Industry: Healthcare Payer IT

BACKGROUND: HIPAA Act of 1996 enforced healthcare covered entities to exchange administrative data in a unified X12 standard, but HIPAA didn’t focus on meaningful information content, data exchange architecture and data exchange security. As part of the Affordable Care Act (ACA), CORE, a committee under Council for Affordable Quality Healthcare, Inc (CAQH), developed rules so covered entities will adopt those standards and reduce the increasing cost of US Healthcare incurred by irregularities caused by data exchange. The adoption of CAQH CORE Rules was voluntary, and only large health plans adopted the data exchange rules. Smaller health plans avoided adoption due to initial capital requirement and created a disbalance. Later under the 21st Century Cures Act the Rules were made Mandatory with non-compliance penalty.

Problem: Health plans operate business with multiple systems and backend applications, with data scattered in various backend systems. The
problem is not the delivery of the data, but more on the cost of delivery and ongoing maintenance.

Solution: Our experts at EIXSYS configured a pre-designed EIXSYS Gateway certified by CAQH CORE for Phase 1 & II as an “out-of-the-box” CORE
Compliant data exchange infrastructure with rules engine running inside Payers hosted environment. We tested with 1-million per hour deidentified records containing request and response to measure the system against high performance load time.

Result: Health Plans can implement CAQH CORE compliant data exchange infrastructure utilizing it as a Software as a Service model without huge capital investment.