A few years ago, a leading U.S. healthcare provider embarked on a daunting mission: replacing a decades-old claims system with FACETS while weaving HIPAA and CMS compliance directly into its workflows. With a budget of over $74 million spread across three years, the initiative was one of the most ambitious of its kind.

At the heart of the project was Amit Nandal, a systems specialist with deep expertise in payer technology. His role was clear but complex—migrate the legacy system into FACETS, rewire core business processes, and build compliance into the system’s foundation rather than treating it as an afterthought.

Modernizing the Core

The provider’s old system had become brittle, costly, and ill-suited for the pace of regulatory change. The FACETS migration was not a simple lift-and-shift. Nandal helped design new workflows across claims, enrollment, provider data, and benefits. each one critical to maintaining operational stability. The task was less about technology replacement and more about future-proofing the entire organization.

Compliance as Product

A defining feature of the program was its approach to compliance. Instead of layering regulations on top of existing workflows, the team embedded them into the system itself. HIPAA transaction sets for claims, enrollment, eligibility, and authorizations were built directly into processing logic.

Nandal also designed automated checks to ensure that only state-registered providers cleared payment, and built dedicated workflows for sensitive categories like maternity claims that required special handling. “Compliance wasn’t something we bolted on later,” Nandal recalls. “It had to live in the system from day one, because in healthcare, every transaction has regulatory implications.”

Building Bridges Between Payers

Another critical achievement was integration with a major managed-care partner. This allowed claims, enrollment data, and authorization requests to move fluidly between organizations, while shared reporting created consistency across providers and members. The result was more than connectivity. It delivered operational efficiency, value-based care enablement, and sharper insights into population health.

Managing the Migration

Large-scale migrations often stumble on data, but here it became a focus. Provider records were cleansed and standardized, fee schedules reconciled, and legacy claims rules carefully mapped to the new platform. Testing was rigorous, covering real-world scenarios and compliance edge cases. When the system went live, targeted training and documentation ensured business users could adapt quickly.

Why It Matters Today

Fast forward to 2023, and the relevance of this transformation is clear. With FHIR-based APIs now powering interoperability, payers must enable patient access, maintain provider directories, and support payer-to-payer data exchange. Real-time prior authorization is on the horizon.

“Back then, we were focused on HIPAA and CMS rules,” Nandal reflects. “Today the same principles apply; only the technology has evolved.”

AI and automation now enrich provider records, detect fraud, and accelerate utilization reviews. Blockchain is emerging as a trust framework. “Interoperability isn’t just a data problem—it’s a trust problem,” he adds. “Blockchain can make sensitive data flows auditable and secure.”

The Quiet Wins That Endure

The FACETS migration left behind a foundation still relevant today: standardized data, embedded compliance, and reliable provider and claims records. Authorizations are faster, provider data remains accurate, and claims rules are clearer.

“These may not be flashy achievements,” Nandal concludes, “but in healthcare, they’re the foundation of trust and sustainability. True transformation is making the right outcome the default.”