Axis provides consulting and development services to one of the country’s leading dental services organizations which provides business services to hundreds of dental offices nationwide, allowing dentists to concentrate on clinical excellence and the highest levels of cost-effective, comprehensive patient care. One of the many services offered by the company to it’s partner offices is insurance verification and coverage analysis. Prior to Axis’ involvement, partner dentist offices took on significant financial risk if they provided services not covered by a patient’s policy. Before a patient’s visit to the dentist, the regional office manually qualified and recognized which procedures were covered by a patient’s insurance policy. In addition to increased financial risk, this manual process was not able to support the company’s planned growth.
Axis has a long-standing relationship with this client, working on other projects including infrastructure and portal design for their data entry facilities. Senior leadership and operations staff have been very pleased with the dedication and quality of work of the Axis team and a number of recommendations have come from both staff and the executive board.
THE BUSINESS PROBLEM
Prior to the Axis implementation, policy coverage was either handled by calling the insurance carrier (a time consuming and tedious task of navigating phone systems and queues) or logging into the carrier’s web portal and navigating countless levels of complexity, extracting and validating insurance coverage data. This situation presented numerous business challenges:
Each insurance carrier maintains their own unique portal structure to publish coverage information. Overall coverage specifics sometimes change between the time an assessment is processed and an actual patient visit; dental offices take on significant financial risk if a patient’s specific coverage changes between the assessment and the time of their appointment.
While taking on the financial risk of unplanned changes, the client has also been growing with great success. As a result, the volume of inquiries have been increasing faster than manual processing can support.
Some insurance carriers offer EDI (Electronic Data Interchange) interfaces to their systems, so a portion of the data exchange could be readily automated, but many insurance companies do not offer EDI interfaces and publish their coverage information only in a static format.
At the time of this project, the client’s own engineering teams were already focused on a large legacy system modernization project, making them unavailable to address this critical business need. In addition, the client’s own team did not have much experience with the kind of automated data gathering and processing required by this project. The client needed to engage a technical partner with a specific kind of expertise.
Based on their long-standing relationship and experience with both the client and complex data extraction projects, Axis architected and developed an automated solution. The solution monitors insurance carrier portals and performs data collection from a variety of large insurance carriers. Critical coverage information is transformed and injected into the client’s back office systems at a rate much faster and less expensively than the manual process.
Not only does the system capture precise insurance coverage data, it also maintains an archive of changes for auditing and business intelligence purposes – functionality which was not possible with the previous manual process.
Technology used for the solution includes a combination of BizTalk, Visual Studio .NET code, Selenium and SQL Server, running on a managed virtual server farm in order to make the solution scalable. The application currently monitors and processes data from the client’s primary, high-volume, national and large insurance carriers which represent a majority of the company’s transactions.
As the solution rolls out, the client is realizing numerous benefits in both hard and soft dollars. The project has reduced the labor cost associated with performing insurance coverage analysis and validation. In addition, automation has allowed the process to run faster and more frequently, keeping related data more accurate than previously possible, greatly reducing the financial risk of the partner dentist offices. Instead of spending time on monitoring insurance company websites, client employees focus on patient care and being subject matter experts.
With this custom architected and developed solution, service departments like Accounting, Revenue Operations and Information Technology can focus on high priority migration and company growth initiatives while learning from the expertise and knowledge provided by Axis.
The client has expressed interest in reusing the technology and lessons learned from this project to address other challenges.