Case Studies

This organization markets on cost containment services to healthcare payers and sponsors, including co-ordination of benefits services and program integrity services. Both services aim at making the healthcare claims paid correctly. Customers of the company involve both government and individuals, like state Medicaid agencies, the Centers for Medicare & Medicaid Services (CMS), Pharmacy Benefit Managers (PBMs) and the Veterans Health Administration (VHA). The company’s co-ordination of benefits services provide validated insurance, finding liable third parties, and program integrity services identify improper payments and overpayments (also could recover it), and reduce fraud and waste. In addition, the company also support Medicaid managed care and Medicare Advantage.

The organization relies on data as an asset to power analytics and intelligence that ensure healthcare claims are paid correctly and by the responsible party, and that those enrolled to receive benefits qualify.  

The processing of claim files requires a lot of manual intervention and some of the data is infested with quality problems. Therefore, the organization’s onboarding time, as well as any subsequent claim processing is typically measured in about 7 days. This has significantly impacted the organization’s ability to provide quick resolution turnaround to its customer as well as resulted in revenue recognition delays. A major contributor to the delays in processing is the fact that upon error, the organization does not have an effective way to explore the data and possible reasons for the problem.

With Eccella’s help, the organization automates the exchange of HIPAA medical and pharmaceutical eligibility information, claims and payments, reconcile information, and gain visibility into its data at all times.

The organization and Eccella are working together to automate the exchange of HIPAA medical and pharmaceutical eligibility information, claims and payments.  Reconciliation has been implemented at the claim level which reduces the back and forth between the organization and the payers during claim processing.  While previously rejected claims were sometimes lost, there is now a centralized measurable backlog of rejected claims which leaves no rejected claim behind.  The organization now has visibility into their data at all times via a data lake in Hadoop, enabling them to make smarter, data driven decisions that save their clients money.