New EDI Strategy Creates Savings for Health Insurance Carrier

Our client is a health insurance company (HIC) that has operated in New York State for more than 80 years, evolving with our nation’s healthcare system along the way.

Challenge

HIC was experiencing issues and limitations with its current electronic data interchange (EDI) set-up – the computer-to-computer exchange of insurance documents in a standard electronic format. First and foremost, HIC analysts were plagued by the fact that many health claims files simply never arrived – there was no exchange at all.

When HIC did receive files successfully, they were difficult to monitor and track, and were often subsequently lost in HIC’s systems. Files were prone to errors, with data quality obviously suffering as a result. HIC suffered wasted time and resources.

HIC originally met with other EDI solution vendors. However, based on an IBM referral and our mix of quality, cost-efficient onshore and offshore developers, HIC chose Prolifics.

Action

We initially engaged with HIC through workshops and demos. Based on those results, we introduced HIC to our Healthcare Integration Kit, which leverages the technologies needed for a configurable integration platform. This solution armed HIC with the EDI processing and monitoring features it needed.

HIC already had most of the solution infrastructure in place. Prolifics only needed to add IBM Transformation Extender Advanced (ITXA), a document transformation software.
The final part was a nine-week QA and user acceptance testing (UAT) phase, where our resources worked side-by-side with HIC’s QA division to carry out testing.

As no additional training was needed, the Prolifics solution proved to be a quick and easy fix for HIC’s issues.

Result

In total, the solution will save HIC an estimated $1M in software and services costs. The solution is expected to reduce the turnaround time for issue resolution. It will create more visibility into the insurer’s systems and improve the quality of its data. HIC’s analysts can be more proactive, addressing issues before they can snowball into much larger problems. Previously wasted analyst time can be reallocated to higher level work.

The Global Transaction Monitoring (GTM) component of the Healthcare Integration Kit proved to be one of the biggest upsides to the solution. It provides the real-time monitoring of messages, event processes, and transaction completion throughout the transaction lifecycle. Additionally, when an error is identified in a file, it can be corrected directly from the GTM dashboard rather than having to open up the entire claim file.

Technology

We used the following technologies to help fix HIC’s issues and help them reach their goals:

• The Prolifics Healthcare Integration Kit – deploys five component assets in any combination as needed: Delivery templates; Foundational Frameworks; Continuous Delivery; One-Click Ready-2-Run; and Global Transaction Monitoring (GTM)
• IBM Integration Bus (IIB)) – connects applications together, regardless of the message formats or protocols that they support
• IBM DataPower – helps organizations meet the security and integration needs of a digital business in a single multichannel gateway
• IBM MQ – allows application programs to use a message-queuing technique to participate in message-driven processing
• IBM Transformation Extender Advanced (ITXA) – a document transformation software, with the Extender Pack for Healthcare