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Perspective: For Payers, It's Time to Get a New Claims and Billing Engine — Decoupling and Change Have Atomized Your Legacy System

Perspective: For Payers, It's Time to Get a New Claims and Billing Engine — Decoupling and Change Have Atomized Your Legacy System

This IDC Health Insights Perspective reflects the observations made by IDC Health Insights analysts over the past years regarding the evolution of claims and billing engines. Nine trends are identified to show how the legacy claims engine is now broken and outmoded to such a point where replacement must be considered, however painful. After the trends are identified, 11 actions are outlined for payers to take when evolving the claims and billing engine.


In This Perspective
Situation Overview
Legacy Claims Architecture as It Was
Current/Future Claims Architecture as It Has Evolved
Trend 1: Member Benefits Record => Unique Person
Trend 2: Member Services => Customer Relationship Management
Trend 3: Local => Global Document Management
Trend 4: FFS Contract Terms => Multiple Reimbursement Methodologies
Trend 5: Adjudication-Based Provider Data => Provider System of Record
Trend 6: Claims-Based Product => Fast Product Speed to Market
Trend 7: Embedded Commissions => Custom Commissions Engine
Trend 8: Embedded Workflow => Ubiquitous Workflow
Trend 9: Changing the Line-of-Business Landscape
Essential Guidance — Actions to Consider for Payer Organizations
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