Building a roadmap for Medicare Payment Systems Modernization

We helped CMS develop a strategic roadmap for modernizing a 50 year old payment system that processes Medicare claims for over 60 million beneficiaries. Through collaborative workshops and a structured prioritization framework, we built consensus across a large, diverse group of stakeholders.

Client

Centers for Medicare & Medicaid Services

The challenge

CMS relies on four legacy mainframe systems, collectively called the “shared system,” to process Medicare claims payments to healthcare providers nationwide. Built 50 years ago, the system processes complex claim scenarios but cannot easily adapt to evolving healthcare needs. Modernizing it presented significant challenges, like:

• No clear starting point for sequencing modernization without creating downstream dependencies
• A mission-critical system with deep technical complexity and extensive dependencies
• 40+ stakeholders across the organization with no shared framework for prioritizing modernization work

Our approach

Conceptual modeling and system analysis

• Created a simplified conceptual model grouping system functions into four components representing the lifecycle of a claim
• Developed a two-phased modernization approach starting with components common across all claim types
• Mapped system functionality against complexity to identify the highest-impact starting points

Workshop facilitation

• Designed and led three virtual workshops with 40+ participants focused on inclusivity and collaboration
• Used structured activities to help stakeholders sort system components by business value and surface dependencies
• Built alignment across a large, diverse group with varying levels of agile and product management experience

Prioritization and roadmap development

• Created a prioritization framework inspired by Weighted Shortest Job First (WSJF) methodology, considering business value, complexity, and technical feasibility
• Synthesized workshop discussions into a strategic roadmap guided by principles of early value delivery and frequent releases
• Structured the roadmap as direct input to the program’s increment planning process

Keys to success

Blue Tiger was a key partner in ensuring the success of this effort led by Guidehouse.

• Roadmap designed to guide incremental delivery from the start
• Simplified a complex system into a model stakeholders could engage with
• Structured facilitation that built consensus across 40+ participants
• Prioritization framework grounded in both business value and technical feasibility

Results and impact

We helped CMS take a critical step toward modernizing payment infrastructure that serves millions of Medicare beneficiaries.

• Delivered a strategic roadmap considering business value, complexity, technical dependencies, and organizational capacity
• Provided clear direction for development teams as direct input to the program’s increment planning process
• Established a two-phased modernization approach that sequenced work to deliver early value while avoiding downstream dependencies
• Enabled CMS to begin modernizing payment systems that process claims for over 60 million beneficiaries