Faster Claims, More Control a Victory for Insurer and Patients

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. 
• The system was batch- and schedule-based. 
• The claims themselves went through a three-hour, multi-step process. 
• HC could not 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.  

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– in this case, a claim’s arrival. Processing would begin immediately upon a claim’s arrival – it would not have to wait to be batch processed.  

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

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. 

HC now has control of their data. What we’ve ensured through the cloud 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, HC 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. 

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

Technology Summary

The GTM solution is built with the latest and newest technologies: IBM MQ Advanced, Mongo document-centric database, Python programming language, and IBM Transformation Extender Advanced (ITXA) when HIPAA compliance is needed. Prolifics provides its unique implementation expertise to build custom data transformation maps and orchestration for the customer process workflows. 

“You can think of this project as a layer cake. The first layer was MQ, the second layer ITXA, and the third the new cloud database. Prolifics brought the icing with the global transaction monitor (GTM) and data visibility.”

Honda Bhyat, Prolifics Sr. Advisor, Integration and Digital Transformation

Access the expanded version of this success story and its technology to learn more or reach out to us a solutions@prolifics.com.