The Electronic Data Interchange (EDI) consists of a file in a specific format that represents data exchanged in a transaction from supply chain to healthcare. EDI 835 Claim Payment transaction provides payments information in reference to claims in EDI 837 Healthcare Claim format. The details include transactions such as charges, deductible, copay, payers, payee, etc. The information is stored a hierarchical structure. The standard of EDI format is well defined and the complexity can be very overwhelming. Additionally, we do not want this high degree of detail slowing our processing time.
One of the problems that enterprise systems face with EDI is file size. A single EDI 835 may contain multiple claim records and the quantity of claims in a single file can make it very difficult to process the file. Systems are often bogged down when dealing with a very…
As we strike out into 2018, the implementation of All-Payer Claims Databases (APCD) across states remains variable and dynamic. Massachusetts maintains a comprehensive implementation, aggregating data feeds from over 80 public and private payers. Massachusetts has leveraged their APCD to create a state-specific risk adjustment model to meet the ACA provision which balances funds from healthier populations to higher risk pools. Late in 2016, Minnesota concluded a feasibility study which determined their APCD could significantly improve risk adjustment vs. the federal model.
On the other hand, West Virginia and Tennessee have put APCD development on hold. California payers optionally submit claims and encounters to a public benefit corporation. Legal, fiscal and political concerns guarantee a fluid situation for insurers.
This blog post is focused on the technical obstacles that health plans face in states requiring APCD submission. Since these databases have phased in over the last decade through both voluntary and legislated…
The X12 HIPAA transaction set is used across the healthcare industry to transmit claim, enrollment and payment information. Given the importance and ubiquity of these EDI files, you might assume that translating them from ANSI to a relational database format would be well-supported with a range of options.
In practice, a task as common as parsing a claim or encounter and storing it in a database can quickly escalate into a significant problem.
One solution we’ve seen involves archiving a snapshot of the EDI file using filestream storage. This can satisfy some retention requirements, but provides little in terms of fine-grained tracking or analytic capabilities.
A more complete approach is to parse the X12 file into its discrete elements and store them in a relational database. The ideal solution captures the full extent of the EDI transactions while also applying a reasonable leveling of flattening to keep in the number of table joins under control.
835 and 837 EDI transactions have transformed the adjudication cycle for providers and health plans over the last two decades, but challenges remain in reconciling payments with claims. Today we’ll focus on the 835 Claim Payment/Remittance Advice. Health plans submit 835s to providers (or their intermediaries) to explain which claims are being paid, and any reductions to the submitted amount and the reasoning for the adjustment. This is an important function – a significant pain point experienced by providers is the reconciliation of their income against claims submitted.
Before this valuable information can be loaded in practice management software, the 835 should pass validation checks. Common issues affecting 835s are balancing errors between the header and detail payment amounts. Imbalanced 835s lower the quality of reporting and can lead to billing errors and lost revenue.
WEDI describes up to seven levels of validation,…
Successful retailers that attract today’s millennial shoppers have three key ingredients in their retail experience delivery:
Help find things that inspire
Help choose what is right
Help buy effortlessly
Online stores are increasingly better at attracting these shoppers and converting them into profitable customers. Physical storefronts are experiencing less foot traffic and conversion rates are lowering. The transformation challenge is thus clear. How can retailers deliver these same customer experience ingredients in the brick-and-mortar environment in ways that are simple, easy and memorable?
To drive traffic both storefronts focus on search and marketing. Ecommerce obviously has the advantage in terms of offering the customer convenience to explore the storefront anytime and from anywhere. For conversion, ecommerce storefronts focus on the following:
Extensive catalogs with digital content that showcases the merchandise.
Customer intimacy based on customer information.
A frictionless shopping journey with ease of search and navigation.
Physical storefronts have…
Whether you call them conversational agents, dialog systems, or chatbots, AI-powered bots that can hold human-like conversations are seeping into our everyday lives.
Chatbots work well in a structured environment with a predetermined dataset. Answering simple questions, for example, would be a task a chatbot could excel at. Which is why chatbots are now replacing the Frequently Asked Questions page on websites.
Here’s what you need to know about how these chatbots work and why you might never see a traditional FAQ page again:
Chatbots can be either retrieval-based or generative, which means they can either retrieve data from a predetermined dataset or generate new responses from scratch. These bots can also be open or closed domain, depending on whether the user can take the conversation anywhere and still expect a reply or whether a user needs to stick to a narrow…
The Customer Data and Analytics (CDnA) team at Microsoft enables strategic data insights that shape the entire organization, from high-level leadership policies to small product decisions. At its core, CDnA creates and monitors indicators, known as “Power Metrics,” for some of the key divisions and businesses in Microsoft. CDnA delivers Power BI dashboards to several teams, including the Windows and Devices Group (WDG), Office, Bing, Cortana and Microsoft CEO Satya Nadella’s Senior Leadership Team (SLT). The SLT leverages the Power BI dashboards to monitor progress on strategic initiatives at the company.
Both CDnA and the Power BI product have mutually benefited from a close relationship since the Power BI public preview in 2015. In fact, the early and ongoing input from this internal Microsoft team and its users has helped make Power BI the “enterprise ready”, robust, and feature-rich platform it…
From left, Rangan Majumder, Yi-Min Wang and Jianfeng Gao on Microsoft’s Redmond, Washington, campus. Photo by Dan DeLong.
Microsoft researchers have already created technology that can do two difficult tasks about as well as a person: identify images and recognize words in a conversation.
Now, the company’s leading AI experts are working on systems that can do something even more complex: Read passages of text and answer questions about them.
“We’re trying to develop what we call a literate machine: A machine that can read text, understand text and then learn how to communicate, whether it’s written or orally,” said Kaheer Suleman, the co-founder of Maluuba, a Quebec-based deep learning startup that Microsoft acquired earlier this year.
The Maluuba team is one of several groups at Microsoft that are tackling the challenge of machine reading. Two other research teams, one at the company’s Redmond, Washington, headquarters and the…
Healthcare is one of the most important factors in how individuals perceive their quality of life.iBut quality health care comes at a price and precious healthcare funding is being lost to fraud, waste and abuse (FWA). In fact, an estimated $455 billion in global healthcare spending is lost every year – ultimately leading to lower quality care and higher premiums and taxes.ii
Everyone plays a role in combatting FWA, but healthcare payers are on the front lines. Recently, three major trends emerged that present an opportunity for healthcare payers to play a major role in combating FWA. Let’s take a look at the way these trends are changing the healthcare landscape.
1. Plenty of healthcare data, not enough insights
Healthcare executives would like to leverage big data, but only a few are able to gain the insights and visibility needed to garner the…
Microsoft announced on July 25 that BP, a leading global energy company, has selected Microsoft Azure as part of its global cloud computing strategy.
The agreement will see BP move advanced workloads to Azure out of existing corporate data centers as part of the company’s modernization and transformation agenda – an agenda which is designed to deliver a sustainable step change in the company’s long-term performance.
By moving its proprietary data lake to Microsoft’s cloud platform, and utilizing Azure services, with state-of-the-art visualization and predictive tools, BP will enable rapid data analysis, with faster insights and decision-making.
“We have been impressed with Microsoft Azure Platform-as-a-Service, and its building block approach, particularly for our advanced workload requirements,” says Steve Fortune, Group CIO of BP.
“The Microsoft cloud provides the hyper scale needed for global businesses like BP to innovate quickly”, says Cindy Rose, Chief Executive of Microsoft UK. “Microsoft Azure will help…