Health Insurer Expedites Claims Process; Ensures Compliance

Pam Roman

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Insurance Company Stakes Its Claim for Modernization, Integration and Automation  

Our client is the publicly traded holding company (HC) of seven insurance companies. They offer Medicare supplements; annuities; and life, long-term care, accident and health insurance to working-class families and senior citizens.  

Challenge

Older System Can’t Keep Up with Today’s Healthcare Demands

HC’s claims-processing system was a homegrown, legacy environment — cobbled together using older technology that wasn’t seamlessly integrated. Running and maintaining the system had become untenable, creating several major headaches for the claims payer:  

  • The system had become non-compliant with HIPAA, exposing HC and its subsidiaries to substantial fines and penalties, as well as potential negative publicity. 
  • The system was batch- and schedule-based, in this case meaning it could only process claims received (transmitted from healthcare providers) by a specific time – 7 a.m. 
  • The claims themselves went through a three-hour, multi-step process that was both unwieldy and error prone. 
  • HC had lost control of their data – both within the process itself (e.g., they were unable to reconcile claims coming in with claims paid out) and with the inability to meaningfully analyze the data for any other business purpose.  

Action

When we sat down with HC and asked them to walk us through their claims processing management system, we identified two fundamental problems: one with modernization / interoperability, or the way HC’s systems accepted data from other organizations; and another with modernization / integration, or the way HC dealt with its own data.  

Automation for Claims Processing

We tackled the interoperability problem first, and our initial step was to move HC from the batch- and schedule-driven system to an event-driven system. An event-driven system’s catalyst is an incident – in this case, a claim’s arrival – rather than an arbitrary demarcation, like a time, (e.g., 7 a.m.) The processing would begin immediately upon a claim’s arrival – it would not have to wait to be batch processed.  

A Clear View of Data Through the Cloud

Then we turned to integration, and, together with HC, determined how to best organize the massive number of incoming claims they received on a daily basis. The client needed control over their claims data, including ease of filing and retrieval, and the capability to readily manipulate data for reports. We recommended they utilize our tech partner Mongo for a cloud-based database. 

At this point, HC’s systems were efficiently interacting with outside organizations and their data was well organized. However, even the most carefully organized data is useless if it lives in a “black box.” So, we provided HC with a global transaction monitor (GTM), which essentially builds a window in the side of that black box. The customized GTM we built for HC is an easy-to-read, easy-to-use, centralized dashboard that allows them to watch a claim make its way through their system. 

Result

Reduced Processing Time

As a direct result of working with us, HC is now HIPAA-compliant, and the organization is in no danger of incurring fines.  

The implemented event-driven system is a more modern, logical approach to data processing that allows HC greater flexibility in communicating with outside organizations. Because of this efficient automation, the three hours needed to process claims has been reduced to a mere 18 minutes. 

Better Control Over Data

HC now has control of their data. What we’ve ensured through the Mongo database and the global transaction monitor (GTM) is that HC has a full audit trail and traceability for everything that comes into the organization digitally and then goes out digitally. We’ve set up digital record keeping for them as part of our solution, one that’s easy for the business units to use in a dashboard format. So, if someone questions a claim, CNO has the original claim, what it looked like, when it was sent, the file name, where it is located, when it arrived and more – the complete digital audit trail, in just a few clicks. 

If a claim is flagged for any reason — incorrect data, compliance error, etc. — the dashboard alerts the claim services employees using a color-coded system. The dashboard also has reporting and filtering functionalities that allow HC to easily access their data and export it into familiar Excel spreadsheets, where it can be sliced and diced into any format they need.  

This modernization and integration project was so successful that HC has asked us to apply these concepts to other aspects of their business.  

Technology

HC’s prior system was made up of traditional, relational databases. Relational databases break up data and organize similar data into tables. For example, one table would hold names, another might hold birthdates. Someone in the claims department using a relational database would have to pull all those individual pieces of information (or request an IT query for that information) to get a full picture of a policy holder. 

Prolifics recommended our partner, Mongo, as our client’s new cloud-based database because it’s a document-centric database that stores information much like you would in a filing cabinet — in a way that fits human logic — with files that go together in related “binders” that are stored together in a “drawer.” Pulling data from a document-centric database is much more efficient than pulling it from a relational database. Business personnel can do it themselves; they do not have to rely on IT members for a query. 

About Prolifics

Prolifics is a global digital transformation leader with expertise in Data & AI, Integration & Applications, Business Automation, DevXOps, Test Automation, and Cybersecurity across multiple industries. We provide consulting, engineering and managed services for all our practice areas at any point our clients need them. Vision to Value. Faster. It’s not just the Prolifics’ tagline, it’s what drives us. Connect with us – solutions@prolifics.com


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