Guide
Workers' compensation claims software: build, buy or modernize?
A practical guide for claims leaders deciding what to do with an aging claims platform, from a team that rebuilt one and has kept extending it for 3+ years.
What a workers' comp claims platform has to handle
Before comparing options, list what your platform must do. Most workers' comp operations need all of these.
Claim intake and setup
Injury reports, claimant and employer records, claim numbering.
Medical and pharmacy bills
Bill review, pharmacy claims with National Drug Codes (NDCs), state fee schedules.
Payments and remittances
Payments out, remittances in, 835 files, EOBs, lockbox batches, zero-pay and short-pay handling.
Correspondence and documents
Letters in and out, including documents that cover many claims at once.
Work queues and collections
Tasks, follow-ups and aging balances, with clear ownership.
Financials
Accounts payable, liability calculations and reserves.
Reporting and compliance
State EDI reporting and Medicare Section 111 reporting where you're responsible for them, plus a full audit trail.
Integrations
Payers, pharmacy benefit managers, banks, accounting and document scanning.
Buy, build or modernize: how they compare
Each path fits a different situation. None is right for everyone.
| Buy a product | Build new | Modernize what you haveOur worked example | |
|---|---|---|---|
| Best when | Your processes are close to industry standard | Your process is your advantage and no product fits | Your platform does the job but its technology is failing |
| How soon you see results | Fastest, if the product fits | Longest | Medium, delivered in phases |
| What it costs | License fees every year, plus setup and integration | Large upfront cost, no license fees | Moderate, spread across phases |
| Who controls the roadmap | The vendor's roadmap decides | You do; you own the code | You do; it keeps your business rules |
| Biggest risk | Bending your process to fit the product | Scope and delivery risk | Data migration, which parallel running reduces |
Buy a product
- Best when
- Your processes are close to industry standard
- How soon you see results
- Fastest, if the product fits
- What it costs
- License fees every year, plus setup and integration
- Who controls the roadmap
- The vendor's roadmap decides
- Biggest risk
- Bending your process to fit the product
Build new
- Best when
- Your process is your advantage and no product fits
- How soon you see results
- Longest
- What it costs
- Large upfront cost, no license fees
- Who controls the roadmap
- You do; you own the code
- Biggest risk
- Scope and delivery risk
Modernize what you have
Our worked example- Best when
- Your platform does the job but its technology is failing
- How soon you see results
- Medium, delivered in phases
- What it costs
- Moderate, spread across phases
- Who controls the roadmap
- You do; it keeps your business rules
- Biggest risk
- Data migration, which parallel running reduces
5 questions that decide it
Answer these honestly and the right path usually becomes clear.
- How much of your process is standard? The more standard, the stronger the case for buying.
- Where do your business rules live? If years of rules sit inside your current system's code, modernizing keeps them; buying means rebuilding them as configuration.
- How many integrations do you depend on? Payers, pharmacy benefit managers, banks and state reporting each add cost to a new product.
- What does a day of downtime cost? If it's high, you need parallel running, whichever path you take.
- Who will own the system in 5 years? A product vendor, your own team, or a partner who stays.
What the modernize path looked like for one claims administrator
A workers' compensation pharmacy claims administrator ran on a 12-year-old PHP platform with a Firebird database. We rebuilt it in .NET and SQL Server.
- Screens, background jobs and data migration ran as separate streams
- A month of end-to-end testing, then a month of parallel running before cutover
- 2 to 5 minclaim ingestion, down from about 1.5 hours
- 30 minclaim allocation, down from about a week
- 3+ yearsthe same team still extends the platform
Questions to ask any vendor, including us
Print this list and take it into every vendor meeting.
- How will you migrate our data, and how will we check it?
- Will we run the old and new systems side by side before cutover?
- Who owns the code and the data?
- How do you test, and who does it?
- What happens after go-live, and who supports us?
- Can you show us a claims system you've delivered?
Workers' compensation claims software FAQ
How long does it take to modernize a claims platform?
It depends on size. Our claims platform rebuild was planned over 12 months, including a month of end-to-end testing and a month of parallel running.
Can you integrate with our payers, pharmacy benefit manager and bank?
Yes. We've built electronic payment-file (835) processing and lockbox batch handling into a live claims platform.
Can AI help with claims correspondence?
Yes. We built AI document processing into the same platform: correspondence becomes validated claim data, with people reviewing anything uncertain.
Do you sign BAAs?
Yes, where health information is involved.
Do you only work on pharmacy claims?
No. The same approach applies to other workers' compensation and insurance claims operations.
Talk it through with a team that has done it
In a 30-minute call with our CEO or CTO, we'll look at your current system, your options and what each path would involve.
- Your current platform and where it hurts
- Which path fits: buy, build or modernize
- What the first phase would involve