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Case Study – Pharmacy Claims Processing

Real-Time Pharmacy Claims Processing Time Slashed with PilotFish Solutions


Innovative technology, as well as extensive implementation and integration experience, delivered a winning solution to meet a client’s demanding pharmacy benefit delivery requirements. Learn how this organization, that offers claim processing services, was able to leverage these services and technology to reduce its implementation times by 75% – from 16 weeks to just 4 weeks.


THE CLIENT

MIP is a PilotFish Value-Added Reseller and authorized implementer of PilotFish’s integration engine solutions products. Their client, Medical Services Organisation (MSO), is a leading provider of integrated health care risk management and third-party administration (TPA) services and solutions, who serves over a million beneficiaries. MSO’s services include hospital benefit management, disease management, 24/7 medical assistance, cost containment, direct billing and provider network management solutions. With over 6,000 contracted providers, this MSO provides medical plans, medical administrators, GAP insurers and primary care providers with significant and unique advantages that improve their competitive position and deliver substantial savings.

THE CHALLENGE

MSO presented the MIP development team with a challenge. MIP was tasked with instituting a seamless solution for implementing real-time pharmacy claims processing between four disparate entities. This consisted of the originating pharmacy system and third parties that included Switch (an intermediary technology linking pharmacies and medical providers), Pharmacy Benefit Manager (PBM) and the Administrative System. The solution had to enable the Pharmacy, Switch, PBM and Administrative System (in real-time) to process a claim submitted at a pharmacy, while seamlessly handling both different data formats and connectivity protocols as well as delivering an accurate response to the pharmacy POS within seconds. On the management side, MSO also requested that the implemented solution offer real-time operational reporting and interface management capabilities.

As an experienced integrator and implementer, MIP follows a proven process. When it receives a request for a solution, the MIP development team first ensures that they have an understanding of the client’s business imperatives and rules. They then consider how this can best be achieved technically in terms of the provisioning or receiving and processing the data. The MIP development team then designs and configures the interfaces. In this case, MSO had already established and was maintaining the necessary relationships between the different entities they needed to interface with. MIP’s role was to provide the overall solution, including the technical expertise, the middleware software and the IT support. The software solution required to meet MSO’s technical requirements had to be able to adeptly handle the acquisition, validation, normalization, and analysis of administrative data from the 3rd party systems used in MSO’s pharmacy claims involving these various entities.

THE SOLUTION

MIP has the established reputation of providing the technical expertise and ongoing support needed to design and implement a solution that could meet the client’s requirements. The PilotFish suite of integration engine solutions, leveraged by MIP, offered all of the connectivity, data transformation, monitoring and management tools needed to meet the technical challenges. The implemented solution included the PilotFish eiPlatform Interface Engine (runtime JAVA server), the eiConsole Integrated Developer Environment (IDE) and the eiDashboard (PilotFish’s web-based application for interface monitoring and reporting).

One feature of the PilotFish software that had a huge impact on MIP’s productivity and the speed of the implementation was the eiConsole IDE. In the eiConsole, interfaces are configured via a graphical automated interface assembly line process. Each interface is constructed from a common set of stages without coding or scripting. Built-in adaptors – connectors, processors, transports and format readers – can be configured in seconds. PilotFish’s built-in lenient parser safeguarded against parsing problems during data exchange between the entities. The visual, point, click, drag & drop Data Mapper for mapping source and target data elements made building the interfaces by the team extremely easy. No custom coding was required, again saving valuable time and resources.  

“PilotFish was instrumental in achieving quick turnaround times once the participating parties technically understood what was required in order for data to be exchanged between them. It was then a very quick and painless process constructing the various routes.”

Robert Pooley, Executive Head, Development Support Services, MIP

The MIP PilotFish development team leveraged the PilotFish software’s flexibility and extensibility to accelerate building the claims processing interfaces and routes. The MSO’s implementation time was cut dramatically from 16 weeks down to 4 weeks. The real-time pharmacy claims processing system was in use at pharmacies in record time – delivering efficient, accurate, quality-checked electronic data interchange.

To meet MSO’s management requirements for real-time operational reporting and interface management, MIP leveraged PilotFish’s eiConsole for transaction monitoring. Utilizing the eiConsole, they could add acknowledgments or use email alerts. In addition, the eiDashboard offered more detailed recording and reporting. For every claim request, MIP ensured that a response was provided – whether in the form of an error or as a valid response.  MIP also recorded and reported on the transaction volumes and response times for added insight. End-to-end message processing was accomplished in 1 – 4 seconds. Interface activity was also monitored with the eiDashboard, ranging from high-level message orchestrations down to discrete operations. Issues that arose could be disposed of with alacrity while MSO management gained advanced reporting and analysis capabilities.

THE BENEFITS

MSO underscored the benefits to MIP that accrued from the successful accelerated implementation of new real-time pharmacy claims processing that required minimal coding from any of the 3rd party entities. From the start, the no-pain, all-gain solution electronically processed claims in real-time against complex financial and pharmaceutical utilization rules.  Responsiveness to member pharmacies secured higher POS satisfaction as well as clarity on claims payment information and timeliness.

This architected solution was an enterprise level, high performance, and scalable data acquisition framework. PilotFish’s software provides the means for configuring an interface by the same assembly line process every time, no matter how complex or simple or what data format is encountered. The MIP team can connect to any Source system or service regardless of the communication protocol, as well. The PilotFish solution MIP implemented for MSO proved to be very robust, too, with zero PilotFish errors. Going forward, the MIP team is confident that interfaces will be easier and less costly to maintain. Together, these benefits deliver overall cost efficiencies with immediate and longer-term benefits.

Another advantage of working with PilotFish is the expertise and experience that PilotFish offers. This advantage was seen, for example, when the connectivity between PilotFish and the PBM required some changes to the Web Services Security (WS-Security) layer. A short consultation with PilotFish engineers quickly deposed of the issue, so that deployment sped along without delay. With more than 17 years of experience in integration and a suite of integration products, PilotFish can be counted on to help avoid all of the common pitfalls of similar projects and deliver the best solution on time and within budget.

THE FUTURE

PilotFish delivers the tools and accelerated integration capabilities that MIP successfully leverages being a Value-Added Reseller and implementer of PilotFish solutions. The partnering of these two innovators provides MIP’s customers with a win-win outsourcing collaboration solution.

Longtime leaders in South Africa’s economy, MIP and their client MSO are well positioned to meet pharmacy claims processing, pharmacy benefit management challenges and adapt with alacrity to new technologies and industry changes that evolve or emerge. Pilotfish’s highly adaptable and extensible integration engine solutions approach serves clients well in responding to opportunities. Adding support for a new system, technology or standard typically takes a just few weeks, which is highly advantageous in South Africa’s changing digital healthcare environment.

ABOUT MIP

MIP is a leading software development company in South Africa that provides diversified systems to accommodate the specialized administration needs of medical aids, employee benefits, life insurance, treasury, lending, collective investments, wealth management, and short-term maintenance and warranty. MIP’s services include over two decades of experience, ingenuity, perception and a distinctive way of dealing with individual needs. As a Value-Added Reseller (VAR) and implementer of PilotFish products, MIP offers Software-as-a-Service (SAS) model that is designed to provide its customers with a win-win outsourcing collaboration solution.

Throughout 17 years and hundreds of implementations, PilotFish has developed and refined a methodology for the configuration, testing, and deployment of interfaces and process orchestrations. We have an unblemished track record of success.

Through years of Bake-Offs and Proof of Concepts (POCs), we have demonstrated the value of our integration engine solutions to future customers. Let us conduct a Free Use Case Evaluation for you to determine where PilotFish can provide the most value to your organization and solve your most complex integration challenges.

To schedule a Free Use Case Evaluation and to learn about what PilotFish Solutions can do for your organization please click the link below, Contact Us or call 813 864 8662.

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