A large non-profit healthcare payor improved adjudication rates by consolidating to a single automated payment system.
SITUATION
Our client, a large non-profit healthcare payor, aimed to centralize their regional health plan. They envisioned a cohesive network of contracted and non-contracted providers serving multiple lines of business, consolidated from multiple claim adjudication systems into a single automated payment system to improve adjudication rates. To achieve this transformation, our client enlisted the technical expertise of Everforth Apex and our seasoned team of technical analysts. Together, we facilitated the migration of all government plans such as Medicaid and Medicare, transitioning from fragmented data and assorted technology systems into the HealthEdge HealthRules Payor® (HRP), ensuring minimal disruption to daily operations.
Success load ratio of 99.98% of all data from multiple legacy claims adjudication systems to a unified payment system.
We designed a phased implementation approach to transfer provider, member, authorization/referrals, and base code sets (subscription-based) transactional data to HRP while phasing out the array of legacy claims adjudication systems. This multi-year undertaking was compartmentalized into three stages, accommodating the complexity of the populations served and guaranteeing a seamless adoption of the new platform.
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Phase I - We successfully transferred Provider, Member, Authorization, and Code Sets data to HRP, achieving comprehensive claims adjudication. The process involved close collaboration with cross-functional teams, culminating in seamless data interchange. We met integration challenges head-on, refining the data structure for a smooth transition to the client's Operational Data Store and Enterprise Data Warehouse.
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Phase II - Building on the learnings from Phase I, we adeptly handled the transition of Medicare HMO/PPO Provider, Member, and Authorization data. Our strategy improved data analysis and integration techniques, further advancing our client's data management frameworks through optimization of conversion tactics.
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Phase III - We embarked on a deliberate expansion of the provider and member database, seamlessly incorporating complex Medicare and Dual data into HRP. Additional planning and sharpened gap analysis were employed to tackle dual maintenance data quality issues proactively, devising updates and coding solutions that sustained operational continuity and minimized disruption.
RESULT
The initiative culminated in a resounding success as our team flawlessly transitioned all data from multiple legacy claims adjudication systems to a unified payment system—delivered on time, within budget, and achieving an impressive 99.98% success load ratio. The integration of HRP data with the client's ODS and Enterprise Data Warehouse was executed with minimal to no impact on existing data extracts and end-user reporting, exemplifying our commitment to providing seamless solutions that empower our clients in the progressive landscape of digital healthcare.
