EDI Delivers Healthy ROI to Insurance Provider

By Samuel Greengard  |  Posted 2014-09-16 Email Print this article Print
EDI aids health care provider

Triple S Advantage Solutions turned to a front-end electronic data exchange that manages health claims data internally and connects to a dozen external systems.

Few industries cope with as many rules, regulations and protections as health care insurance providers. As a result, it's critical that enterprise applications, databases and other tools work seamlessly, effectively and securely.

At Triple S Advantage Solutions, an independent licensee of the Blue Cross and Blue Shield Association in Puerto Rico, the need for an electronic transaction gateway and portal to manage complex and highly sensitive data covered by the Health Insurance Portability and Accountability Act (HIPAA) is at the center of the business. Only a few years ago, as the company took on new accounts and expanded the business, executives struggled to fully manage data and operations.

"There was a lot of growth taking place, and there were challenges related to the integration of the business with information technology," recalls Ken Wiens, CIO for the privately held firm. "We weren't able to handle compliance issues as effectively as possible. We also knew we needed to make some changes and become faster and more efficient."

Triple S Advantage Solutions turned to the Wovenware software firm to develop a front-end electronic data exchange (EDI) solution that manages claims data internally and also connects to a dozen external systems operated by outside providers and drug stores. The system connects 24 separate applications and maps data across the organization. This helps the company determine claims and Medicare eligibility, while also processing payment information and tackling other tasks.

The system automates tasks that previously required manual processing. Improving business processes and workflows was vital for both legal and practical reasons.

"It is important that we reject ineligible claims as early as possible in the process," Wiens explains. "We are legally required to remit back to the provider member why we are unable to pay the claim. So, there is a need to interact with the database instantaneously and obtain eligibility status while we're at the front end of the process."

The EDI system also aids in compliance. Over the last few years, the regulatory environment has become more complex.

"We have witnessed a new set of requirements, certifications and other compliance criteria from the federal government," Wiens points out. "We have very specific issues revolving around provider requests for electronic fund transfers and how they interact with the EDI solution."

In some cases, he adds, data arrives in proprietary formats. That required developing specialized software to map the data.

The EDI solution has delivered healthy ROI. In the past, Triple S Advantage required two full-time equivalent employees (FTEs) to handle nearly 22,000 members. "The files came in from clearinghouses and had to be manually identified and matched with the specific health care product," Wiens explains.

Today, the company has one FTE employee processing claims from 120,000 members. "All the forms come in, get queued and move into the system automatically," he reports. "There have been enormous labor savings, but also a huge uptick in speed and accuracy. We have dramatically improved our performance, along with achieving the metrics Blue Cross/Blue Shield has established."


Samuel Greengard is a contributing writer for Baseline.


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