Online Payment Solution for Medical & Healthcare Industry
Business Requirement
Traditionally clearinghouses for medical and other claims used to employ manual methods to verify bills information, match bills with attachments, verify claim numbers and then format the bills to the payer requirements. However, this is not a scalable model. To achieve a higher bills processing throughput, an electronic method was desired that would take in bills and attachments in any format produced by provider specific Practice Management Systems at one end, and give out neatly formatted reports for the payers and Bill reviewers at the other end, without any manual intervention. Providers had to be given immediate feedback in case any critical data was missing in the bills, so that they could provide missing data immediately to reduce delays. This could never be achieved with a manual system. In addition, the cost of manual processing was getting prohibitive and affecting margins.
Solution Benefits
Calsoft Labs provided the technology solution for this challenge faced by ClearingHouse, Inc. The solution consisted of a fully automated Transactions Processing Hub to provide fully automated electronic bills and attachments processing. This Hub would consist of a the following series of steps:
- The input to this Hub would be the HCFA 1500 and the UB 92 formatted bills from the providers in electronic form. These electronic bills are generated by the Practice Management Systems currently in use at the provider locations and hence no new systems need to be installed. Therefore, providers have a zero adoption cost.
- The electronic bills and their attachments (digital images, documents etc) are uploaded to the Hub using a simple yet secure file transfer mechanism.
- An Input-mapping engine would parse and transfer the data on the bills into a relational database. The mapping engine runs on business rules created by a business expert.
- After the input engine has finished its job, the validations process would kick in to validate the data in each of the claims submitted. In case any data is missing, electronic notifications would be generated to alert the provider immediately.
- The next process would be to match the bills with claim numbers made available from the payers. Any bills that do not match would not be dispatched to the bill payer.
- Then the bills and attachments clearing engine would step in to match bills to their valid attachments and discard any orphan attachments.
- After the bill passes through all the above process, it is picked up by the output-formatting engine to generate the NSF, PDF or ANSI formats as required by the payer. Payer could also receive the bills and attachments as XML data so that it could directly be fed into their payment systems without manual intervention.
The main business advantages of this solution proposed by Calsoft Labs are:
- Faster processing with quicker payment resolution
- Lower processing costs
- Savings in medical treatment and indemnity claim costs
- Sustained competitive advantage over traditional clearinghouses
- Zero adoption costs for providers
Schematic of the electronic Clearinghouse:
Technology Architecture
The web based front-end of this solution uses Active Server Pages on Microsoft IIS. SSL is used to provide page security. Secure FTP process is used for uploading of bills and attachments to the Hub. Business rules are provided using COM components created in MS Visual Basic and Visual C++. The database used is MS SQL Server. XML parsers are integrated into the solution to provide efficient data transformation between systems. The three-tier web based architecture leverages Windows DNA. Windows CDONTS components are used for workflow-enabling this application.
- Having dynamic content and rich entertainment in the device.
- Ability to meet time-to-market requirements.
- Lower cost of development.
- Guaranteed support.