The Client:
When companies don’t want to have to buy, negotiate, and maintain relationships with an insurance vendor, they hire an insurance broker—that’s where our client comes in. They act as the middleman between businesses and insurance companies, selling and soliciting insurance on behalf of their own clients for compensation.
Our client designs, implements, and manages employee benefits programs on behalf of companies. They process claims, publish plan documents, handle customer service for members, and more. In short, they take away the headache of business insurance plans for companies while expanding the reach of the insurance vendors they work with.
The Business Need:
When a patient needs a medical treatment or medication, a pre-certification process is completed to ensure the patient’s insurance vendor will cover the cost of the health services they’ll receive. Our client works as the bridge between the insurance vendor and the requestor to verify the patient is eligible and their services are covered.
The ideal pre-certification process can be broken down into four steps:
Currently, our client has no way of creating the necessary XML file, and their employees are forced to input the data and validate the information manually. The goal for this project was to develop a way to automate the process, so data could be validated and transformed without the need for manual user input.
What Geneca Did:
Basing our project goals on our client’s needs, our team set out to complete the following objectives:
- Automatically run eligibility testing on and translate any information from the insurance vendor
- Save information in database under correct columns as a result of accurate translation and mapping
- Create file output based on information from insurance vendor and any additional data our client wants to add
To begin, our team mapped the fields from insurance vendors’ files to our client’s database. Once that was complete, we were able to run eligibility testing on patient information automatically.
Once a patient passed eligibility testing, we then used the information stored in the database to successfully create an XML file that can be uploaded to our client’s third-party claims system and ultimately returned to the proper insurance vendor. This automatic process replaced the manual entry of data into the claims system fields, saving our clients’ employees time and effort.
The Results:
The project was completed on time, and all our project objectives were met. Rather than manually entering information for all four of their vendors, our client can now automatically transform vendor information into XML files. From there, they can upload the XML files into their third-party claims system and return them to insurance vendors.
We effectively removed multiple steps in a previously complex process, saving time for employees and cutting out manual entry errors, creating a more efficient business overall. Our client is left with a software solution that makes their pre-certification process faster and more reliable.