Automating Services and Contracts Systems for a Healthcare Provider
The client is a provider of healthcare, dental, pharmacy, group life, disability and long-term care benefits in the United States. The company had in place a services and contracts system and wanted improvements to be carried out to the same. Infosys automated the service code update process and introduced an archival strategy, which led to smoother operations.
The client already had in place a services and contracts system and wanted improvements to be carried out to the same. It was doing independent pricing for HMOs (Health Maintenance Organization) and traditional systems and these had to be improved and the pricing system made uniform for all entities.
Another problem was that there was no HIPAA (Health Insurance Portability and Accountability Act) compliance. The client also had legacy systems, which were handling the return of Capitated Coverage Decisions (CCD) for providers and these too had to be enhanced.
Infosys was asked to deliver various enhancements to the services and contracts system. This threw up a variety of challenges like:
- The service code update process had to be automated and optimizations needed to be carried out on the annual rate loading process. Given the scope of operations, this was a demanding task
- The rates table had grown in size and this was hampering processing time. Infosys had to incorporate an archival strategy so that this could be improved
- The various Service Code Service Rate (SCSR) programs that were used to pay claims had to be modified to ensure that their performance was enhanced. For this, the database size had to be stabilized by analyzing and purging unnecessary information. This was critical because the SCSR, as a data repository of service codes and corresponding rates, was a crucial component of the system
- Apart from this, the Health Insurance Association of America (HIAA) update process had to be improved and automation performed for the annual Health Care Provider Code (HCPC) coding changes from the American Medical Association (AMA)
The Infosys Global Delivery Model enhanced the existing processes and introduced major changes, which led to smoother operations. The Infosys team, which consisted of four personnel, spent one year implementing the modifications required for the project.
The requirement analysis showed the team the areas of concern and also the various changes required. The scope of this project included approximately 70 online and 95 batch programs in SCSR and 67 online and 11 batch programs in the legacy contracts system, which were mainframe applications developed using COBOL and CICS (Customer Information Control System), using databases like DB2 and IDMS (Integrated Data Management System). Modifications to these modules were finalized while designing the solution and during the development phase, program specifications and individual unit test plans were created.
The code was reviewed to understand the underlying complexities and then modifications carried out. To ensure robustness, the developer tested it and then passed it on to an independent testing unit. This two-layer process helped to make certain that there were no bugs.
The next phase was integration and accordingly, the system integration test plans were developed and deployed. Infosys also provided assistance for implementation testing and final acceptance from the client's end.
The benefits of the implementation included:
- The HIPAA compliance that Infosys introduced into the pricing system helped the client to manage the legal aspects more easily
- The new code now automatically updates service code, service code affiliation, geographic area affiliation, service type, etc. This makes the claims process error free and effortless, which in turn ensures quality service care from the client to its customers
- The optimization of the annual rate load process also reduced overheads considerably
- The archival strategy for the older rates increased performance in claims processing as well