sweateqty

Problem:

The company I worked for did not have a website to help facilitate the processing of claims.  Their competitors had websites and this created a competitive disadvantage when marketing to new clients or renewing existing contracts with insurance carriers.

Considerations:

The claims database was in an obscure software package that would not talk to other applications (no ODBC connection possible).  It was determined that we could export a textfile in a nightly process.

We needed to accomplish the following:

- Display recent authorizations to medical providers

- Display recent accepted claims to medical providers

- Provide an eligibility lookup application

- Allow online claims entry

Solution:

I would need to create separate SQL database to store the data.  I needed to establish a secure VPN connection from the external facing website to the internal facing SQL server.  I created a nightly import routine to import and verify the new test files into SQL Server.

In creating the website, I needed to secure the website with an SSL certificate, I chose the most trusted name in SSL certificates: Verisign; due to the fact that we were dealing with Medical Data.  I chose to write the website in ASP.  I had to build a login screen that accessed the existing provider data for verification, the insurance carriers that they worked for and the connections to eligibility so that the providers would only have access to the patients that they served.  Building the authorization, accepted claims and eligibility modules were relatively easy essentially I only needed to display the data in an easily readable format.

The claims data entry module was a much more complicated: after login and entry into the claims entry module, the provider is prompted to enter in an authorization number.  Since all of these claims were authorization based, we already had a lot of data about what the claim was for.   The provider data was already populated from the login information, much of the claims data was populated because we knew from the authorization number who the patient was so what needed to be added was the diagnosis code, the quantity and the CPT code.  Because I already knew what the CPT code ranges and quantities would be, I was able to add error trapping for CPT codes at the data entry stage.  As a matter of fact, since there was so much of the claim that was pre-populated we were able to achieve above a 98 percent claim acceptance rate, much higher than any other form of claims acceptance.  The extreme low amount of data entry and pre-population made the medical providers that I worked with extremely happy and enthusiastic.

Due to the lack of ODBC connection to the legacy database, I simply dropped a text file with the date as part of its name,  the legacy system picked up the file at night, did error checking, inserted the good claims and generated an error report.  I built another application to pick up the error files and generate HIPAA complian emails as to the status of the claims that were entered.  All claims were also faxed the same morning.

Results:

The resulting website was simple, elegant and secure.  Many providers personally told me that this was the easiest and best claims entry system that they had ever used.  They were comparing the new website against the major local insurance carriers in South Florida.

When I left the project over twenty percent of all claims were being entered by external medical providers.  It would have taken over two full time claims positions to hand enter this quantity of claims.   The ROI here is easily measurable in terms of saving extra employee salaries, but what is the impact of retaining and gaining clients or the goodwill garnered from having such a valuable system working for you?  It is far beyond the money saved on salaries.

Epilog:

The above is of course an extremely condensed version of what actually occurred as such a project requires a lot of time, planning, implementation and testing.  There is an extensive amount of consulting with the Claims Staff, Medical Providers (Doctors and their data entry people) and Management.  Nothing is created in a vacuum.