{"id":6941,"date":"2022-04-28T14:07:25","date_gmt":"2022-04-28T19:07:25","guid":{"rendered":"https:\/\/prolifics.com\/us\/?p=6941"},"modified":"2025-09-17T21:35:14","modified_gmt":"2025-09-17T16:05:14","slug":"faster-claims-more-control-a-victory-for-insurer-and-patients","status":"publish","type":"post","link":"https:\/\/prolifics.com\/usa\/resource-center\/case-studies\/faster-claims-more-control-a-victory-for-insurer-and-patients","title":{"rendered":"Faster Claims, More Control a Victory for Insurer and Patients"},"content":{"rendered":"<div class=\"wp-block-cover alignfull is-light has-parallax has-custom-content-position is-position-top-left lazyload\" style=\"background-image:inherit\" data-bg-image=\"url(https:\/\/prolifics.com\/usa\/wp-content\/uploads\/2022\/04\/Prolifics-Quick-FHIR-Solution-scaled-1.jpeg)\"><span aria-hidden=\"true\" class=\"has-background-dim-40 wp-block-cover__gradient-background has-background-dim\" style=\"background-color:#000000\"><\/span><\/p>\n<div class=\"wp-block-cover__inner-container\">\n<h2 class=\"alignwide has-white-color has-text-color\" style=\"font-size:48px;line-height:1.2\"><strong><em>Faster Claims, More Control a Victory for Insurer and Patients<\/em><\/strong><\/h2>\n<div class=\"wp-block-columns alignwide\">\n<div class=\"wp-block-column\" style=\"flex-basis:60%\">\n<p class=\"has-text-color\" style=\"color:#ffffff\"><strong>A &#8220;Layer Cake&#8221; of Modernization, Integration and Automation<\/strong><\/p>\n<div class=\"wp-block-buttons\">\n<div class=\"wp-block-button is-style-outline\"><\/div>\n<\/div>\n<\/div>\n<div class=\"wp-block-column\"><\/div>\n<\/div>\n<\/div>\n<\/div>\n<h4><strong>Challenge<\/strong>&nbsp;<\/h4>\n<h5><strong>Older system can\u2019t keep up with today\u2019s healthcare demands<\/strong>&nbsp;<\/h5>\n<p>HC\u2019s claims-processing system was a homegrown, legacy environment \u2014 cobbled together using older technology that wasn\u2019t seamlessly integrated. Running and maintaining the system had become untenable, creating several major headaches for the claims payer:&nbsp;<\/p>\n<ul>\n<li>The system had become non-compliant with HIPAA.&nbsp;<\/li>\n<li>The system was batch- and schedule-based.&nbsp;<\/li>\n<li>The claims themselves went through a three-hour, multi-step process.&nbsp;<\/li>\n<li>HC could not meaningfully analyze the data for any other business purpose.&nbsp;&nbsp;<\/li>\n<\/ul>\n<h4><strong>Action<\/strong><\/h4>\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 modernization \/ interoperability, or the way HC\u2019s systems accepted data from other organizations; and another with modernization \/ integration, or the way HC dealt with its own data.&nbsp;&nbsp;<\/p>\n<p>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\u2013 in this case, a claim\u2019s arrival. Processing would begin immediately upon a claim\u2019s arrival \u2013 it would not have to wait to be batch processed.&nbsp;&nbsp;<\/p>\n<p>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.&nbsp;<\/p>\n<p>At this point, HC\u2019s 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 \u201cblack box.\u201d 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.&nbsp;<\/p>\n<h4>Result<\/h4>\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<p>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.&nbsp;<\/p>\n<p>HC now has control of their data. What we\u2019ve 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\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, 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 \u2013 the complete digital audit trail, in just a few clicks.&nbsp;<\/p>\n<p>This modernization and integration project was so successful that HC has asked us to apply these concepts to other aspects of their business.&nbsp;&nbsp;<\/p>\n<h4>Technology Summary<\/h4>\n<p>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.&nbsp;<\/p>\n<blockquote class=\"wp-block-quote\">\n<p>\u201cYou 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.\u201d<\/p>\n<p><cite>Honda Bhyat, Prolifics Sr. Advisor, Integration and Digital Transformation<\/cite><\/p><\/blockquote>\n<p>Access the expanded version of this <a href=\"\/us\/resource-center\/case-studies\/portland-state-university-success-story-pdf\"><mark style=\"background-color:rgba(0, 0, 0, 0)\" class=\"has-inline-color has-vivid-cyan-blue-color\">success story and its technology<\/mark><\/a> to learn more or reach out to us a <a href=\"mailto:solutions@prolifics.com\"><mark style=\"background-color:rgba(0, 0, 0, 0)\" class=\"has-inline-color has-vivid-cyan-blue-color\">solutions@prolifics.com<\/mark><\/a>.<\/p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Faster Claims, More Control a Victory for Insurer and Patients A &#8220;Layer Cake&#8221; of Modernization, Integration and Automation Challenge&nbsp; Older system can\u2019t keep up with today\u2019s healthcare demands&nbsp; HC\u2019s claims-processing [&hellip;]<\/p>\n","protected":false},"author":34,"featured_media":30023,"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-6941","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\/6941","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=6941"}],"version-history":[{"count":0,"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/posts\/6941\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/media\/30023"}],"wp:attachment":[{"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/media?parent=6941"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/categories?post=6941"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/prolifics.com\/usa\/wp-json\/wp\/v2\/tags?post=6941"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}