April 2022
Faster Claims, More Control a Victory for Insurer and Patients
Faster Claims, More Control a Victory for Insurer and Patients
A “Layer Cake” of Modernization, Integration and Automation
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.
Protecting – and Expanding – the IBM Footprint with Cloud Paks
Insights from Greg Hodgkinson, Prolifics CTO and IBM Lifetime Champion
IBM’s Cloud Paks provide the perfect delivery platform for us as a digital engineering company, where we aim to simplify the complex solutions our customers need. We partner with IBM – again and again – with proven business outcomes on Cloud Paks for customers across retail, finance and healthcare – guiding their journeys all the way from proof-of-concept (PoC), through implementation and into production.
We are the experts in taking on-prem, traditional IBM platforms to the cloud. Need to move from IIB to ACE? We’re the best! We have a dedicated expert migration factory that gets them onto ACE and to the cloud with Cloud Pak for Integration, with a step-wise approach that is low-risk, and a skilled offshore team to bring low-cost. You’ll find that we know the Cloud Paks – for Data, for Integration, for Business Automation – inside and out, from big picture to hands-on-keyboards. IBM footprint continues, in the cloud!
What’s next? As the Paks grow, so do we. We’ve a recent PoC success with IBM Cloud Pak for Watson AIOps, proving the proactive automated anomaly detection with a customer’s own systems and data, reinforcing the value in their terms, and getting them to commit to a pilot rollout. Let us do the heavy lifting to prove out the business case for your prospects! It’s all part of what we do as an IBM Platinum Business Partner. Connect with us and we’ll be happy to share Cloud Pak success stories – and get ready together for your next customer.
Prolifics Earns Two Coveted World HRD Congress Awards
Hyderabad, INDIA, April 2022 – Prolifics, a global digital transformation leader, is proud to announce it received two awards at the 30th edition of the World HRD Congress, held two weeks ago in Mumbai, India.
The World HRD Congress honours top initiatives in human resource practices. Prolifics’ awards are:
- Award for Best Talent Management
- Award for Innovation on Learning and Development (L&D)
Satya Bolli, Prolifics Chairman & Managing Director, said, “We’re excited to have received these awards. They reflect our dedication to recruiting, training and keeping the best people, and is part of our commitment to making Prolifics the IT employer of choice.”
Prolifics is a perennial World HRD Congress award winner, with recent company wins for “Best Employer Brand,” “Best Leadership Development Program,” and “Best Workplace Practice,” as well as individual awards for our HR personnel.
Partha Patnaik, Prolifics Global Head of Human Resources, said, “Prolifics is consistently rated as a ‘Dream Company to Work For’ in our industry. We’re proud of these accolades – it means we’re getting great talent to come on board with us, and success breeds more success.”
The World HRD Congress is an independent and not-for-profit organization governed by an advisory council. Its stated purpose is to make “work and working lives better.” The World HRD Congress looks to make a real difference to the HR community, business and the economy.
Prolifics is always looking for the best and brightest. Start your career as a “Prolifian” here.
About Prolifics
Prolifics is a digital engineering and consulting firm helping clients navigate and accelerate their digital transformation journeys. We deliver relevant outcomes using our systematic approach to rapid, enterprise-grade continuous innovation. We treat our digital deliverables like a customized product – using agile practices to deliver immediate and ongoing increases in value.
We provide consulting, engineering and managed services for all our practice areas – Data & AI, Integration & Applications, Business Automation, DevXOps, Test Automation, and Cybersecurity – at any point our clients need them. Email solutions@prolifics.com or visit us at prolifics.com.
Media contacts:
Pamela Roman at Pamela.Roman@prolifics.com, US- 1 (818) 877-0073
Sharath Rahula at Sharath.Rahula@prolifics.com, INDIA +914067771633
Court System Runs Smoother with Business Automation
Our Client
A state government office needed to prevent delays in the Administrative Office of the Courts (AOC) to better fulfill the administrative responsibility of the courts.
Challenge
A State Administrative Office of the Courts (AOC) needed to improve the efficiency of making payments to attorneys, interpreters, and expert witnesses in order to support the intent of the courts in upholding the constitutional rights of citizens to a fair and speedy trial. Their current systems had long time delays between screens causing delays in the payment of auditing claims.
One of AOC’s specific goals was to pay claims no later than 30 days from time of submission; however, auditors were working on claims 45 days old. As is a common challenge in the public sector, the existing software platform was no longer supported and could not be upgraded. They needed both a short-term solution to help clear the immediate backlog and a longer-term solution to set them up for future success.
Action
Based on our prior work within the state, Prolifics was able to bring a broader approach and understanding to the program. We balanced the strategic needs of the state’s centralized executive branch with the long-term needs of updating the systems for AOC and identified the best way forward for the courts.
Initially, AOC had three different applications that performed parts of the claims auditing and payment interface, but these applications were not integrated throughout the department. These systems siloed the information from the attorney, witness, and interpreter claims, making it difficult for judges to review and approve claims online. It was an inefficient, noncentralized system that contributed to the backlog and resulted in inaccurate and unpaid claims.
Prolifics removed AOC’s dependency on physical paper and the old method of sending claims in via receipts and envelopes. (Many attorneys and expert witnesses were running from case to case and trying to manage the paperwork in their cars between court appointments.) By digitizing the process online and removing the barriers created by the prior systems, the people relying on AOC were able to streamline communications. Prolifics was able to set AOC up with an automated method of catching and addressing claims that otherwise would have slipped through the cracks.
Results
Prolifics’ business automation created the opportunity for AOC to intentionally allocate resources to better serve the attorneys, expert witnesses, interpreters, and the reviewing judges. Prolifics set AOC up for success by streamlining their processes and setting up a stronger infrastructure capable of handling upwards of 10,000 claims per month.
The new system reduces the average claim processing time from 45 days to fewer than 10 days, and resolved claims in limbo. Importantly, it now provides transparency and tracking. Before, an attorney or other claimant wouldn’t know where their claim was in the process. But now, with the new reporting capabilities, you are able to pinpoint exactly where the claim is and its status.
“We’ve named the solution created from this implementation the Prolifics ACAP solution – for ‘administrative claims and payments,’” said Salem Hadim, Head of Prolifics’ Smarter Process Practice. “Our state client has built their website pages around this solution, saying that the new system: ‘…will allow users to more accurately and efficiently input and track claims for payment. The new system will provide users with more feedback and transparency on their claims. The payment process will be streamlined on the backend, improving turnaround times…’ The pages provide registration, training, claims submission, tracking, reminders, videos and more.”
In addition, by implementing intelligent automation and incorporating artificial intelligence and machine learning (AI/ML), Prolifics has set up AOC for continued efficiencies.
About Prolifics
Prolifics is a global digital engineering and consulting firm helping clients navigate and accelerate their digital transformation journeys. We deliver relevant outcomes using our systematic approach to rapid, enterprise-grade continuous innovation. We treat our digital deliverables like a customized product – using agile practices to deliver immediate and ongoing increases in value.
We provide consulting, engineering and managed services for all our practice areas — Data & AI, Integration & Applications, Business Automation, DevXOps, Test Automation, and Cybersecurity across multiple industries — at any point our clients need them.
Vision to Value. Faster. It’s not just the Prolifics’ tagline, it’s what drives us. Email us at solutions@prolifics.com or visit us at prolifics.com.
Your Guide to Automation Types
Know When, and Which, Automation is Right for You
You want your business to run smoother, your employees to be more productive, and your company to experience faster growth. The experts tell you that you must embrace automation. But what does that really mean? There are many choices and options based on what you’re trying to do. This blog cuts through the definitions to direct you to the level you really need.
| Robotic Process Automation |
| Business / Intelligent Automation |
| AI-Powered Automation |
| Across the Enterprise |
| Hyperautomation |
| Extreme Automation |
| Process Mining |
The basics: robotic process automation (RPA) – freeing up your employees for more important work
Gartner defines robotic process automation (RPA) as a “productivity tool that allows a user to configure one or more scripts (which some vendors refer to as ‘bots’) to activate specific keystrokes in an automated fashion. The result is that the bots can be used to mimic or emulate selected tasks (transaction steps) within an overall business or IT process.”
Robotic process automation (RPA) is the most basic form of automation, running repetitive, mundane and/or previously manual tasks. For example, maybe your employees are spending time inputting information manually from documents into systems, or rekeying data among non-integrated systems. With repetitive work like this, employees become distracted, bored or tired – leading to mistakes and less work completed. This lack of accuracy not only diminishes individual productivity, but it creates a downstream ripple effect in the rest of your business processes. Even with entry-level positions, mundane tasks can leave employees frustrated, leading to turnover and increased hiring and training costs.
Advances in RPA have made it easier, quicker and cheaper to rollout automation with reduced risk. It’s quick – often going from “ideation to operationalization” in three to four weeks. RPA can run repetitive, mundane and/or previously manual tasks 24 hours a day – quickly with an extremely low error rate. Once programmed, it never needs a refresher course, and updates or changes are implemented easily – without additional training costs. RPA is not intended to replace employees – even lower-level workers. It’s meant to free up those employees for more important duties as “knowledge workers.”
The next level – getting knowledge workers the information they need
After straight RPA, more capabilities can be added to automation to affect larger business scenarios. These are designed to help your knowledge workers do their jobs better, and drive efficiencies in other processes. This type of automation goes by a couple different names, for example:
IBM defines intelligent automation (IA) as “…the use of automation technologies – artificial intelligence (AI), business process management (BPM), and robotic process automation (RPA) – to streamline and scale decision-making across organizations. Intelligent automation simplifies processes, frees up resources and improves operational efficiencies.”
Gartner defines business process automation (BPA) as “the automation of complex business processes and functions beyond conventional data manipulation and record-keeping activities, usually through the use of advanced technologies. It focuses on ‘run the business’ as opposed to ‘count the business’ types of automation efforts and often deals with event-driven, mission-critical, core processes. BPA usually supports an enterprise’s knowledge workers in satisfying the needs of its many constituencies.”
An example of “run the business” and supporting knowledge workers is the exception scenarios, like claims processing in healthcare insurance. While most claims processing never needs human intervention (because of RPA), your claims process specialists – a knowledge worker – must review certain claims for such things as over-threshold amounts, suspected fraud, audit, and other exceptions. Often there are repetitive tasks associated with these exceptions, like compiling facts, figures and information out of different data sources, business applications and/or policy documents. Your knowledge worker needs to get this specific information, based on whatever the exception kick-out is, to make a decision. But compiling the info (even assuming no mistakes are made) slows down the worker, the decision, and the process – resulting in inefficiencies and higher costs.
Intelligent automation / business process automation is the answer here. This automation application learns where to get the information needed to process the exception – quickly, accurately and completely. Imagine the knowledge worker getting the exception report along with all the information needed to make the decision.
Intelligent automation / business process automation is especially valuable when volume is considered. Claim filings can vary widely based on events and time of year. IA bots, also known as digital worker assistants or simply digital worker, can be easily added or removed to scale up or down based on volume, helping to stabilize your knowledge-worker hiring.
| More about bot? Check out “What Robot Do You Need?” |
Intelligent automation / business process automation is not just for claims exceptions. It can be used across multiple industries to actually make decisions based on the information it gathers. Examples include:
- Healthcare: Check on provider data to determine “in-network” or “out-of-network” status.
- Banking and financial services: Reconcile accounts and post journal entries.
- Mortgages/loans: Process documentation and related decisions for loan applications
Like straight RPA, intelligent automation / business process automation is not meant to replace workers. As defined, it gives them the information they need to do their jobs quicker, more efficiently and more accurately.
AI-powered automation – “Tell me what’s next?”
IBM defines AI-powered automation as “a continuous closed-loop automation process where data patterns are discovered and analyzed, such that decisions on insights from the data can be translated into automated actions, with AI providing proactive optimizations during each stage of the process.”
AI-powered automation, also referred to as artificial intelligence/machine learning (AI/ML), are at the top of automation capabilities. An AI-powered automation solution can complete complex decision making on its own. This is because new AI/ML techniques look at large amounts of data, make connections, and generate insights better and quicker than a knowledge worker ever could.
For example, intelligent automation can make a decision on a loan by collecting data and aligning it with the parameters set by the financial institution. An organization using AI/ML, by contrast, can analyze the entire historical loan portfolio on an ongoing basis, and recognize, for example, that a certain combination of factors leads to a much higher risk of default. If the loan application has those factors, the AI-powered automation solution will deny the loan.
AI-powered automation is for “what’s next” questions – such as who’s likely to default on a loan, what’s your customer’s next purchase, or when might your equipment breakdown. You would use artificial intelligence and machine learning tools to automatically detect sophisticated data patterns to predict potential outcomes, giving you better decision-making insight. Does AI-powered automation replace workers? Again, we would say no – AI/ML gives your company opportunities for sophisticated, strategic work that generates competitive advantages.
Automation across the enterprise
So far, the automation definitions have related to processes, business segments and the related workers. There are automation scenarios that look at large parts of, if not the entire, enterprise.
Gartner define hyperautomation as “a business-driven, disciplined approach that organizations use to rapidly identify, vet and automate as many business and IT processes as possible. Hyperautomation involves the orchestrated use of multiple technologies, tools or platforms…” For Gartner, this includes:
artificial intelligence and machine learning (AI/ML); event-driven software; RPA; business process management (BPM); and low-code/no-code tools.
KPMG discusses extreme automation as “the integration of multiple disruptive technologies – all at once – across all processes. In the next three to five years, for example, organizations are likely to have robotics and artificial intelligence (AI) everywhere, with electronic brains assisting in human decisions… the confluence of cloud applications, blockchain, cognitive automation, natural language processing, and more – is expected to create an all-new operating model…”
A Prolifics differentiator – Process Mining coupled with automation
Prolifics Process Mining discovers what is actually happening in a process by following the digital trail of data through your systems. Every day your customers, employees, vendors and others generate a digital footprint when they utilize your company systems. These digital footprints get captured in these systems, such as ERPs, CRMs, application databases, log files, audit tables, Excel documents and many others. Process Mining shows you how data moves through your organization – visualizing and diagraming the actual flow, including variations, exceptions, gaps and siloes.
Process Mining will let you know exactly what’s happening by using hard data – it’s not an opinion from an interview or a subjective process mapping. Process Mining quickly identifies inefficiencies, where to improve and how to get to your desired business outcomes. You can readily compare what you currently have to what you want: a new policy or procedure; defined standard; or best practice. You can now make automation changes – any type or level of automation – with confidence.
How can we help?
If you’re interested in any of the automation concepts discussed here, we’ll sit down with you for a free discovery workshop. If we can help and you want to go further, we’ll jump start the automation solution, including deploying and customizing as needed for your environment. If AI-powered automation is involved, we’ll also install and set up that platform. With Prolifics automation, we offer a quantified result expressed in improved time, increased volume, better data, better decision-making and overall better outcomes. To learn more, email us at solutions@prolifics.com.
Do you want more on automation and “bots?”
Join us for Prolifics next Innovation Sandbox, “BOTS: Taking on Today’s Challenges.” This free, online event will feature two innovators in the automation space. They will share their creations designed to help improve the healthcare experience and to provide the right support for employees facing mental health concerns. In addition, a special guest will talk about what they’re doing to encourage more companies and individuals to innovate and automate with purpose. The live event will air on Prolifics TV on Tuesday, April 26, 2022, at 10-11 a.m. ET. Learn more and register here Your Guide to Automation Types.
Collaborative, DevOps Approach Modernizes Systems Quickly
Our Client
Our client is a UK leader in resource management services (RMS) and outsourced recycling services. This is a new client for Prolifics; MuleSoft introduced us. RMS chose Prolifics in part due to our DevOps expertise and hybrid delivery model.
Challenge
Over the past few years RMS has undertaken a massive business expansion – acquiring a lot of other companies to come under their group umbrella.
RMS had been using a monolith legacy application for more than 20 years. While it suited the business well in the past, it’s now reached a state where a simple change – like introducing an additional field – would take considerable time and expense.
In addition to this lack of agility and accommodation, RMS had a looming, drop-dead renewal date on the legacy license itself – with a huge cost connected to this extension.
RMS decided to replace the monolith legacy application system with Salesforce to enable various APIs and other integrations. They then decided to couple Salesforce and MuleSoft.
Action
RMS chose Prolifics based on our DevOps capabilities and our hybrid onshore/offshore delivery mix.
As with any Prolifics engagement, when we go in, we address the immediate needs while still working on the bigger picture. This means immediate value without a project being held up.
We went in for initial discussions on project approach. RMS saw the benefit from Prolifics – rather than just providing a group of offshore developers, we could provide the entire package through our hybrid delivery model. This included the local UK team supported by offshore architects and offshore development capabilities.
The first part of the engagement was understanding what RMS had and what the actual requirements were. So, we went through that inception phase to understand:
- What used to get done?
- What does the technical landscape look like?
- What is it that needs to be integrated?
In the phases that followed, a lot of time was spent with RMS as we configured the platform and built the new environment. RMS wanted to ensure that they could do rapid deployments and manage the platform going forward, correcting one of the original problems of changes taking months.
One of the themes through our entire work with RMS was that they had been learning and developing Salesforce at the same time. So, we would come out of phases without a fully signed-off, completed design, because we wanted to be able to work in the agile way. In true DevOps fashion, we wanted to accommodate changes as we were going along – accommodate the changes and the changing levels of knowledge that RMS had as they were going along.
Result
Prolifics is still currently in the implementation phase, with a “big drop and go live” scenario with MuleSoft, Salesforce and all other apps going live at one time. This is not the optimal method, but due to the workings of the legacy system, one large “cut over” is necessary.
To-date benefits include:
- Overall systems architecture is in place
- Implementation of reference architecture and platform has been set up
- Integration of all apps interacting with legacy system to Salesforce, Azure and AWS cloud using new integration platform
- Documentation of everything in a corporate-based wiki, as well as the MuleSoft platform
After “go-live,” RMS will have:
- Reduced costs
- API-led connectivity and reusable APIs
- Reduced time managing APIs
- Up to 20 percent time savings for the development of new applications
Prolifics has created the foundation for changes to occur at RMS in a swift and efficient fashion. To find out more about RMS’ transition away from their legacy system, read the full case study.
About Prolifics
Prolifics is a digital engineering and consulting firm helping clients navigate and accelerate their digital transformation journeys. We deliver relevant outcomes using our systematic approach to rapid, enterprise-grade continuous innovation. We treat our digital deliverables like a customized product – using agile practices to deliver immediate and ongoing increases in value.
We provide consulting, engineering and managed services for all our practice areas – Data & AI, Integration & Applications, Business Automation, DevXOps, Test Automation, and Cybersecurity – at any point our clients need them.
Email: solutions@prolifics.com or visit us at prolifics.com