By NextBestFitPhase 1: Enactment & build · Step 1.3
Build the claims, payment & data systems
Months 0–18, then continuous · UHA Chief Information Officer; MACs; U.S. Digital ServiceDiscuss this step
Pros & cons of this step
Pros
- +Medicare already pays most claims within 14–30 days at very low cost per claim.
- +One claim format ends the per-payer billing complexity that costs providers 8–13% of revenue. Jiwani et al. 2014.
Cons
- −Medicare's core systems are decades old (some COBOL); scaling them 4x carries real risk.
- −Concentrates cyber risk: an attack on one payer would stop payment nationwide. Cf. the 2024 Change Healthcare ransomware attack.
- Extending legacy systems is faster but locks in technical debt. Rebuilding is cleaner but riskier on an 18-month deadline. The plan extends first and rebuilds in Years 3–6.
Trade-off behind each cost item
- Heaviest during the 18-month build and Year 1; tapering as later waves reuse the same systems.
Trade-off behind each system change
- Revenue-cycle, clearinghouse & claims-editing vendors~72k jobs displaced; providers' overhead falls.
- X12 claim transactions (837/835/270/271) across payersHuge simplification; single point of failure.