Building an integrated EDI solution for faster healthcare claims processing.

Healthcare providers rely on efficient and effective claims processing to ensure that they receive reimbursement for services provided. Historically, claims processing in healthcare was a manual and time-consuming process, but the implementation of Electronic Data Interchange (EDI) has revolutionized the industry.

While EDI offers a faster, more reliable, and more efficient way to process claims, it comes with a new set of challenges that require deep data and digital expertise. To ensure that this technology works for you and your organization, it is necessary to design and configure an EDI solution that meets your specific requirements.

With the expertise of our Digital Transformation team, we have been working on building such solutions for our clients. Here is a deep dive into an integrated EDI framework that we created for a healthcare provider to improve their claims management and processing.

The Challenges:

• Complexity: Simplifying the reading and interpretation of EDI claims which contain large amounts of information input through codes and specialized language, especially as inaccurate or incomplete data can lead to costly delays or denials.
• Lack of standardization: Creating standardized formats and data structures for EDI files that can be shared and understood across stakeholders on various systems, encompassing all three types of healthcare claims i.e., professionals (like doctors), institutional (like hospitals), and dental claims.
• Repricing & Auditing: Incorporate Reference-Based Pricing (RBP) for repricing of claims, and ensuring the seamless bundling and unbundling of HCPCS codes for auditing, adhering to guidelines set out by Centers for Medicare & Medicaid Services (CMS).

The Solution:

Our business analysts began the process by understanding the depth and coverage of EDI files in healthcare. This specifically covered the various formats, structures, and syntax for the 837 EDI file used most commonly in healthcare. They mapped each field of both HCFA (used by healthcare providers) and UB-04 (used for institutional claims) forms and shared the data with our Digital Transformation (DT) team.

Based on their assessment, our DT team began working on building the solution using EDI Fabric, which provides a set of tools and resources to develop the software. The scrambled data was first converted into JSON format to make it easier to understand and use. This helped us further map the data fields and values, saving time as we built the application.

Next, we clubbed the different classes of 837 EDI files into one master database. The team implemented Object Relations Mapping (ORM) and changed the structure of the EDI in order to club all three types of claims (Professional/ Institutional/ Dental).

Furthermore, it was necessary to integrate the solution with different data-interchange formats to ease the readability and processing of data across various systems. The application was built to generate output files in formats such as UTF8, .x12, and JSON to meet the different client requirements.

The Outcome:

• An application that can both read and edit EDI file formats, including tasks such as adding price amounts, and adjustment codes for bundling or unbundling claims information.
• Integration of auditing and repricing on one application, creating more flexibility, ease of use, and agility, and hence providing higher ROI.

From claims submission to auditing, our deep digital and domain expertise can help you streamline operations with solutions customized to your organizational needs. To learn more about our healthcare services and talk to one of our healthcare experts, click on the button below and fill the form.