Faster Claims Process a Win for Health Insurer and Patients

A “Layer Cake” of 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 was facing the possibility that the could lose 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.  

Faster Claims Processing

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

IBM technologies became the foundation for fixing HC’s interoperability and integration issues. (Prolifics is an IBM Platinum Business Partner.) The first component was IBM’s MQ Advanced middleware. This solution allows HC to manage large (and growing) volumes of data with high availability and extra security; and share that data across any environment with ease.

Honda Bhyat, Prolifics Sr Advisor, Integration and Digital Transformation (DX) Practice, said, “The MQ layer provides the robust connectivity, security, and communication mechanism that transports the data correctly once, and once only, with integrity, tracing ability and visibility. It’s the communication fabric to interoperate all the different HC microservices and pass the data between these services.”

The second component, or layer, is the IBM Transformation Extender Advanced (IXTA). This is a document transformation software – a transaction-oriented, data integration solution that automates the transformation of high-volume, complex transactions without the need for hand-coding. Specifically for HC, IXTA is scalable, flexible, and supports HIPAA with the integration of data from multiple technologies across the company.

Bhyat said, “For HC as a payor, this second layer provides all the intelligence of transforming the data from what it is in – the HIPAA format that the internal systems need – to the formats needed to communicate information to the banks, which are external. Whenever there are compliance audits or questions, we can say yes, we use the IBM tool. It provides all of that compliance checking and compliance reporting and validation.”

For the cloud-based database, we recommended our tech partner Mongo. 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.

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