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Exchanging Healthcare Claims Digitally with Data Integration Tools

Aug 28, 2015 BizTalk Dennis Junk

Healthcare Claims DigitalThe documents explaining all the requirements for healthcare insurance claims run to over 600 pages. Not only have the transfers of information between businesses in the healthcare industry, along with the regulations governing them, become vastly more complicated over recent years, but they’ve also been undergoing more frequent changes. It’s seldom the case anymore that patient details are uploaded and shared in any way other than digitally, and so having good procedures and good technology for recording, storing, and transferring data is critical for healthcare providers and insurers alike.

Until the past few years, the most common way for a business to handle claims exchanges with a partner, or among the several partners making up a network, was to treat each pipeline individually. An insurance company, for instance, would have developers custom-code a solution so it could receive claims from a specific doctor’s office. The custom solution would increase efficiency, as the claims would automatically be taken through the appropriate channels. But the continuing effectiveness of each solution depended on the system as a whole remaining stable.

Of course, nothing in the healthcare industry—or almost any other industry for that matter—stays stable for long anymore. Richard Spice, Aptera’s Senior Integration Engineer, explains that “The big shift going on right now is from thinking of each pipeline as its own project to having an overall plan and an overall system for handling integrations in general. And the technology supporting these systems—tools like Cloverleaf or BizTalk—are just so much easier to use than those mashups of a bunch of other solutions.”

An Integration System

Instead of treating connections and information pipelines as an afterthought, as tasks to be tacked on to the end of projects to incorporate new applications or bring on new partners, many businesses are now handling integration as a continuous project in its own right. They hire dedicated staff and appoint a chief integration steward to make decisions for the long-term success of the system as a whole.

“In the healthcare industry,” Spice says, “you pretty much have to work with other offices, but not all of those offices are going to be running on the same software. You can hand-code all the connections you need, but you’re going to have redo everything if there’s an update or a change in the regulatory requirements. What technologies like Cloverleaf and BizTalk let you do is take forms or different types of data from any other business and make it work with your own software and your own processes.”

The basic idea is that something like an insurance claim has countless fields for the various types of information. By tagging what kind of information each field contains, you can map each item onto another format—or several other formats. You can also record and store that information securely for other uses. The technology works in a similar way when it’s used to translate data from one application so that it can be used by another application.

Custom-coded connectors do much the same things, of course, but with a tool like BizTalk you can create new connections, or make adjustments to existing ones, in a fraction of the time. You can also configure multiple systems to subscribe to a message processing through one of the data integration tools so that every system that relies on a particular piece of data can receive updates at the same time. This guarantees they use the same source of information, and reduces the risk of having inconsistent data.

Why Use Integration Technology?

Spice explains how easy it is to use a BizTalk solution he built for a company that provides support and administrative services to healthcare organizations: “If the claim or the form is the same and all you’re doing is bringing on another partner company, you just need to configure a new endpoint. You type in a name and an ID number, and all the other processing just works. It only takes a few minutes.”

If you need to add more information or more sections to a form, you’ll have to modify the underlying schema. That can take more time, but it still won’t be anywhere near the amount of time or resources you’d have to devote to custom-coding a new connection. And, as Spice points out, “That 600-page pdf that describes all the rules and requirements for healthcare claims—you get a schema for that with BizTalk.” Out of the box, BizTalk comes with schemas for over 10,000 industry-standard forms.

By integrating data from multiple sources and across multiple applications, you’re also making it possible to identify patterns that may suggest avenues to still other gains in efficiency. BizTalk’s Activity Monitoring allows you to put hooks into certain items that are being channeled through your system. For instance, an insurance company could monitor items like diagnoses and the price of the various treatments to find out which ones are the most cost-effective. These details could inform decisions about policy that lead to greater profitability. 

The bottom line is that the healthcare industry is only going to get more complicated. Hand-coding connectors and pipelines for claims is already prohibitively time- and resource-intensive, and it’s only going to worse. By making it easier for businesses in increasingly large and complex networks to communicate and exchange information with each other, and by making it easier for systems within organizations to share the same data, integration technology is advancing to fulfill a demand that’s probably going to become ever more pressing in the future.

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Topics: BizTalk Data Integration