Case Study
Case Study: Modernizing Dental Claims Processing for MCADS
Transforming MCADS’ dental claims for efficiency and speed
The client
Centers for Medicare & Medicaid Services (MCADS)
Dental Claims Processing
Challenge
The Centers for Medicare & Medicaid Services (CMS) faced a critical challenge in their Medicare claims and dental claims processing system. The existing dental claims processing system was outdated and caused administrative inefficiencies, increased operational burdens, and slower service delivery for providers and beneficiaries. By tackling dental claims, the CMS team saw an opportunity to trailblaze the development of a modernized system. The goal was to pave the way for future projects, creating a foundation that could support the eventual migration of other processes.
They wanted to develop a modern claims processing platform that could efficiently handle Medicare and dental claims in accordance with updated Medicare policies. The platform would further serve as a foundation for ongoing improvements and integration into the larger MPSM ecosystem, supporting CMS’s healthcare access objectives and access to affordable healthcare. The new system needed to be delivered within less than a year of the contract award.
Our approach
Recognizing the rapidly changing needs of the healthcare industry and the importance of building a sophisticated system that would serve as the foundation for claims processing at CMS, Team Flexion embraced its culture of evolving with the needs of users and moved forward with an adaptable technical foundation.
We partnered with Wisconsin Physicians Service Insurance Corporation (WPS) to leverage WPS’s expertise as a Medicare Administrative Contractor (MAC). We then created a Lean UX Canvas to validate our core assumptions, focused on processing 100% of dental claims without disrupting existing systems and ensuring timely provider payments. To guide our work, we developed a simple “happy path” scenario for validating and paying a basic claim, which served as the foundation for handling more complex cases.
Flexion’s Lean UX Canvas
The technical foundation of the project was built on an option-enabling architecture, which allowed for incremental changes and ensured flexibility. Following its three core rules, of Option-Enabling Architecture, Adaptability, and Quality Assurance & Production Readiness, our team ensured that the system could adapt to policy changes and technological advancements without significant rework. Flexion prioritized quality assurance and production readiness throughout the project, implementing a Quality Assurance Surveillance Plan (QASP) to track key metrics like delivery lead time, deployment frequency, and change fail rate. This adaptive, collaborative approach ensured the project met its goals while staying flexible for future improvements.
Technology stack
Outcomes
Flexion successfully timely delivered a scalable dental claims processing system that seamlessly integrated into the Medicare system while ensuring data integrity and a human-centered user experience. This modern system served as a foundation for processing various claim types, moving away from legacy mainframe systems. Additionally, the project team played a key role in agency transformations, implementing effective change management and modern production release processes.
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