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Benefi ts and pricing are keys The current business drivers in healthcare are creating new areas of differentiation within claims process- ing that infl uence the approach orga- nizations should take towards today’s claims modernization efforts. Health- care legislation is driving substantial and urgent change, compliance is becoming pervasive and market growth is focused in high-touch, high-customization segments, including increased com- petition for national business. There is growing support for new delivery and provider payment models, such as patient-centered medical homes, accountable care organizations, pay for performance and other outcomes-based reimbursement vehicles. Product com- plexity is growing, with value-added and service-focused benefi ts built for retail markets, just as price and tra- ditional benefi ts become increasingly standardized. As a result, the greatest areas for change and differentiation go- ing forward will be in benefi ts, pricing and patient responsibility – core claims processing components that have yet to be optimized by any modernization efforts.

The quintessential claims adjudi- cation platform, one that is quick to install and easy to modify, has yet to materialize. Outsourcing is fine for commodity-type activities, but not for differentiating areas where companies must have the control to try new things and innovate in attempts to create mar- ket advantage. The best bet for claims transformation today is targeted BPM augmentation applied to the benefi ts and pricing components of claims ad- judication, as well as the product and provider contracting processes that support them.

The advantage to payers of modu- larly applied claims technology in lever- aging legacy investments and providing speed to value in this era of changing and competing business and technology priorities has been noticed by leading industry analysts. One healthcare ana- lyst lists common workfl ow, business rules and data models, integration

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services and security as key elements to the emerging technology best suited to enabling healthcare payers to respond to the demands of the reforming mar- ket. BPM technology, which fi ts these criteria and has proved itself across numerous claims challenges, now must be applied to the new and most com-

plex components of the claims process of benefi ts, patient responsibility and pricing. BPM technology, applied stra- tegically to re-invigorate sluggish claims adjudication platforms, can ultimately replace core systems at reduced risk while also facilitating innovation and streamlining ineffi ciencies.

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