Healthcare Payer Sees Huge Cost Savings with EDI Modernization

September 4, 2023

Our client

This organization is a health insurance plan provider serving several million members.   

Challenge

Processing medical insurance claims is a major part of our client’s business. They serve several million members, and use EDI, or electronic data interchange, to process claims and integrate business documents coming in from a multitude of healthcare providers. 

Our client felt boxed-in by their incumbent, legacy EDI claims processing system, which had become the “only game in town” for the vast majority of health plan providers. They felt that parts of the system were inefficient and unwieldy, and lacked transparency and flexibility. Also, they felt the cost of the legacy system was not in line with what the incumbent provided, adding a financial component on top of the operational issues. Specifically, our client told us that: 

  • It was not an easy system to integrate with other applications 
  • “Forced” upgrades took months to install and often cost millions of dollars 
  • Any type of customization could only be done by the legacy vendor, at high per hour rates 
  • Live / real-time data was basically inaccessible, and the legacy vendor had to write any new database requests 
  • The legacy vendor was charging the client by transaction, plan member, and server. 

The client made its mandate clear – replace the legacy system. 

Action

Prolifics knows that to be a fully modern healthcare organization, a plan provider needs to be efficient and customer-centric in its claims processing; with all systems communicating with each other quickly, securely, and in compliance with all regulations. Saving even pennies per transaction will add up to significant cost reductions. 

The client looked at several different EDI claim processing system providers, and ultimately chose Prolifics EDI Modernization for Healthcare, a modern, open, and cloud-ready alternative to legacy systems. As presented to our client, EDI Modernization for Healthcare:  

  • replaces costly legacy integration systems with a modern alternative that the organization owns 
  • offers an open system with an open data model that integrates with virtually any existing business system 
  • is built on an off-the-shelf software for significant cost savings 
  • is fully customizable, extendible, and scalable 
  • increases claims throughput up to 10 times compared to a legacy system 
  • does not include exorbitant licensing fees or hidden costs 

Result

The client is switching from their legacy system to Prolifics. The client’s reasons include: 

  • Cost savings 
  • Easy integration with other applications and databases 
  • Customizable and easy-to-generate reports 

“I immediately saw two exceptional capabilities that Prolifics EDI Modernization for Healthcare provides for EDI transactions processing. First, agility – I can customize the user interface exactly to my business needs. Second, data transparency – I can clearly follow what’s happening in each step of the EDI transaction process.”  M.P., Lead IT Applications Consultant for our client. 

Technology

Prolifics EDI Modernization for Healthcare: 

  • replaces costly legacy systems for EDI X12 integration in claim environments. 
  • provides comprehensive HL7 V2/V3 and X12 support for 270/271, 276/277, 278, 834, 835/820, 837, NDC, and more 
  • offers unlimited customizable dashboards/reports 
  • provides 100% transaction correlation and archival 
  • presents a single-pane-of-glass audit console 
  • is fully containerized and cloud-ready 

The solution is meticulously engineered by Prolifics’ healthcare EDI experts using an off-the-shelf tech stack and includes: 

  • IBM ITXA Standards Processing Engine 
  • IBM MQ Advanced and MFT 
  • IBM App Connect Enterprise 
  • IBM Sterling B2B Integrator Gateway 
  • MongoDB – Next-gen document-oriented database for lightning-fast runtime document management 
  • Prolifics GTM Business Transaction Monitor for transaction tracking, archival, and single-pane-of-glass auditing 
  • The ability to work with an organizations existing technology

Learn more 

Let’s discuss how Prolifics EDI Modernization for Healthcare can increase efficiency and cut operational costs in your claim environment. Click here to connect to an expert. 

Visit our EDI Modernization for Healthcare site. 

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