Claims Processing and Plan Administration System Assessment and Replacement

Our client, a leader in providing online, real-time Claims Processing and comprehensive Plan Administration services, determined that its legacy Claims Processing systems’ limitations were impeding the efficiency of its service delivery and the choices it could offer its more than 10,000 client organizations. The company was concerned that in the future, these issues could restrict its ability to attract new and retain current customers. Accreon was contracted to help migrate its legacy Claims Processing applications to a more flexible system that would offer better agility in the marketplace.

Phase 1: Discovery

During the Discovery phase, Accreon conducted a systems assessment to evaluate existing Claims Processing systems. This involved reviewing the IT systems supporting the Plan Administration and Claims Processing. This review allowed our team to gain an understanding of the systems and the use and management of the IT within the organization. Demos and high-level analysis presented good coverage of core processing, but identified limitations such as insufficient plan design flexibility, the need for manual intervention during Claims Processing, and a variety of different systems/user interface styles used by staff to perform their tasks.

​Many of the limitations were widely acknowledged and stemmed from the fact that Plan Administration and Claims Processing were supported by legacy computer systems that were becoming increasingly difficult to maintain and unable to keep pace with the industry; an industry that is becoming increasingly competitive to deliver more services and features via multiple channels at competitive rates. Our client was addressing these challenges by improving systems incrementally and building new web-based functions that integrated with the backend legacy systems. These functions were providing customers and staff with improved functionality and usability, but were limited by the underlying legacy systems that managed the plan data and adjudicate the claims.

While conducting the systems assessment, much of our focus centered on the two legacy systems that were identified as the core components of claims processing: the Multi-Benefit System (MBS) and the DRUG System.

Our client’s desired future state was a single system for Plan Administration and Claims Processing developed on a modern technology platform that would provide a stable base for the future. Due to the size and complexity of the company’s Extended Health Care (EHC), Dental, and Drug business and the systems that support it, our team recommended an incremental replacement of the current systems over several projects, by:

  1. Replacing the MBS, including both the Plan Administration and Claims Processing for EHC and Dental.
  2. Replacing the DRUG system, including incorporating plan features and Claims Processing support for Drug programs into the new system.


Phase 2: Requirements Definition

During the Requirements Definition phase, Accreon determine the most effective software development methodology to employ for detailed design, development (coding, testing), and implementation (data conversion and training). We estimated the work required to replace the MBS, developed a schedule, and provided firm pricing to achieve Design, Development, and Implementation.

With the new systems supporting the EHC, Dental, and Drug programs, subsequent projects will replace the masking layer between the new system and any remaining components/sub-systems. This will be accomplished by either making updates to the remaining systems or by replacing them, depending upon an assessment of the system, corporate strategies, and priorities at that time.

Our client’s goal is for its Plan Administration and Claims Processing systems to be supported by one system, with the supporting components and systems updated or replaced to work with the new system and its database. Accreon will continue to work with them to achieve this goal incrementally through several successive projects.

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