How Care Management Platforms Complement CRMs
In the healthcare industry, payer organizations are constantly seeking technology solutions to streamline processes, enhance member engagement, and drive better health outcomes. Customer Relationship Management (CRM) platforms are being evaluated for care management, including Utilization Management (UM), Case Management (CM), Disease Management (DM), and Appeals & Grievances. However, CRM platforms were never designed to be clinical and operational tools for managing these complex, revenue-driven processes.
Instead, care management platforms are purpose-built for CM and population health management (PHM), offering a more cost-effective, scalable, and compliance-ready solution. They also complement CRM platforms by enabling personalized, last-mile engagement while ensuring payers meet regulatory and clinical standards without costly customizations.
Why CRM Platforms Are Not Purpose-Built for Care Management and PHM
1. CRM’s Data Model Was Never Designed for Healthcare’s Complexity
CRM platforms were originally built to manage customer relationships in sales and marketing with a data model structured around leads, opportunities, and transactions — not members, care pathways, or clinical interventions.
When repurposed for payer business processes like UM, CM, and DM, CRM requires extensive customization and third-party integrations to accommodate healthcare-specific workflows. These workarounds lead to:
- Implementation delays and increased costs for healthcare organizations
- Scalability issues in handling real-time clinical data
- Challenges in integrating with Electronic Health Records (EHRs), Health Information Exchanges (HIEs), and Social Determinants of Health (SDOH) sources
By contrast, care management platforms are designed to ingest, process, and analyze these multi-faceted data sources natively, making them more effective for population health initiatives.
2. Care Management Platforms Offer Prescriptive Care Pathways, Avoiding the Burden of Third-Party Apps on CRM
A key capability of care management platforms is the inclusion of prescriptive care pathways with clinical content based on evidence-based guidelines. These pathways provide structured interventions for managing chronic conditions, high-risk populations, and preventive care, ensuring care teams follow proven best practices.
In contrast, when using a CRM platform, payers must often rely on third-party apps from CRM cloud marketplaces to procure the clinical content. This leads to:
- Higher implementation costs due to the need for external app integrations and increased vendor and contract management
- Ongoing maintenance and content updates, adding complexity and operational burden
- Increased dependency on multiple vendors, making long-term sustainability difficult
With a care management platform, clinical content is embedded and maintained by the vendor, ensuring payers receive up-to-date, compliant, and evidence-based workflows without additional cost burdens.
3. Compliance and Regulatory Reporting Are Built Into Care Management Platforms
Payers must adhere to strict regulatory and compliance requirements from entities like CMS and NCQA. Care management platforms come prepackaged with compliance-ready reporting capabilities, including:
- CMS and NCQA-aligned regulatory reporting
- Pre-configured workflows based on the line of business (Medicaid, Medicare, or ACOs)
- Automated audit trails and quality measure tracking
CRM platforms, on the other hand, require significant customization and manual configuration to achieve compliance, further increasing implementation time, costs, and risk exposure.
4. CRM Implementations Are Expensive, Time-Consuming, and Often Outsourced
Implementing a CRM for payer operations is a high-cost, multi-year endeavor. Organizations typically outsource CRM customization to large consulting firms, which must first learn the payer’s business processes before they can reconfigure the CRM. This results in:
- Significant time investments (often taking years to implement)
- Unpredictable total contract value (TCV) due to continuous refinements and scope changes
- High reliance on external consultants rather than vendor accountability
- Added overhead of managing multiple contracts and vendor relationships
By contrast, a care management platform vendor takes on full accountability for delivery, ensuring:
- A streamlined, contractually defined implementation
- A faster time to see value with pre-built payer workflows that need minimal modifications and align directly to business needs
- Lower cost and operational risk compared to a CRM-based approach
5. CRM Complements Care Management Platforms by Enabling Omni-Channel Member Engagement
CRM platforms best support capabilities for campaign management and omnichannel engagement, including:
- Call center interactions
- Outbound messaging (email, SMS, IVR, push notifications)
- Marketing and member engagement campaigns
When care management platforms integrate data with CRM platforms, it helps customer support representatives with real-time UM, CM, and Appeals data to address real time member and provider inquiries
While care management platforms focus on clinical and operational workflows, they integrate seamlessly with CRM platforms for the "last mile" in engaging members and real-time authorization and appeal request status. This ensures member outreach is timely, personalized, and informed by real-time health data, a critical factor in improving health outcomes and member and provider satisfaction.
6. Care Management Platforms Adapt to CMS Regulatory Mandates
Care management platforms closely monitor CMS regulatory mandates, ensuring critical new mandates are seamlessly integrated into their product roadmap. These mandates are translated into enhancements or new product innovations, allowing payers to remain compliant without the need for costly manual adjustments. By proactively evolving in response to regulatory changes, care management platforms help payers reduce compliance risks and stay ahead of industry shifts.
For example, the CMS Interoperability and Prior Authorization Rule (0057) mandates faster electronic prior authorizations and data exchange improvements. Care management platforms proactively incorporate such regulatory updates, ensuring payers have the tools to stay compliant and optimize operational efficiency.
Care Management platforms come prepackaged with CMS and NCQA-aligned regulatory reporting, including:
- Automated audit trails and compliance tracking
- Pre-configured workflows for Medicaid, Medicare, and ACOs
- Streamlined submission of required reports
CRM platforms, however, require extensive customization for compliance, increasing costs and risk exposure.
The Right Tool for the Right Job
While CRM platforms provide valuable capabilities for member engagement and outreach, they are not designed to support payer operations or care management workflows. Trying to force CRM to function as a care management system creates unnecessary complexity, cost overruns, and compliance risks.
Instead, a care management platform, which is purpose-built for clinical workflows, regulatory compliance, and PHM, ensures that:
- Clinical care pathways are evidence-based and pre-integrated
- Compliance reporting aligns with CMS and NCQA standards
- Implementation is faster and vendor-led, rather than costly through CRM consulting engagements
- Member engagement is optimized by integrating CRM for outreach
CRM platforms alone are not enough for effective care management. A care management platform is essential for driving better outcomes, improving efficiency, and ensuring regulatory compliance, while CRM supports engagement at the last mile.
By leveraging the strengths of both platforms, payers can achieve the best of both worlds, efficient operations, seamless compliance, and high-impact member engagement.
