Partner Ecosystem and Digital Health Integration

Q5: How do you currently manage integration with external digital health and specialty partners? (Select all that apply)

We manage digital health partners on an ad-hoc, manual basis. Integration relies on flat files or email for eligibility/enrollment. We maintain a preferred vendor list, but integration primarily covers basic eligibility/member files. Data feedback on partner utilization/outcomes is limited and lagged. We use a formal **API gateway** to integrate digital health partners. We actively use partner data to inform TCOC reports and drive member outreach. We curate a seamless, "partner-agnostic" ecosystem where new vendors can be onboarded via standardized APIs in days, guaranteeing integrated member experience.

6. Sales-to-Claims Systems Integration: The Product Catalog Failure

Q6: To what extent does your sales quote/order data seamlessly flow into your claims and eligibility systems? (Select all that apply)

Benefit definitions (sold via quote) are manually entered into eligibility, claims, and compliance systems, leading to high error rates and slow "Quote-to-Card" time. We use **RPA** for basic data transfer between the quoting system (CRM) and the enrollment system, but claims/adjudication rules still require significant manual configuration per client. We use a conceptual or partial **Enterprise Product Catalog** that automatically generates the Summary of Benefits (SOB) and eligibility rules based on the sale. We have a single, unified **Enterprise Product Catalog** that is the authoritative source for sales, enrollment, and claims adjudication (zero-touch configuration).

7. Compliance and Reporting Burden

Q7: How is your organization managing the administrative and data burden of regulatory compliance (NSA, Price Transparency, ERISA)? (Select all that apply)

Compliance reporting is managed by manual teams in different departments (Actuarial, Operations), leading to high cost and inconsistent data quality. We use vendor tools to manage basic Price Transparency file generation (MRFs), but the advanced notification process is still viewed as a massive, unsolved IT challenge. We have automated data pipelines that link contracted provider rates to member data, enabling streamlined reporting and a plan to meet advanced notification requirements through phased IT projects. We treat compliance as a competitive advantage. Our integrated platform enables near real-time auditability and documentation, significantly reducing compliance cost and risk.

Your Payer Front Office Assessment Results

Overall Maturity Stage:

Maturity Gap Analysis (Category Scores)

This chart shows your organization's highest demonstrated maturity level across each of the 7 pillars. The dashed line represents the Target (Stage 4) Maturity.

Your Current Strategic Focus:

Your overall maturity indicates a strategic focus within this quadrant:

1

Strategize & Execute

(High Impact, Low Effort)

2

Invest & Transform

(High Impact, High Effort)

3

Optimize & Maintain

(Low Impact, Low Effort)

4

Re-evaluate / Foundational

(Low Impact, High Effort)

Impact (Value)

Low Impact

Low Effort (Agile)

High Effort (Complex)

Quadrant 1 (Top-Left) represents the ideal state of High Impact, Low Effort, aligning strategic value with operational agility.

Detailed Roadmap Recommendations (Per Pillar)

Focus your transformation efforts based on the specific maturity gap in each of the 7 core pillars:

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Payer Front Office Maturity Assessment