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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 HEALTH MANAGEMENT TECHNOLOGY

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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