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Why the Healthcare Industry is Utilizing EDI as the Standard in Managing Increased Enrollment and Regulation

Gabriel Gomez

Over the past few years, the healthcare industry has undergone a complete overhaul of how it processes information. This was brought about by a growing list of new and complicated regulations handed down by federal and state governments that stem from the Healthcare Insurance Portability and Accountability Act (HIPAA) and the Patient Protection and Affordable Care Act (ACA), designed to improve the efficiency and effectiveness of the industry. These regulations include standardization of the electronic transmission of Electronic Data Interchange (EDI), which also protect the security and privacy of electronically transmitted information provided by their patients.

These mandates created an immediate challenge to healthcare organizations, because it required the industry to take increased ownership and control of Electronic Health Records (EHR). In order to meet this demand quickly, healthcare providers scramble to leverage a variety of methods to manage their EDI enrollment and claims processing. Options to achieve this includes the use of expensive 3rd party solutions, or custom developed in house solutions, which are often unproven and unable to scale.

For example, Healthcare organizations are often required to adhere to government regulations which dictate the scope of EHR storage. If these providers are unable to process that information at a given moment, they miss out on reimbursements, funding and revenue. Additionally, the transfer of the EDI files between parties such as payers and providers are required to adhere to strict data quality rules in order to gain these benefits. Validation Standards such as WEDI SNIP levels and CAQH CORE Compliance are two examples of rules providers are to abide by. For example, if a provider does not meet requirements laid out in a given SNIP level, they may be subject to a lower rate of reimbursement for Medicare and Medicaid claims.

 

A Better Data Solution

It’s clear a better solution is in order, and many managed healthcare organizations have found relief for these mounting data woes with the use of EDI.

So what does an EDI Management System actually do?

An EDI Management System automates the process of transferring EDI messaging between payers, providers, and managed healthcare organizations. This allows healthcare providers the ability to process patient transactions FASTER and at a LOWER COST. It’s no surprise that many managed healthcare organizations consider EDI processing the key part of their day-to-day operations.

Technologists at Tallan recognized this need early on and worked with our many healthcare clients to bring a unique and reliable EDI solution to market. That solution is Tallan’s T-Connect Suite, a software set that utilizes reusable frameworks and tools to automate the process of submissions, reconciliations, and reporting, helping the healthcare organizations save both time and money in the process. In fact, T-Connect can be up in running in as little as an hour!

T-Connect’s flexibility and ability to scale to changing business requirements allows healthcare organizations to utilize the product in conjunction with an integration platform such as Microsoft BizTalk, Dell Boomi, or Mulesoft. The product offers enterprise level capabilities by providing knowledgeable insight into daily processing, monitoring, and platform scalability through EDI solutions. The T-Connect Suite consists of the following accelerators and components: Core Services, HIPAA Accelerator, EDI Trading Partner Automaton Tool, Database Toolkit, HIPAA EDI Viewer, Data Enrichment Accelerator, EDI File Splitter, EDI Validator, Operations Portal, Data Analytics Dashboard, and Foundation Utility Pack.  
Tallan T-connect Features

The combination of these accelerators and tools give organizations in the healthcare industry a product that can intake, validate, enrich and persist EDI files that come down the pipeline. The inclusion of our Tallan Support Services ensures that a client’ solution is always up and running, whether a custom developed solution, or the T-Connect Suite.

Unlike 3rd party options, T-Connect’s reusable blue print solutions, can intake, validate, store, and report on all HIPAA EDI X12 transaction types. Additionally, data remains under the control of the organization – not the 3rd party provider – enabling ongoing flexibility based on changing needs and built-in reporting dashboards that can help teams more visually interpret the data being filtered and analyzed by the system.

 

Below the T-Connect Analytics Dashboard showing the Claim view. This rich and highly visual data dashboard can help clients better visualize and analyze their claim data.

 T-Connect Analytics Dashboard

 

The T-Connect Operations Portal serves to show the up-to-the-minute status of every EDI file processed within the T-Connect HIPAA EDI Accelerator. It shows every file, transaction, and record, along with its status and file contents.

 T-Connect Operations Portal

 

 

Healthcare EDI Technology at Work

APWU, or the American Postal Workers Union Health Plan is a nationally recognized healthcare provider that offers fee-for-service High Option Plans and a Consumer Driven Option Health Plan. Their services are offered to all employees or retirees covered under the Federal Employees Health Benefits (FEHB) Program. Based out of Glen Burnie, Maryland, the organization is made up of 200 employers that provide health plans to over 205,000 individuals around the country.

In order to continue meeting government regulations and providing satisfactory service to their patients, APWU needed to address challenges adhering to regulatory requirements, ensuring enterprise level dependability, and reducing speed to market among others.

Specific challenges APWU faced included finding a way of implementing a new 3rd party claim system. With no integration experience in-house, APWU turned to a 3rd party capable of providing a system that adheres to their business processes. But in order to continue to comply with government regulations and standards, APWU needed a product to specifically address 837D or dental claim capabilities. Due to custom business rules and validations that were too complex and complicated, the organization needed a system that was readily available with minimal downtime.

With the seamless installation of Tallan’s T-Connect Solution Accelerator, APWU was able to pre-process solutions to route claims based on the organization’s new claim system member enrollment against their existing legacy system to provide real-time solutions. Now with their EDI processing stored in their relational database, APWU was able to use the system for outbound claims, repricing rules, data enrichment, and validation procedures right away. And most importantly, the system was highly available, scalable, and supported massive amounts of transactions in the process. With the addition of mentoring and training provided by Tallan, APWU staff members were ready to manage and support their new EDI system moving forward.

 

 

With the Tallan T-Connect Suite, healthcare providers now have the ability to ease their claim submission and rejection process – saving time and money, and giving them the tools they need to grow with these regulations and their patients.

Click here to learn how T-Connect is powering healthcare data processing.

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