Heads up: this issue is from January 29, 2026. Because it covers time-sensitive coding and regulatory topics, some details may have changed since. See the latest issues for current guidance.
How many of you have been through a Medicare or other payer claims adjudication system conversion? A few of them in my lifetime have been ok, while others have been unmitigated disasters, with delays, incorrect claim determinations, and mismatches between policies and claims. This proposed program (it is not a proposed rule) is the blend of FOUR legacy systems written in COBOL (programming from ancient digitheads). Think of a billing system conversion times 100. This is why you should be aware of this NOW before it goes any further.
This is a REQUEST FOR INFORMATION--it is not a proposed rule, not a directive, not an executive order. CMS (Claims Might Suck) just wants COMMENTS for now. And, it is a good idea to comment before it's too late. As a spoiler alert, I will posit that there is too much emphasis on fraud and waste. Every administration believes it can pull money out of the air by finding more fraud.
Here's a bit about the Request for Information, including objectives and scope. These are taken DIRECTLY from the RFI., except my editorial in parentheses.
Introduction
The ClaimsCore program seeks to re-platform Medicare Fee for Service claims processing by replacing legacy “Shared Systems”, including the Multi-Carrier System (MCS), Fiscal Intermediary Shared System (FISS), and Durable Medical Equipment Claims System (DME) as well as the Common Working File (CWF--one of the greatest CMS oxymorons of all time as it doesn't always work) with a flexible and interoperable platform that puts Medicare beneficiaries at the center of every decision (Really? Their A/R isn't going to hell). CMS proclaims that a Software as a Services (SaaS) Commercially-Available-Off-The-Shelf (COTS) product, configured and integrated by skilled teams, will deliver instant adjudication (!!!!!), policy agility, real-time claims status (Sure, Jan), best-in-class tools, improved fraud prevention capabilities, and tighter integration across CMS, Medicare Administrative Contractor (MACs), providers, and partners. Pretty lofty goals, if you ask me.
Objectives
- Replace Shared Systems and the Common Working File
- Replace FISS, MCS, DME, and CWF with an enterprise-class, real‑time platform while maintaining uninterrupted Medicare Fee‑for‑Service operations during transition (a good goal). Such a replacement could transform the way FFS Medicare does intake, eligibility and coverage checks, edit/rules execution, payment determination, EOB/EOP generation, adjustments and reprocessing, reporting, and audit/traceability, etc. (This is pretty ambitious)
- Beneficiary-first Experience: sub-second adjudication, faster explanations of benefits, and better visibility into patient responsibility. (I love the patients, but this will have a lesser impact on them than on us.
- Reduce Provider Burden: Provider burden is reduced through increased transparency and consistency, shrinking administrative overhead, and improved revenue certainty. (I'll believe this when I see it)
- Fraud, Waste, and Abuse (FWA) reduction (i.e., Payment Integrity): speed and flexibility in designing and implementing pre-payment risk scoring and edits, improved payment accuracy, auditing, and anomaly detection to prevent improper payments and protect beneficiaries and taxpayers. (Big Bro is watching your billers)
- Policy Agility and Flexibility: configuration-driven rules to evaluate, back test, quantify impact, and implement new and alternative payment models without long code cycles.
- Provider transparency & efficiency: comprehensive APIs and interfaces that provide real-time claims status, surface underlying data, allow MAC-operated systems to interact with claims, and reduce provider burden.
- Risk Management of Platform Obsolescence: full retirement of COBOL (good idea) mainframe systems and the Common Working File with real time, performant, scalable, maintainable, well-supported systems.
- High Availability (HA) and Scale: Target 99.9% uptime with elastic scaling at current and future volumes, eliminating nightly downtimes and dark days (We've had a bunch of those lately).
- Disaster Recovery (DR) and Business Continuity Plans (BCP): Provide mission-critical DR and BCP for the ClaimsCore solution with defined RTO/RPO objectives and regular failover/DR drills aligned to CMS enterprise continuity plans. That sentence wins the award for most abbreviations in a single thought.
- Interoperability: HIPAA X12, REST/FHIR APIs, and custom flat files integrate efficiently across CMS, MACs, clearinghouses, and provider systems. (CMS might want to move away from Change Healthcare)
Benefits for Medicare Beneficiaries
According to CMS, "ClaimsCore will deliver immediate improvements to the Medicare experience while enabling deeper transformation in the future (What does that even mean?). According to CMS and its PR Agency, from day one, beneficiaries will see faster claims resolution, stronger fraud protection, and near-real-time explanations of benefits. As providers adopt new APIs (Application Programming Interfaces), beneficiaries will gain cost and coverage information at the point of care, including accurate out-of-pocket estimates (which may not be accurate due to Medigap and Medi-Medi) and seamless digital access to claims and explanations.
Whatever. To read more, click here. To submit comments (you need to use the form), click here.
