Canada
Puerto Rico
USA
Belgium
France
UK
India
Client Background
The client is a diversified, multi-national FORTUNE® 50 major health insurance provider in US, providing various health insurance plans under Medicaid, Medicare and commercial line of business.
Client Need
As a corporation which has multiple payers in the same region, the customer wanted to integrate plans, members and health plans pricing arrangements of same region into a single system
To achieve this, there was a need to integrate entire region data from one payer to another payer. The customer wanted to integrate below modules such as enrollment, provider, authorization, lab claims
Client wanted to review the provider contract to identify the compensation terms based on the LOB like Medicare, Medicaid, Commercial etc. and assign the Pay class that needed to be configured in the Amisys /DST
Client needed an accurate reimbursement configuration to be done in pricing system which would pay accurately to providers
Solution
Reviewed provider contracts to identify the compensation schedule terms based on the LOB like Medicare, Medicaid, Commercial etc
Identified reimbursement terms Standard versus Custom and key terms on the provider specialty
Assigned the payclass guide based on the reimbursement methodology and provider specialty ( Physician, Ancillary, Hospice, Home Health, Ambulatory etc.)
Created Change Requests in service now to make sure the configurations are being done as per the contract
Realized Benefits
Pricing configurations are being done as per the provider contract reimbursement terms
Health plan would be able to accommodate/ pay accurately to their providers
Improved payment accuracy & relationship with providers
Helped them to ensure a healthy network of providers
Improved member satisfaction
Tools & Technologies
IBM Datastage
Sybase
Greenplum Database
Atomic
Emptories
Ambulatory
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