Background: Our client process over 1.6 million provider medical claims and over 5.7 million American’s health benefit enrollment data is managed on daily basis. Several years worth of data has been stored in the data warehouse before it is archived.
Problem: Providers are submitting claims but are not measuring their performance of claims submitted, success rate, rejections methods of submitting claims, key diagnosis, EDI adoption, and many other measurements to see how they perform measuring with peers. There are no defined approaches on how to improve the provider claims submission experience.
Solution: The Eixsys team built a dynamic, role-based reporting portal as a hybrid cloud model, which validates and aggregates data received from Electronic Funds Transfer data sets, provider enrollment, and the claims Data warehouse to provide utilization reports. The goal was to distribute a timely report to Network Providers that identifies various key indicators relating to claim rejections and denials, along with EFT, and EDI adoption in near-real time (monthly depending on provider volume). The goal of all reports was to measure and aggregate key performance around claim administration that is meaningful and actionable.
Result: A dynamic, hybrid cloud, role based reporting portal; this portal has capabilities in identifying, payment risk, and vulnerabilities assessment of claims status and rejections in real-time. It also has the ability to measure and aggregate key performance around claim administration and Real-time EDI and EFT adoption.