{"id":5443,"date":"2021-08-11T17:57:42","date_gmt":"2021-08-11T17:57:42","guid":{"rendered":"https:\/\/prolifics.com\/us\/?p=5443"},"modified":"2025-10-06T17:13:49","modified_gmt":"2025-10-06T11:43:49","slug":"health-insurer-expedites-claims-process-ensures-compliance","status":"publish","type":"post","link":"https:\/\/prolifics.com\/usa\/resource-center\/case-studies\/health-insurer-expedites-claims-process-ensures-compliance","title":{"rendered":"Faster Claims Process a Win for Health Insurer and Patients"},"content":{"rendered":"\n<h2 class=\"wp-block-heading\"><strong>A &#8220;Layer Cake&#8221; of Modernization, Integration and Automation<\/strong><\/h2>\n\n\n\n<p>Our client is the publicly traded holding company (HC) of seven insurance companies. They&nbsp;offer&nbsp;Medicare supplements;&nbsp;annuities;&nbsp;and life, long-term care, accident and health insurance to working-class families and senior citizens.&nbsp;&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Challenge<\/strong><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Older System Can&#8217;t Keep Up with Today&#8217;s Healthcare Demands<\/strong><\/h3>\n\n\n\n<p>HC\u2019s claims-processing system was a homegrown, legacy environment \u2014&nbsp;cobbled together using older technology that wasn\u2019t seamlessly integrated.&nbsp;Running and maintaining the system had become untenable, creating&nbsp;several&nbsp;major headaches for the&nbsp;claims payer:&nbsp;&nbsp;<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>The\u00a0system had become non-compliant with HIPAA, exposing HC and its subsidiaries\u00a0to\u00a0substantial fines and penalties, as well as\u00a0potential\u00a0negative publicity.\u00a0<\/li>\n\n\n\n<li>The system was\u00a0batch- and schedule-based,\u00a0in this case\u00a0meaning\u00a0it could only process claims\u00a0received\u00a0(transmitted\u00a0from healthcare providers)\u00a0by\u00a0a specific time\u00a0\u2013 7 a.m.\u00a0<\/li>\n\n\n\n<li>The claims themselves\u00a0went through a\u00a0three-hour, multi-step process that was\u00a0both\u00a0unwieldy\u00a0and\u00a0error prone.\u00a0<\/li>\n\n\n\n<li>HC was facing the possibility that the could lose control of their data &#8211; 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.<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Action<\/strong><\/h2>\n\n\n\n<p>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&nbsp;modernization&nbsp;\/&nbsp;interoperability, or the way HC\u2019s systems accepted data from other organizations;&nbsp;and another with&nbsp;modernization \/&nbsp;integration, or the way HC dealt with its own data.&nbsp;&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Automation for Claims Processing<\/strong><\/h3>\n\n\n\n<p>We tackled the interoperability problem first, and our initial step was to move HC from&nbsp;the batch- and&nbsp;schedule-driven system&nbsp;to an&nbsp;event-driven system. An event-driven system\u2019s catalyst is an incident \u2013 in&nbsp;this case, a claim\u2019s arrival \u2013 rather than&nbsp;an&nbsp;arbitrary&nbsp;demarcation,&nbsp;like a time, (e.g., 7 a.m.)&nbsp;The processing would begin immediately upon&nbsp;a&nbsp;claim\u2019s arrival&nbsp;\u2013&nbsp;it would not have to wait to be batch processed.&nbsp;&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>A Clear View of Data Through the Cloud<\/strong><\/h3>\n\n\n\n<p>Then we turned to integration, and,&nbsp;together with HC, determined how to best organize the massive&nbsp;number&nbsp;of incoming claims they received on a daily basis.&nbsp;The&nbsp;client&nbsp;needed control over their&nbsp;claims&nbsp;data, including&nbsp;ease of filing and retrieval,&nbsp;and the capability to&nbsp;readily&nbsp;manipulate&nbsp;data&nbsp;for reports.&nbsp;We recommended they&nbsp;utilize our tech partner Mongo for a&nbsp;cloud-based&nbsp;database.&nbsp;<\/p>\n\n\n\n<p>At this point, HC\u2019s systems were efficiently interacting with outside organizations and their data was well organized.&nbsp;However,&nbsp;even the most carefully organized data is useless if&nbsp;it&nbsp;lives&nbsp;in a&nbsp;\u201cblack box.\u201d&nbsp;So,&nbsp;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.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Result<\/strong><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Reduced Processing Time<\/strong><\/h3>\n\n\n\n<p>As a direct result of working with us, HC is now HIPAA-compliant, and the organization is in no danger of incurring fines.&nbsp;&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Faster Claims Processing<\/h3>\n\n\n\n<p>The implemented&nbsp;event-driven system is a more modern, logical approach to data processing that allows&nbsp;HC greater flexibility in communicating with outside organizations.&nbsp;Because of this&nbsp;efficient&nbsp;automation,&nbsp;the three hours&nbsp;needed to process&nbsp;claims&nbsp;has been reduced to a mere 18 minutes.&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Better Control Over Data<\/strong><\/h3>\n\n\n\n<p>HC now has control of their data.&nbsp;What we\u2019ve ensured&nbsp;through the Mongo database&nbsp;and the&nbsp;global transaction monitor (GTM)&nbsp;is that&nbsp;HC&nbsp;has a full audit trail and traceability for everything that comes into the organization digitally and then goes out digitally. We\u2019ve set up digital record keeping for them as part of our solution, one that\u2019s 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,&nbsp;the file name,&nbsp;where it is located,&nbsp;when&nbsp;it&nbsp;arrived&nbsp;and more \u2013 the complete digital audit trail, in just a few clicks.&nbsp;<\/p>\n\n\n\n<p>If a claim is flagged for any reason \u2014 incorrect data, compliance error, etc. \u2014 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.&nbsp;&nbsp;<\/p>\n\n\n\n<p>This&nbsp;modernization and integration&nbsp;project was so successful that HC has asked us to apply these&nbsp;concepts&nbsp;to other aspects of their business.&nbsp;&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Technology<\/strong><\/h2>\n\n\n\n<p>IBM technologies became the foundation for fixing HC\u2019s interoperability and integration issues. (Prolifics is an IBM Platinum Business Partner.) The first component wa<a href=\"https:\/\/www.ibm.com\/products\/mq\/advanced\" target=\"_blank\" rel=\"noopener\"><strong>s IBM\u2019s MQ Advanced<\/strong><\/a> 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.<\/p>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\">\n<p>Honda Bhyat, Prolifics Sr Advisor, Integration and Digital Transformation (DX) Practice, said, \u201cThe 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&#8217;s the communication fabric to interoperate all the different HC microservices and pass the data between these services.\u201d<\/p>\n<\/blockquote>\n\n\n\n<p>The second component, or layer, is the <a href=\"https:\/\/www.ibm.com\/docs\/zh\/ste\/10.1?topic=extender-transformation-introduction\" target=\"_blank\" rel=\"noopener\"><strong>IBM Transformation Extender Advanced (IXTA)<\/strong><\/a>. This is a document transformation software \u2013 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.<\/p>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\">\n<p>Bhyat said, \u201cFor HC as a payor, this second layer provides all the intelligence of transforming the data from what it is in \u2013 the HIPAA format that the internal systems need \u2013 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.\u201d<\/p>\n<\/blockquote>\n\n\n\n<p>For the cloud-based database, we recommended our tech partner <a href=\"https:\/\/www.mongodb.com\/\" target=\"_blank\" rel=\"noopener\"><strong>Mongo<\/strong><\/a>. HC\u2019s 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.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">About Prolifics<\/h3>\n\n\n\n<p>Prolifics is a global digital transformation leader with expertise in Data &amp; AI, Integration &amp; 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\u2019s not just the Prolifics\u2019 tagline, it\u2019s what drives us. Connect with us &#8211; <a href=\"mailto:solutions@prolifics.com\">solutions@prolifics.com<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A &#8220;Layer Cake&#8221; of Modernization, Integration and Automation Our client is the publicly traded holding company (HC) of seven insurance companies. They&nbsp;offer&nbsp;Medicare supplements;&nbsp;annuities;&nbsp;and life, long-term care, accident and health insurance [&hellip;]<\/p>\n","protected":false},"author":34,"featured_media":29565,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"content-type":"","footnotes":"","_links_to":"","_links_to_target":""},"categories":[69],"tags":[],"class_list":["post-5443","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-case-studies","has-post-title","has-post-date","has-post-category","has-post-tag","has-post-comment","has-post-author",""],"acf":[],"builder_content":"","_links":{"self":[{"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/posts\/5443","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/users\/34"}],"replies":[{"embeddable":true,"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/comments?post=5443"}],"version-history":[{"count":0,"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/posts\/5443\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/media\/29565"}],"wp:attachment":[{"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/media?parent=5443"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/categories?post=5443"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/tags?post=5443"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}