Transaction Lifecycle Management For
Healthcare Payers
END-TO-END VISIBILITY IN REAL TIME MEANS GREATER EFFICIENCY,
BETTER SERVICE, AND LOWER COSTS
As a healthcare payer, the inability to quickly view and tie together all the points
in the transaction lifecycle doesn’t merely slow you down, it costs you money.
The root of the problem is that, over time, most healthcare payer organizations
have evolved numerous incompatible point solutions to handle various aspects
of member/provider relations and claims resolution. This complexity and lack of
integration creates multiple challenges:
CLAIM RESOLUTION. Manually tracking wayward claims throughout
their full transaction lifecycle in multiple disparate systems is
time-consuming, and therefore costly. Even answering a simple
question like, “Did we pay this claim?” can require an hour or more
of manual research.
AUDITS. Audit costs are also increased by the need for cumbersome
manual research to match up eligibility inquiries and responses,
status requests and responses, claims submissions, remittance advice,
and EFTs.
QUERY HANDLING. Slow claims resolution results in queries from
providers and payers that must be dealt with by extra personnel.
IT INVOLVEMENT. The need for constant back-and-forth interaction
with the IT organization engages two individuals when only one could
do the job if there were better visibility into the transaction lifecycle.
SOLUTION BRIEF | 2
In addition to being costly, the inability to efficiently manage the transaction
lifecycle can result in poor customer service, with multiple call-backs required to
resolve a problem. As the healthcare market evolves from a business-to-business
to a business-to-consumer model, poor transaction lifecycle management will
become a competitive disadvantage, and ultimately affect the top line.
TOTAL VISIBILITY, FASTER PROCESSING
TIBCO transaction lifecycle management solutions can solve all these problems
and provide a rapid ROI. They do so by tying related transactions from disparate
systems together in real time, so claims personnel can easily and quickly track
transactions from start to finish—including EFTs. The result is faster processing,
better service, and lower costs.
With TIBCO payer healthcare solutions, researchers can find all the transactions
associated with a particular claim in a few seconds—without help from IT, and
without being a technical expert in EDI. Specifically, they can:
• Trace documents through all the major application steps from beginning to end.
• Figure out where or why a claim is stuck in the process between submission
and payment.
• Locate the relevant transactions associated with any given claim.
• Determine what the actual problem is, for example, a syntax error, missing data,
and so on.
This means, for example, that a researcher investigating an eligibility request can
find the related eligibility response, claims, claim attachment requests, claim
attachments, status requests, status response, provider relations activity (from
CRM systems), business process management actions, remittance advice, and
EFT. Researchers can click on any transaction in the lifecycle and analyze a log
of involved application activity. Errors are highlighted, with direct links to the
companion guide for a detailed description of the problem.
STATISTICAL ANALYSIS FOR CONTINUOUS IMPROVEMENT
TIBCO solutions collect data in real time to enable managers to identify problem
touch points in the transaction lifecycle where process improvement can reduce
the need for rework. Less rework, plus the ability to consistently meet SLAs,
translates into ROI.
TIBCO TRANSACTION LIFECYCLE MANAGEMENT AT-A-GLANCE
SUMMARY
By enabling healthcare payers to tie together disparate systems and the
transactions they process, TIBCO transaction lifecycle management increases
efficiency and transparency, improves service, and cuts costs.
BUSINESS CHALLENGES
• Manual tracking of transactions drives up the cost of transaction processing.
• Difficulty in identifying and tying together related transactions hinders
individual claims resolution and creates audit problems.
• There is no way to proactively spot potential errors or omissions before they
cause problems with members or providers.
SOLUTION BRIEF | 3
KEY FEATURES
• Tracks the full transaction lifecycle from beginning to end, including EFTs.
• Captures the real-time status of transactions within their routing path and
processing systems.
• Provides automated notifications based on user-defined criteria to identify
problem transactions that are stuck in the system.
• Highlights specific problems within forms (syntax errors, incorrect codes, etc.)
for correction.
• Derives relational information from documents, grouping relevant details for
statistical research and underwriting purposes.
BUSINESS BENEFITS
• Reduces FTE requirements and cuts operational expenses through increased
throughput and elimination of manual research.
• Reduces the number of provider and member telephone queries that must
be handled.
• Increases audit transparency so auditors can quickly and easily track related
transactions with no need for support from the IT organization.
• Reduces IT expenses for report generation.
• Ensures that provider SLAs are met.
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05/29/2014