CI by stariya


									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,
                             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
                                                                                   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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