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…
Setting Verbose mode for a Boomi Process using a Dynamic Process Property
In most instances developers will have to accommodate certain reporting, notification and logging requirements of a given interface within the Dell Boomi AtomSphere platform.
Often times, the logging or emailing may need to be disabled for testing and/or faster iterative cycling through test cases and, of course, to not annoy the user community with email test messages.
The most straightforward way to accomplish or implement a verbose or Test Mode Boolean flag (as is very common in other platforms) is to create and enable a Dynamic Process Property and then assign its default value while allowing to reassign the same with extensions directly after deployment.
It’s no secret that paying for healthcare in the United States is extremely difficult to do. Payment systems for healthcare across the country are highly fragmented; many payers and providers use multiple formats for remittance. This creates challenges and frustration for patients, providers, and insurance companies, particularly at a time when there is increased pressure to reduce costs. Other industries use B2B automation processes in standard languages like EDI to standardize and automate payment systems; B2B challenges abound for the healthcare industry.
The B2B challenge in healthcare remittances
Thanks to the Affordable Care Act, there are now in motion some new initiatives related to healthcare payment reform – chief among them, the transition from fee-for-service to value-based care. “The ramifications of this transition for payers are significant,” says John Tyler, Data Science Platform Manager at Premera Blue Cross. “Payers are going to…
TriZetto’s QNXT is a widely adopted platform for claim processing and membership administration. QNXT relies on the Microsoft stack, particularly BizTalk, .Net and SQL Server, to process and store EDI messages.
These technologies give developers many tools for customizing and tracking HIPAA transactions, but the complexity of implementing business rules and lifecycle reporting on EDI data are constant concerns for health plan payers.
Tallan’s T-Connect EDI Management Platform is an optimized integration solution founded on three core design principles:
An accessible API. One of the most common challenges our partners face is implementing business logic on EDI. T-Connect loads all HIPAA transactions into a fully compliant hierarchical data structure that can be manipulated with familiar tools such as Visual Studio and .Net.
Full database persistence. Going from EDI to a relational database is a frequent business need, but capturing the full set of fields present in an 837 alone represents…
On the provider side of healthcare integration, HL7 (particularly v2) is a critical message type to understand. While it is standardized and heavily used by various EHRs/EMRs, it’s used in slightly different ways. There are efforts to further standardize and normalize its use across the board (such as with v3/FHIR), many EHRs and EMRs continue to use 2.x messages. Common HL7 messages include admissions/transfer/discharge (ADT), scheduling (SIU), lab orders and results (ORU, ORM), and medical reports (MDM). Choosing the right platform can be challenging.
Some of the challenges of HL7 2.x messages include:
The ability to add non-standard custom segments or additional data anywhere in the message (whether they are completely custom “Z Segments” or other segments that aren’t typically part of the message, such as IN1 segments in an ADT message to include additional insurance information).
A myriad of parsing and manipulation libraries…
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…
From my limited experience working for a client in the Health Care business I saw the magnitude of positive change the right solution can have on a problem. In the health care business it is often the case that patient information needs to be managed in such a way that it is easy to organize and manipulate patient data, by many different people. In a lot of cases a lot of this work and organization is done manually, whether it is a manual process on a computer or whether it is still done on physical paper. These manual solutions obviously slow down the workflow and add a level of complexity to organization that can be greatly simplified with a conceptually simple solution, The Queue Manager.
The Queue Manager, as you may have assessed from its name is comprised of a simple…
In the healthcare business today, a problem exists in integrating various information systems. The issue can be partially attributed to the fact that these systems only serve one specific department within a healthcare business. Having such an issue can lead to inefficient patient care. For example, if patient’s health information is spread out over a number of different departments that do not collaborate, this could lead to negative implications on their overall care.
To address the aforementioned issue and in an attempt to resolve challenges faced during system integration of healthcare applications, queue manger technology is being integrated in the healthcare industry. Specifics on queue management can be found here, but in short, a queue management application is an interface that sends and receives messages to/from other queue managers, allowing programs to run independently of each other, at different speeds…