Empowering Claims Processing with a New User Experience  

Client:

Our client provides and administrates healthcare benefit plans that serve a variety of US market segments. 

Challenge: 

Our client’s claims processing division is responsible for managing the validity and payment of insurance claims through electronic forms called EDI X12 transactions (like 837, 835, and 834). They relied on a manual process centered around a computer program known as the “green screen application,” known for its character-based and text-heavy interface. The green screen application was used to deal with these forms. For example, when a provider sent an 837 form, someone had to manually enter that information into the green screen application. Similarly, when the insurance company sent a response (835), the team had to handle it within the green screen application. 

This approach hampered the efficiency of their claims processing, introduced the potential for errors, and posed challenges in terms of recruiting and retaining skilled employees. Furthermore, it led to a less-than-smooth experience for their clients. Our client wanted to speed up processes to sign more profitable yet restrictive contracts. However, the current system’s slow scalability was a hurdle to achieving this goal. 

Specific challenges include:

• Difficulty recruiting claims examiners. 
• Lack of skills among prospective employees to navigate the obsolete tools used in the adjudication process. 
• Extensive training period for new claims examiners, stretching up to nine months. 
• Daily challenges associated with using the green screen application leading to a high employee turnover rate. 
• Inability to respond promptly to client needs due to the inefficiencies of the manual adjudication process. 

Our client needed a more user-friendly and modern user-interface to enhance the efficiency and accuracy of their claims processing operations. 

Action: 

While most EDI X12 (834, 837, 835, etc.) transactions are seamlessly processed in the background, there are instances where claims are rejected, necessitating end-users to delve into understanding and resolving the issues. Since EDIs are not easily comprehensible for end-users, a more user-friendly approach is needed.  

Prolifics addressed this by using Rocket Software and developing a Web UI on top of ‘green-screens.’ These UIs consolidated essential identifiers into a single-pane view, providing users with a quick overview of various aspects of the claims management process and expediting the process. They also combined errors, alerts, and comments; improved navigation flexibility; and created a manager’s dashboard that enables work assignment based on availability, skillset, confidentiality, and specific SLAs. 

This tool allowed Prolifics to leverage our client’s prior investments in their green screen technology while introducing a fresh web interface layer to the existing application. Prolifics not only assisted with the implementation but also took responsibility for managing ongoing services related to the application. This included tasks such as maintenance, support, security, and other essential activities to ensure a smooth and effective operation. 

The project unfolded in three iterations, incorporating quality assurance and user acceptance testing early in the process. This approach helped Prolifics’ experts to identify and rectify issues in subsequent iterations. The result was a significantly improved final product, delivered by Prolifics on time and under budget. 

Results: 

This solution transformed our client’s approach to claims processing, offering a simplified web interface that not only streamlined the user experience but also automated critical elements of the claims management process.  

• Employee efficiency increased by an estimated 25%, increasing claims throughput. 
• The time required to train newly onboarded claims examiners in the easier-to-use web interface reduced to as little as three months.  
• Projections indicate that this solution will deliver over $2 million in business and IT efficiencies over the next three and a half years. 

Furthermore, this solution includes brand-new functionalities that were previously beyond the reach of the green screen application, marking a significant step towards modernization and efficiency. 

• Claims assignment: Newly implemented dashboards help the organization prioritize contracts and claims. Where the claims assignment process was once based on manual emails and spreadsheets, tasks can now be easily allocated, and supervisors can freely communicate with examiners via internal messaging capabilities.  
• Screen aggregation: Where examiners were once limited by a green screen that was only 80 characters wide, Prolifics has combined multiple green screens into a single interface, gaining visibility into several pieces of the claims management process at once to speed the process. Examiners can skip steps entirely if they are irrelevant to the claim in question. 
• Web-enabled functionality: The web interface integrates in-line help, explanations of commands, and other quality of life features that improve the usability and approachability of the system. 
• Reference data: Key data is aggregated into a single view and presented side-by side with consolidated claims management screens. 
• Search capabilities: Search tools eliminate manual searches within spreadsheets to find claims, diagnosis codes, examiners, and other reference material. 
• Audit history logging: Previously, the Company lacked comprehensive audit logging features. The updated application captures a complete audit history of the claims process. 
• Future expansion: Built-in frameworks designed specifically for the project give the Company the ability to extend the implementation in the future, adding new commands and other functionality. 

Technology:  

Rocket Modern Experience is a powerful mainframe modernization tool that makes it easy to modernize any legacy green screen application into a friendly web, mobile, or cloud experience. Utilizing this technology empowers Prolifics to maximize our client’s prior investments in green screen technology by seamlessly integrating a fresh web interface with the existing application. 

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About Prolifics  

At Prolifics, the work we do with our clients matters. Whether it’s literally keeping the lights on for thousands of families, improving access to medical care, helping prevent worldwide fraud or protecting the integrity and speed of supply chains, innovation and automation are significant parts of our culture. While our competitors throw more bodies at a project, we apply automation to manage costs, reduce errors and deliver your results faster. We accelerate your journey throughout the digital environment – Data & AI, Integration & Applications, Business Automation, DevXOps, Test Automation, and Cybersecurity. We treat our digital deliverables like a customized product, with agile practices to deliver immediate, ongoing increases in value. 

 

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