Getting the Most Out of Claims Management Through Cloud Integration

Tom Kerr (TK): I’m Tom Kerr. Managing medical bill review claims can be a challenge for claims professionals. To get a better understanding of current solutions to address these issues, we welcome Rebecca Morgan back to the Enlyte Envision podcast. Rebecca, thanks for joining us today.

Rebecca Morgan (RM): Thanks for having me. Happy to be here.

TK: So, let’s start with the first question here, Rebecca. What are some of the main issues the industry faces when it comes to managing medical bill review, automated payments and unified claims?

RM: At the highest level, integration with expert systems, like medical bill review and payments, and a host of other solutions, is critical to proper claims handling. Integrations can be complicated, costly and difficult to get them right.

So, a lot hinges on getting the right data to the right system at the right time, and there can be dozens of these integrations required to fully manage a claim through the entire process.

Reimbursement for medical bills is a highly complicated and highly regulated process, so between compliance with fee schedules and other regulatory requirements, litigation, case law, all of that is just constantly changing, and that’s why the industry needs a medical bill review solution that they can trust to do it right.

Then, when it comes to the electronic payments after the medical bills have been processed, it’s equally important that this process be as integrated and hassle‑free as possible.

So, the problem we sometimes see when provider payments are made without integration with medical bill review is that the payment and the EOB, they go out separately. That’s when you get phone calls from the provider saying, “I didn’t get paid. Where’s my check?” There’s a disconnect there.

That’s why it’s important that the payment process is integrated with the bill review process, so the payment and EOB go out at the same time, ensuring the provider understands how they are being reimbursed at the same time that they’re actually receiving that payment.

TK: OK, and how have companies worked at handling these issues over the past few years?

RM: Well, Guidewire has been working to encourage their customers to move to cloud‑based versions of ClaimCenter. The benefit to an insurance carrier is that changes to the system and upgrades will be much easier to manage going forward.

Since upgrades will be happening much more frequently among these customers, it’s critical that the integrations with expert systems, like medical bill review, evolve with the upgraded versions of ClaimCenter.

That’s what the new cloud version of the Accelerator does for customers. The Casualty Solutions Accelerator for Guidewire Cloud is a prebuilt integration between Guidewire, ClaimsCenter, cloud versions and our Enlyte Casualty Solutions bill review products SmartAdvisor and DecisionPoint. And that’s really a unique offering to the market because integrations are just hard. A lot of money is spent by claims organizations on IT, and this is one way Enlyte can help to accelerate those integrations and minimize the work for claims organizations when they need to integrate expert solutions, like our bill review solutions.

TK: OK. And how does moving to the cloud help solve some of these claims issues?

RM: It’s really about accelerating integrations for our claims organizations for carriers or TPAs or employers who are leveraging Guidewire Claims Center as a claims platform. They have a need to create those integrations. And we even hear sometimes that claims organizations have to integrate with 50 to 100 different expert systems.

At Enlyte, we have many of those systems that are important in adjudicating claims. And so, we’re able to provide this prebuilt integration that not only accelerates the time that it takes to create that integration, But it’s also going to do it in a best practices standard way so that our joint customers can really get the very best integration possible when they leverage this Accelerator.

TK: Who is the Accelerator built for? Is it claims leaders, adjusters, IT decision makers?

RM: It’s actually all of the above. It’s very important for IT decision makers because an IT department is always looking to minimize the budget that they have to spend on these integrations. So, a prebuilt integration means that they don’t have to do as much work to create that integration. We’ve already done the work for them.

For claims leaders, it’s important for some of the same reasons, they don’t have to go and fight for those IT resources that are in such short supply. But they also get a very tried and true best practices kind of integration out of this.

For adjusters, we’ve taken special care to create an experience that is very efficient and streamlined. The adjuster spends most of their time in a day inside Guidewire ClaimCenter. That is their core claims adjudication platform. But they have to use other systems throughout the day, expert systems that sort of plug into their claim system. And our bill review systems do that.

We want to make that experience for the adjuster seem like they’ve never left their core claim system center. And so, we use single-sign-on deep linking. And I’ll give you three examples. The first is the adjuster can go from inside Claims Center directly to the homepage of our bill review systems.

The second is what I would consider to be a deep link. The adjusters are in the claims page inside Claim Center, and they have a hyperlink that will take them directly to the claim view inside the bill review system.

And then lastly, inside Claims Center, you’ve got a medical bill represented as an invoice. So, they click on that invoice and that takes them again into the bill review system where they can look at the bill detail page inside our Enlyte bill review.

TK: Got it. But what about for IT and architecture teams? What does the integration pattern look like?

RM: This is a really great benefit of the way that we have chosen to architect this Accelerator. We have built it using the Built by Guidewire program, which means that Guidewire engineers have actually built the Guidewire side of the integration. And our Enlyte engineers have, of course, built the APIs or web services that that integration is going to access.

Now, what does this mean? Guidewire Cloud customers are on a much more regular upgrade cycle than they ever have been in the past. It used to be on-prem type environments, Guidewire customers would go years in between upgrading their version of Guidewire.

Now that’s not the case. Now, Guidewire customers are taking much more frequent upgrades, once a year or even multiple times a year, So what does that mean now for the Accelerator? Well, within the Built by Guidewire program, that accelerator is automatically upgraded. And so, when our customers choose to use the Accelerator to perform the integration, as they take their Guidewire ClaimCenter upgrades, that accelerator is always going to be ready for them to take the upgrade along with it. And so, there’s no waiting for changes that are going to lag in those accelerators or wondering if it’s going to be compatible with the next version. It’s always going to have an associated release for each of the Guidewire release versions.

TK: OK. So, what does typical implementation look like and what are some of the bigger accelerators or blockers?

RM: Yeah. In a standard implementation outside of the use of a prebuilt accelerator like this, a lot of time would have to be spent mapping the claim system to the bill review system. We eliminate all of that via this prebuilt integration because that technical work is already done. And so those are the pieces that are really going to accelerate.

We’ve also spent all that time working out the workflows. Those pieces are eliminated through the use of this prebuilt implementation. Each claims system, each claims organization is unique. And as we go through an implementation process with a customer, we are going to make sure that we don’t need to customize based on individual business workflows. And certainly, our systems can accommodate all of that.

We have powerful configurability and business rules that we can use to help implement the secret sauce for a claims organization. And so those pieces are still important to address in any implementation. But the accelerator really kind of takes off the table all of the core integration, implementation, data mappings, workflows, etcetera, and allows us to focus on those things that are really higher value, higher impact kinds of tasks.

TK: What levers exist for customers to configure rules without code and maintain control?

RM: Yeah, there’s actually a couple of different ways that customers can customize their implementation of these products. First of all, there are business rules that can be leveraged inside claims center itself. And many of those rules are actually built into the accelerator. For instance, rules that will help to facilitate automated approval of certain populations of medical bills are built into the accelerator and can be customized based on claims organizations own business practices. And that’s done, by the way, without code.

The second level is rules and configurations that are built into our bill review systems. So, we have a very powerful business rules engine in bill review that allows us to accommodate specific customer customized workflows, facilitate higher levels of automation, automatically performing tasks that otherwise a human might be able to perform.

The last thing is configurability. Claims organizations across the board operate differently. They have different risk tolerance, different policy language, different interpretation of regulations. And our systems have to be able to accommodate those different interpretations. So, all of our bill review systems are set up to allow our customers to configure according to how they want to operate their business.

So, those are just a few examples of some varieties of rules and configurations that can happen without the use of involving an IT department. They’re business users that can facilitate those changes.

TK: OK, so, what feedback have you received from customers so far regarding the Casualty Solutions Accelerator for Guidewire Cloud?

RM: We’ve actually had a lot of interest in the Accelerator. Customers who are moving from on‑prem versions of ClaimCenter to the cloud version of ClaimCenter have their work cut out for them. There’s a lot of work involved in initially moving from on‑prem versions to the cloud.

Once they’re there, customers will benefit from much simpler upgrades, but there is an initial investment in getting there. Customers are also interested in taking advantage of an integration that is built on best practices and provides a more standard approach to data exchange and workflows.

They’re interested in taking advantage of work that has already been done for them in the form of this prebuilt integration.

As we set out to create this new cloud version of the Accelerator, we talked to a lot of customers to understand what they would like to see included in the Accelerator. We’ve taken that feedback and incorporated that into this version of the Accelerator, and we’re really excited to see what customers are going to do with it.

TK: Thanks, Rebecca. And this closes out our Enlyte Envision podcast series for 2025. Here’s to a safe and peaceful 2026. And, until next year, thanks for listening.

If you’d like to learn more about the Enlyte Casualty Solutions Accelerator for Guidewire Cloud, you can find details on Enlyte’s Guidewire solutions page.