Infinite built a robust, efficient healthcare product that replaced a legacy system of 30 different applications that handled over 2 million Medicaid claims a month.

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The Customer

The client is a Fortune 500 Healthcare company with more than $21bn in annual revenue and more than 77,000 employees supporting client operations in 100 countries and 750 global locations. The customer supports US states and Healthcare providers with Medicaid Management Information Systems (MMIS). An MMIS is composed of many functional components like Provider and Member enrollment, claims processing and payment systems with high end reporting solutions working together to pay Medicaid claims to active providers. In addition it contains robust reporting capabilities and is required to interface with outside entities while also tracking correspondence and communications.

Challenge

The customer had an existing legacy system of 30 different applications with this product, some of which were COTS products like DocFinity and xPression. This disparate nature of the system posed significant challenges to efficiency and interoperability. The system needed to process around 4 million claims a month that would result in provider payments of $400mn. In addition, the system needed to maintain and enroll approximately 40000 providers and determine eligibility of 1 million recipients.

From an architectural standpoint the system needed to be designed to process up to 100,000 claims in 2 hours and determine eligibility of 5000 members in 30 minutes.

Solution

Infinite’s analysts studied the requirements of the system and recommended a product that was built on IBM WebSphere suite. With the margin for error being virtually zero, the product would need robust architecture to support the functional demand. Service Oriented Architecture (SOA) was used to build this product, keeping needs of the stakeholders of the system in mind. Blaze Advisor Rules Engine was chosen because it enabled changes in rules to be made directly in the database, rather than in program code. This would reduce the time taken to make the change in rules that determined the processing logic.

Outcome

Infinite’s robust solution had measurable business impact. Once the product was built, it reduced the cost of development and implementation. Similarly, time of development, customization and implementation for the client was brought down once the product was deployed. A key business advantage was the ability to quickly incorporate the change in Healthcare regulations.

The scalable application with high availability in a clustered environment with multiple node support could reduce the processing time of claims and payment for recipients or providers.

Technology Overview

  • IBM Rational suite that includes Application Developer 7.5, Software Architect 6.0, 7.0, Integration Developer 7.0, BPEL and Portal Server 5.1, 6.0
  • Java-J2EE, EJB, Web Services, Hibernate, JSF, Portlets, AJAX
  • FairIssac Blaze Rules Engine
  • Cognos for Reports
  • IBM Rational Test Manager
  • IBM DB2 and Oracle 10g Database for efficient storage.
  • IBM Rational Multisite Clear Case for Configuration Management
  • IBM Rational Multisite Clear Quest for Defect Management
  • Build Forge for automated Build, Packaging and Deployment
  • Integration with COTS products like DRG grouper, BloodHound and RugGrouper.
  • Electronic document management system using Docfinity & Filenet.
  • For letter generation, printing in PDF format using xPression,

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Challenge

  • Need to replace an ageing legacy system of 30 different applications.
  • Need to process 4 million claims a month resulting in provider payments of \mn.
  • Process up to 100,000 claims in 2 hours and determine eligibility of 5000 members in 30 minutes.

Solution

  • Service Oriented Architecture (SOA) based approach with Blaze Advisor Rules Engine enabling rapid changes to rules in the engine.
  • Automated process includes claim submission and payment generation processes, as well as recovery of the amount from third parties.
  • Online enrolment, provider claim submission capabilities and EDI interfaces built in to the system.

Outcome

  • Cost of development and implementation brought down by building the product.
  • Time of development, customization and implementation for the client was brought down once deployed.
  • Ability to quickly incorporate the change in Healthcare regulations.
  • Reduction in the processing time of claims and payment for recipients or providers

Customer Quote

“I write to express my great gratitude for a job well done. The dedication and effort which team has put into building this product has been above and beyond the call of duty” ¬– IT Manager, Fortune 500 US Healthcare Company

About Infinite

Infinite Computer Solutions is your partner in growth, providing flexible solutions that reduce costs, enable new business competences and drive continuous process improvements that contribute to increased revenues. With a global team of over 5000, Infinite partners with Fortune 500 companies from Telecom, Healthcare, Energy & Utilities, Media & Content and Banking & Finance industries to provide Application Management, IT Infrastructure Services and Product Engineering Services including Mobility & Messaging Products, Enterprise Mobility Management and Solutions.