Case Study: Developing New Claims Process

Project Description

Third party insurance claims provider (client) needed to create a new proprietary claims process, at the request of Aetna, with a hard HIPAA deadline in four months. At the onset of the partnership, our client was responsible for the submission, processing and payment of claims and then pertinent information regarding the claim would be directed to the appropriate insurance company.

The Challenge

In May 2012, Aetna requested a change to this process to be completed on or before January 1, 2013. The process change included our client submitting and processing the claims, however the check to pay the claim would then be paid through Aetna with strict adherence to HIPAA regulations. A proprietary program needed to be written that would allow them to create this new process flow.

The Response

Work for the project began in September of 2012 after much go-around with the requirements and expectations leaving a four-month window for the completion of the project that would be compliant with HIPAA standards. The client was using a homegrown PowerBuilder based .Net system with the data stored in Oracle Database. The data needed to be readjusted within the file transfer process and claims processing.
TxMQ assembled a team of four members, including three PowerBuilder specialists and one Oracle specialist to create a new program that would allow the system to record claims, send them electronically, adjudicate the claim, and update the file to send back to Aetna for payment. Our PowerBuilder specialists worked long and hard to write and re-write the program several times ensuring its compatibility with Aetna systems. Our Oracle specialist continually worked to make updates to the copy scripts as the project progressed.

The Result

The team was forced to request a deadline extension when it was discovered that Aetna was not running the most recent version of HIPAA. However, within a month’s time, the adjustments to the new system had been implemented and the system went live with no issue.
Photo courtesy of Flickr contributor “Army Medicine”