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Technology Solutions for the Finance and Insurance Industry

 

 

Project Profile: Web-based Insurance Claim Review 

            

Business Situation

The client processes millions of medical insurance claims annually in more than 20 office locations. The company intended to increase the processing volume and the process efficiency with this new Claim review system and integrate with a Workflow system that would accurately track documents.

The client needed an enterprise-wide, internet-based Insurance Claim review system that would have a rich GUI with an application look and feel, but still be quick and easy to operate. Also, the application had to eliminate the use of mouse, reduce the number of keystrokes required to enter the bill data and make the application so intuitive and easy, that an individual with minimal training could operate the application.

 

The Role of Masfin Consulting

The Masfin consulting covered all aspects of development from project management support, needs analysis, design, architecture and development and deployment of the software and integrated with the clients’ staff to achieve a joint project environment. Within a time-frame of six-months the project was live and in production.

The application was developed as a Web based with an easy to use front-end which, in order to increase speed and cut down on error generation, makes optimal use of previously observed patient/provider/client relationships. All client-side applications were written in MS VB 6.0, this thin-client allowed the flexibility and manageability of a web application with the rich GUI options provided by most desktop applications and was delivered over the public internet through a fire-wall.

Each of the Jurisdictional rules (including payment rules) and Edits were maintained in a Rules Server, which expresses rules dynamically as formulae, with a scripting language, allows for pre-loading of rules, and does not require a technical staff to maintain.  All the objects in the business services tier were stateless and all data communication from Clients ó Services tiers was via XML. The application was a paperless system, with optimal configuration is dual screen mode where the primary screen, a standard monitor, contains the data entry GUI; the secondary screen, a flat panel, presents the document currently being worked with.

Benefits

Claim Review application can be accessed via the World Wide Web, a private intranet, or through a secure internet connection.

The Claim-review application is a rules-based system facilitating the review and re-pricing of medical bills for payers of automobile, workers' compensation, and group health claims, and can be maintained by non-technical personnel. 

Multi-tiered architecture supports paperless work flow, distributed data entry, and electronic bill submission.

The Claim-review rules server is dynamic and formula-driven for rapid customization and ease of maintenance. And enables, sophisticated analysis of bills designed to identify duplicates, over-utilization and mis-coding; Reimbursements calculated automatically with savings reports generated.

Designed for speed and ease of data entry, with hot key-entry and does not require the use of mouse.

Full view of all input events, system driven events and claim history.

Integrated with a fully featured imaging and workflow tool driving down processing time and expense.

Powerful ANSI compliant and XML based EDI component for seamless interfacing to existing claim and case management systems, pre-certification as well as PPO or Network.

Products used

MS Visual Studio Suite, Visual Basic 6.0, XML, ASP, Internet Explorer, Kodak Imaging, Windows DNA, COM+, MTS, Crystal Reports, Power-Designer, MS-SQL Server and Kofax-Ascent image capture software.

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