Rapid EDI 834 Integration with a Team of 2? No Problem!

Employers are hard-pressed to find new ways to manage rising healthcare costs and improve employee health. Handling and processing complex healthcare data is resource intensive – eligibility, medical claims, prescription claims, biometrics, plan data and expenses, wellness programs, etc. Many turn to third parties to zero in on how to best spend healthcare benefit dollars and realize both reduced costs as well as a healthier workforce. Strategic use of data and analytics by this leading third-party administrator (TPA) is critical to delivering value and innovation to its growing employer client base. See how PilotFish’s Healthcare Integration Solutions and its eiConsole for X12 EDI provide a competitive edge.

THE CLIENT

The client is a full-service TPA that develops sustainable employee benefits plans designed to decrease healthcare costs for its member organizations. They offer a full array of administrative services to members as well as predictive analytics. By leveraging emerging technology and forward-thinking partners, the client is transforming and disrupting an industry that has traditionally been dominated by monolithic companies. Success and rapid growth demanded that new EDI healthcare integration solutions were needed to automate processes, optimize financial resources and scarce technical talent to achieve greater operational efficiency.

THE CHALLENGE

Healthcare data exchange requires extensive use of HIPAA EDI transaction sets. Of challenging complexity were: EDI 834 Benefit Enrollment and Maintenance, EDI 837 Claims Transactions and NCPDP.  Each of this national TPA’s customers, new and existing, presented a pressing need for rapid integration while ensuring data quality. With a large and growing client base, volumes of EDI data of widely dissimilar quality and formats (EDI, CSV, PDFs, Excel, etc.) arrived daily – requiring efficient and accurate processing.  The current one-off interface building was untenable. In-house processes of custom coding and mapping for each client interface using the TPA’s scarce technical resources had become a limiting factor to growth. The imperative business need was to automate processes and ensure 100% quality checks to speed up implementations and deployments while increasing quality and reducing costs.

THE SOLUTION

PilotFish, Inc., a leader in healthcare integration, was selected for its EDI integration solution that successfully addresses the complexity and issues inherent at every stage of healthcare EDI data exchange. PilotFish’s eiConsole for X12 EDI incorporates over 22 years of deep expertise in EDI structures and data mapping to ensure data quality and reliability seamlessly. With PilotFish’s eiConsole for X12 EDI, EDI transactions are all parsed and mapped simply and quickly – regardless of format and source. The selection group was impressed by the PilotFish integration engine’s built-in capabilities for incoming data translation, outgoing transaction construction, acknowledgment generation, process orchestration and scheduling.

PilotFish’s eiConsole for X12 EDI delivered features and modules that stripped away the technical complexity of parsing, validating, mapping and producing all HIPAA EDI files. In this case, it streamlined and automated the handling and processing of member EDI 834 Enrollment and Maintenance data at scale. This was done while also meeting the company’s goals to inaugurate 100% consistency and error checking – all priorities set for the eiConsole. PilotFish’s graphical automated interface assembly line process and visual drag & drop Data Mapper quickly negated the company’s need for custom coding and scripting thus saving the client time and money. As every configuration followed the product’s intuitive user interface and consistent methodology, the clients’ business users could easily handle up to 90% of the work – freeing up their higher-level IT talent and further reducing their costs.

Preprocessing and validation are simple matters with the eiConsole’s built-in functions that are easily invoked and set for EDI or other data to be cleared to enter the processing stage and system. PilotFish was able to identify submission errors immediately and prevent processing delays. Automating error and consistency checking of incoming and outgoing data via PilotFish’s eiConsole met the client’s priority goal to move expeditiously to 100% checking and reporting incomplete data and incorrect data. Reporting data anomalies and inaccuracies to each one of the vendors that the TPA worked with immediately improved the data quality and accuracy of members and other information exchanged. This was both a cost-savings and a boost to customer satisfaction.

THE BENEFITS

Being on time and on budget achieved kudos for performance from the executive suite. Rapid EDI 834 integration proved to be “no problem” as predicted! In just a few weeks, by leveraging PilotFish’s ease-of-use, the team of 2 (one solution architect from PilotFish’s professional services team and one of the client’s business analysts) completed the initial 834 benefit enrollment project successfully. The speed and efficiency corroborated the selection team’s decision that PilotFish would optimize both financial and IT resources early in adoption.

As business users quickly proved to be self-sufficient and enabled to do up to 90% of the EDI configuration work, scarce resources and developers could be redeployed to strategic projects in the plan to move the business forward and achieve growth targets. Throughout each stage, PilotFish’s expertise, experience and an unparalleled track record of success in EDI healthcare integration allowed this large national TPA to avoid the common pitfalls in dealing with HIPAA EDI 834, and any other EDI transaction set and data exchange. Onboarding of new customers became seamless, fast and pain-free. More rapid EDI integration with the PilotFish Integration solution for EDI sped up customer implementations and deployments for measurably increased customer satisfaction as well as earlier revenue capture.

THE FUTURE STATE

Growth plans played a large part in the selection of PilotFish software. A priority factor is that PilotFish supports every major healthcare standard and source – X12 EDI, NCPDP, HL7, CDA, FHIR, XML and data sources outside of healthcare. That means there is only one software product to learn and employ for any information exchange. Across the company, interfaces will be consistent and easier to maintain with savings flowing to the bottom line.

The company confidently is forging ahead to improve and automate EDI 837 Claims Transactions to achieve greater speed and accuracy in pricing. The client also looks to launch work with NCPDP in the near future.

Demonstrated successes using PilotFish’s Healthcare EDI Integration Engine Solution confirm greater agility, faster project completion, speedier implementations and reduced costs overall. Going forward, this TPA disruptor plans to leverage its partnership with PilotFish as it aggressively introduces innovative new products and breakthrough services to its rapidly growing and expanding member base.

HL7 is the registered trademark of Health Level Seven International.
X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.