Eligibility Interoperability Challenges

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Eligibility Interoperability Challenges
Presented March 22, 2000 at the WEDI National
Conference
Presented by - Jeff Kessler, VP Business
Development MedServe Link, Incorporated - Greg
Koller, Manager of New Development United
Wisconsin ProServices, Inc.
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Session Objectives

• Explore the challenges healthcare organizations
  face in developing secure, reliable access to
  payer eligibility sources and delivering
  protected information dependably to providers.
• Review approaches using Internet technologies
  including application integration, based on
  eXtensible Mark-up Language (XML) for ANSI X12
  compliance, and digital certificates for securing
  trust relationships between constituents,
  providing a framework for other HIPAA
  transaction/requirements support.

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Profile ProServices

• a Health Information Services company
  specializing in developing office management
  solutions by electronically connecting payers and
  providers. ProServices has used client-side
  software applications and Web technologies to
  build an extensive health information network in
  Wisconsin and a national presence in Home Health
  Care.

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Profile ProServices

• ProServices Health Information Network Includes
• Over 800 payers
• 140 hospitals
• 3000 Physicians
• 300 Home Care Agencies
• 8 Million transactions (500,000 interactive)

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Profile MedServe Link

• a regionally focused, leading E-Health company,
  providing a Business-to-Business electronic
  gateway for payers and providers of e-commerce
  and ASP services.

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Profile MedServe Link

• Current Customers
• Provider Aggregators, Payers
• 500K/Mo interactive transactions
• Strategic Partners
• Content, Regional Networks
• IHSD, MedNet/CQS
• Product Offering
• Electronic Gateway Services
• ASP Services
• Intranet (outsourced)

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Why we teamed up?

• Met at WEDI/AFEHCT security pilot
• Share complementary business models
• Regional presence
• Challenges to expand Internet operations
• Business relationship/issues key
• Technology surmountable
• Unique timing/market conditions

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Electronic Gateway
Security
MedServe Electronic Gateway
Payers
Providers
Hosting
HIPAA
Admin. Billing
E-Commerce/Partners
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Gateway Applications
Initial Future ASP Eligibility
Financials Referral
Purchasing Claims HIS Remit
Advice PMSS Claims Status Outcomes Patient
Search Clinical Apps
Providers
Payers
E-Commerce/Partners
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Challenges

• ADOPTION
• Providers
• 1 connection with 1 process, instead of 50
  connections to 50 partners
• Ease of use, integrate into workflow
• Payers
• Resources expertise infrastructure
• Compete on administrative capabilities/service
• Aggregators role
• MSO, IPA, IDNThird party also gains from single
  integration
• Future Users

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Meet Key Payer Concerns

• Lower Costs
• Med/Loss Ratio
• Administrative Costs and Errors
• Increase Service Levels
• Patient/Member/Employer
• Provider Network

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Meet Key Payer Concerns

• Meet Regulatory Compliance
• HIPAA, States
• Optimize IT Investment
• Technical/Personnel Infrastructure
• New Technology overlay w/Legacy
• Support unique business needs and still be
  integrated

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Global Concerns

• Privacy/Security
• Risk
• Mission Criticality
• Costs
• Opportunity
• all drives adoption

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Creating a shared network

• WHY?
• Connecting data centers
• Eliminate need for redundant data sources
• Maximize usage of development
• Transaction definition
• Aligning business practices
• Business processes, contracting, enrollment are
  standardized for end-user

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Integration Diagram
Providers
Payers Systems/ Databases
MedServe Data Center
Proservices Servers
Providers
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Creating a shared network

• HOW?
• Connecting data centers
• Utilize current data source and application built
  around it
• Utilize XML to reformat partners application to
  resemble your own
• Agree upon standard for conversion, make dynamic
• Standard should have regulatory compliance - HIPAA

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Creating a shared network

• Aligning business practices
• Business processes, contracting, enrollment are
  standardized for end-user
• Trusted relationship begins with agreement on
  these Processes
• Consensus must be reached to avoid dramatic
  changes to each parties processes.

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Security

• Security Chain of Trust essential Key
  element to HCFA Interoperability.
• Security must be HCFA/HIPAA compliant on all
  sides.
• Must be Cutting Edge, or it is useless
• Costs of staying on top are prohibitive
• Shared/Trusted Security is imperative
• Provider/User
• MedServe
• Certificate Authority
• Payer/Data Source

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Digital Certification Diagram
CyberTrust
MedServe
Certificate Data
Application Software
Registration Authority
Shared Secret\ Data
CyberTrust Front End
Internet
MedServe Web Server
Subscriber Data
Shared Data
Subscriber
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What are the Advantages?

• Payers
• Providers
• Our Companies

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Advantages Payers

• Alternate Distribution
• Raise provider penetration, out-state
• Opens path for future interactions
• Reduce costs
• Every 3-5000 (_at_15 min/ea) electronic trx reduces
  monthly FTE
• Improved provider relations
• Common Eligibility (Transaction) front-end
• HIPAA Compliance - reduces risk
• Technical Infrastructure Redundant Data
  Centers
• Defined Cost of Ownership

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Advantages Providers

• Simple user interface and access
• Training, adoption, usage improvements
• Security (preparation for HIPAA)
• Sound business policy
• Cost efficiencies realized
• Time and FTEs
• Standards compliance (preparation for HIPAA)

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Advantages Our Companies

• Leverage existing
• Infrastructures
• Investment/resources
• Capabilities/talent
• Relationships
• Build critical mass
• Demonstrate open approach
• Neutrality for payers/providers
• Increase client satisfaction

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Closing Thoughts

• Unique time/opportunity
• Be Patient/Be Aggressive
• ROI models will emerge
• Awareness will rise
• Security increase control, reduce risk
• Proven/trusted partners
• Good business sense drivenQATHANK YOU!