Case USA3: Why a Health Insurer Mistook Member Portals for Enterprise Architecture Integration

Overview:

A persistent pattern in our US diagnostic series is confusing unified portals with actual enterprise integration.

Health insurers rolled out member self-service features, appointment booking, and claims tracking, celebrating them as EA maturity milestones. But the underlying systems — eligibility, provider directories, and claims adjudication — remained inconsistent, with duplicated rules and fragmented behavior.

P1–P6 Insight Preview:  While portals improved customer-facing processes (P2) and component usability (P4), our analysis found deep integration gaps in system behavior (P3) and missing governance alignment from strategy (P1) through operations (P6).

Role Disconnects:

CEO: “Our members have a single point of access” — yet their data journeys are still disjointed.

CIO: “Our portal integrates all services” — but it integrates the interface, not the enterprise.

Sales Head: “Our digital touchpoints are competitive” — but backend inefficiencies slow fulfillment.

Chief Enterprise Architect: “We have a unified front-end, but fractured systems” — the enterprise model is missing.

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