The Five Tools Health Plans Use Today
Health plans aren't starting from zero. Every ops team has some version of operational measurement. The problem isn't the absence of data - it's the absence of the right data, at the right speed, from the right layer of the stack.
Monthly Ops Reports
What it does: Backward-looking summary of KPIs compiled from claims and case data, delivered monthly.
Where it breaks: 3-4 weeks old by delivery. SLA breaches are discovered after the damage is done. The member experience is already impacted, the case is already non-compliant. You're doing forensics, not operations.
Vendor QBR Decks
What it does: Quarterly performance reviews from delegated UM, PA, and claims vendors.
Where it breaks: The data comes from the vendor's own systems. There's no independent case-level verification. The QBR always looks good because the vendor controls the narrative. You delegated the work, but you don't have an independent view of the results.
BI Dashboards (Tableau / Power BI)
What it does: Custom views built by your analytics or BI team from claims and administrative data.
Where it breaks: Built on outcome data, not workflow data. Shows what happened to the patient, not what happened to the case. No real-time visibility into where cases are right now. Adding a new view takes months because the BI team has a 6-month backlog. And the dashboard can't tell you what a case costs - because that requires operational flow data it doesn't have.
The 3-Week Spreadsheet
What it does: Manual data pull from multiple systems, reconciled by an analyst, delivered as a one-off analysis.
Where it breaks: Takes 3 weeks to produce, arrives outdated. Consumes senior analyst time that should be spent on action, not data assembly. Not repeatable, not auditable, and not something you can hand to a regulator or a CFO with confidence.
Process Mining (Celonis / UiPath)
What it does: Discover and analyze business processes from system event logs. Enterprise platforms with healthcare modules.
Where it breaks: Enterprise-generic. No health plan workflow language - no PA, UM, care management, or claims models out of the box. No AI impact measurement capability. 12-month implementation timeline. Built for manufacturing and supply chain, adapted for healthcare. Different inputs, different buyers, different outcomes.
Three Questions None of These Can Answer
Where is this case right now, and is it going to breach SLA?
Monthly reports can't answer it - they're weeks old. BI dashboards can't answer it - they're built on claims data, not live workflow state. You need real-time case-level visibility from the workflow systems themselves.
What does it actually cost to process a case - by type, by resource, by automation level?
The spreadsheet that attempts this takes weeks and arrives outdated. BI dashboards show claims cost, not operational cost. Nobody has unit economics - cost per touch, cost per rework loop, cost per vendor interaction - because that requires operational flow data, not claims analytics.
Is the AI we deployed actually making the operation faster and cheaper?
Your AI vendor's dashboard shows model performance - throughput, accuracy, uptime. But did the case move faster? Did it cost less? Did the human still have to intervene? That requires an operational baseline (before AI) and case-level handler tagging. No BI dashboard, no vendor report, and no process mining tool provides this.
What Operon Does Differently
Operon Reads Your Workflow Data. Everything Else Reads Your Claims Data.
Claims data tells you what happened to the patient. Workflow data tells you what happened to the case - who touched it, when, for how long, at what cost, and whether AI was involved. That's the data layer that monthly reports, vendor QBRs, BI dashboards, and process mining tools don't have. It's the layer that answers the three questions above. And it's what Operon was built to capture.
How We're Different
| Competitor | What they do | What they don't do | Operon positioning |
|---|---|---|---|
| Process MiningCelonis, UiPath | Generic enterprise process mining. Healthcare module launched March 2025, focused on hospital revenue cycle. | No health plan workflow language. No PA/UM/care mgmt models. No AI impact measurement. Not healthcare-native. | Celonis discovers generic business processes. We measure health plan clinical operations. Different inputs, different buyers, different outcomes. |
| AI GovernanceCredo AI, Fiddler | Model monitoring, bias detection, drift, explainability, policy compliance. | No operational data. Can't tell you if the operation got cheaper or faster. No workflow visibility. No unit economics. | AI governance platforms tell you if the model is behaving correctly. We tell you if the operation is performing better because of AI. |
| Clinical AnalyticsOptum, Inovalon, Cotiviti | Risk adjustment, quality measurement, claims data analytics, population health. | No real-time process intelligence. No operational workflow visibility. They analyze outcome data; we analyze operational flow data. | They tell you what happened to the patient. We tell you what happened to the case. Both matter - but only one shows you where the operation is breaking. |
| RPA & AutomationUiPath | RPA + process mining. AI-powered anomaly detection in claims (launched April 2025). | Enterprise complexity. Not healthcare-specific. Requires months of implementation. Process mining is a feature, not the product. | UiPath automates tasks. We measure whether the automation worked. Complementary, not competitive. |
| Point Solution AI VendorsCohere Health and others | AI tools for specific workflows (PA automation, claims processing, etc.). | Vendor dashboards measure their own performance. No independent verification. No cross-vendor comparison. | Your AI vendor's dashboard measures their performance. Operon measures your operation's performance. One is marketing; the other is truth. |
Let's See If We Can Help
No pitch deck. No pressure. Just a conversation about what you're trying to solve and whether we're a fit.
Good fit if you're:
- Running clinical workflows and can't see where cases stall or why
- Managing multiple vendors and teams with no unified performance view
- Trying to answer 'what does a case cost?' without a 3-week spreadsheet
- Running AI in production but can't prove the ROI
Book a Call
- 30 minutes with our founding team
- Discovery, not a demo
- Honest assessment of fit
Or email us at sales@operon.cloud