New System Routes and Applies Prices for Claims for 577,000 Members
The client, which adjudicates federal employee healthcare claims, worked with xScion to develop end-to-end technology that coupled with their current system to improve claims processing pre- and post-adjudication. xScion supported the client in all facets of the design, architecture, build, testing and implementation of the new platform. The modernized software not only improved adjudication rates for the client but was also designed for use by other health plans.
The Challenge
The client needed to improve their pre- and post-adjudication claims process without completely replacing their current infrastructure. They sought to develop a modern pre-and-post-adjudication Software-as-a-Service platform that would be built on a robust physical software platform. Processes needed to meet client and government specific guidelines for claims adjudication and the client sought to reduce overall cost with the adoption of new tools and technology.
The Change
xScion supported the end-to-end development of technology to solve the client’s challenges. The latest technologies on Unix/Windows platforms were used to transform the mainframe legacy applications for both the pre-adjudication claim engine and the post-adjudication claim voucher system. A two-way interface with the adjudication claim engine was developed under the new architecture with a flexible voucher payment cycle for each plan, pluggable voucher payment rules and standardized/flexible interfaces with other external systems.
The Value
As a result, the client has decreased manual processing hours, reduced errors and increased accurate auto-adjudication, which improved the end payment results for providers and members.
The client now has an expedited, more efficient claims process that is used to serve over a million federal healthcare members. The new platform provides a flexible near real-time pre-adjudication claim engine through a HIPAA compliant parsing/edit validation format and features multi-tenant capabilities to serve different plans.
Newly implemented technology has enhanced the client’s overall capabilities. They can now easily interface with other corporate applications including Explanation of Benefits for Patient/Provider, Financial systems with GL Transactions/Cash Management/Check Writer and Corporate Common Gateway to exchange data with third-party systems. The data platform implemented has a robust scale-out architecture that supports future data analytics and reduces the expense of complex data queries and server license costs through adoption of open sources.