Real-time, scalable switch for routing healthcare transactions The Client is a transactions clearinghouse that It was architected to use Internet Industry enables physicians and hospitals to submit communication protocols. A key financial transactions to payers over the Internet. requirement was to support uninterrupted HealthCare routing of millions of transactions. This was ClearingHouse Business Challenge accomplished by developing a highly scalable application server on the Solaris Deployment Historically hospitals have used paper based server platform using CORBA technologies. Summary forms to conduct transactions with insurance This server featured automatic load companies. These transactions covered a wide balancing, automatic discovery of services, Real-time transaction range of business processes such as Eligibility and automatic failover to ensure smooth, switch Checks, Patient Referrals, Payment uninterrupted 24 X 7 operation. Support for 15 transaction Authorization, Claim Submission, and Claim types Status Inquiry. The switch included a powerful engine for defining and implementing business rules Over 1 Billion These paper based process resulted in and business workflows. This enabled the Transactions to-date redundant data entry and data maintenance conversion of various proprietary since the same information had to separately transaction formats into HIPAA compliant Support for leading keyed into multiple systems. Also, the storage EDI ANSI X12 4020 formats. Both real-time Practice Mgt. Systems and retrieval of these paper forms was laborious, and batch modes were supported for Automatic Translation of time consuming, and error prone. These transaction execution. UB-92, HCFA 1500, and processing inefficiencies resulted in an increased Web Forms transaction costs and increased processing Interface to Practice Management delays. Systems (PMS) Gateways to legacy payer systems Hospitals have attempted to use EDI An Application Programming Interface (API) transactions over proprietary communications was developed to enable different PMS to HIPAA Compliant networks (e.g. dial up lines). However usage of submit and receive transactions from the ANSI X12 4020 support these of these networks is limited by their high switch. This API supports a variety of costs. different claims formats like UB-92, HCFA 70% - 80% Physicians 1500, and Web based Forms (HTML). The Technical challenge flexibility of this approach ensured that 90% Insurance leading PMS from vendors like Medical Companies The project involved using the Internet to offer Manager, IDX, MiSys, and InfoCure could payers and providers a cost effective way to be supported. The interface was designed streamline transaction processing. However to use open Internet standards for Configuration numerous technical challenges had to be communication. Transaction security was resolved. A highly scalable, reliable, and secure enforced through HIPAA compliant 128-bit Solaris Server infrastructure had to be built to route millions of encryption algorithms. This enabled CORBA protocol transactions between payers and providers. hospitals to reduce communications costs Providers and Providers communicate through a by using Internet based connectivity instead Support for MQ myriad of different transaction formats. The of expensive, dedicated dial-up Messaging, ODBC system had to be flexible enough to connections. accommodate all these formats. 128 – bit encryption Gateways to legacy Insurance High Performance Internet based Switch applications Benefits Custom gateways were built to enable bi- Achieve HIPAA compliance directional transactions with payers’ legacy systems. These gateways supported a wide Eliminate redundant data range of data access protocols including entry MQ Series, ODBC access, and direct TCP/IP socket based access. Supported Reduce transaction payers included Humana and Promina processing costs Health Plan. Accelerate claims settlement processes A centralized switch was built to route transactions between payers and physicians.
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