Patient Benefit Management System and Data Warehouse

Industry: Healthcare/Health Insurance

Overview: A Pharmacy Benefit Management company that helps organizations provide lower cost prescription drugs to their employees was being weighed down by manual processes that have failed to scale with the explosive growth their business has experienced.

Challenge: The organization utilizes many manual, spreadsheet-based processes alongside a third-party Salesforce based system to provide their service to clients. With existing manual processes they were unable to meet increased demand to quickly scale operations.

Solutions: Our solution was to build a data warehouse, automated processes, and an easily accessible web application to replace cumbersome processes. By the end of the initial project our team also provided a plan to continue to improve operations and processes through future upgrades, and modifications.

Technologies: MS SQL Server, Node js, Angular


Summary:  Our customer, a Pharmacy Benefits Management organization, helps its customers offer lower prescription drug prices for medications not typically covered by traditional health insurance offerings. Their business had begun to grow rapidly, and it became clear that they couldn’t rely on the spreadsheets and manual processes they had put in place as they scaled up to meet demand. At the same time, they wanted to decrease their reliance on the third-party application they used to manage benefits.

TxMQ helped our customer build a data warehouse to store critical information about client companies, their enrolled employees, and their prescription drug claims. Microsoft SQL Server was chosen as the database technology to fit in with the customer’s Microsoft-centric environment.

In initial development for the project we automated processes to ingest data from flat files and the third-party Salesforce application to build a solid base on which to build scalable, automated replacements for existing manual processes. Now a company agent can easily input, access, and report information through a web application that can quickly generate lists of covered medications, enable exception processing, invoice customers, and support reporting.

The implementation enabled the company to scale more quickly to meet client demand and have grown both it’s client base and revenue more than it ever could have with the legacy solution. Though the initial project has made huge advances in capabilities, the overall modernization effort is ongoing and the client continues to rely on TxMQ as a trusted partner to enable them to continue to grow their business.

4 Ways BPM Can Boost Healthcare Revenue

Healthcare – it’s the digital era’s slipperiest slope. On the one hand, technology can greatly enhance the way we document and share patient data. On the other hand, since digital health records are vulnerable to security breaches, there are complex regulations about how providers record this data.
What does this dichotomy add up to? A cluster of complicated conundrums, that’s for sure. Unused data swells up behind bottlenecks, patients don’t have enough access to information, hackers have too much access to information and confusing legislation gets churned out constantly to try and smooth out the process. On top of all that, there are old school providers who not only have trouble digitally documenting encounters, they have trouble even understanding why they’re supposed to do it this way in the first place.
That’s why I think it’s important that healthcare organizations consider using BPM (business process management) solutions. The only way to sort out the mess is to streamline your workflow, so that the decision-makers in your organization can analyze the entire landscape of your healthcare documentation process. Here are some ways BPM can help:

  • Take advantage of data analytics
  • Respond to tech and policy developments in the industry
  • Plan for and meet important state and federal deadlines
  • Manage software applications used in routine encounters
  • Coordinate information exchange, which improves quality of care
  • Get different providers and team members on the same page

So that’s a nutshell version of how BPM software can improve efficiency, streamline workflow and promote collaboration in healthcare. But what does that mean for your company? How does that translate into more revenue?
4 Ways BPM Can Boost Healthcare Revenue

  • Reduce documentation and billing errors – Less errors means more payments and better reimbursements. With a streamlined workflow you don’t have to stress out about losing income because your providers struggle with their EMRs.
  • Earn incentive payments – Payment reform is a reality. The more valuable care you provide, the more opportunities you have to receive incentive payments from the private and public sector.
  • Boost patient satisfaction – When your patients are happy, they spread the word. If your patients are unhappy, they spread it even louder. Satisfied patients improve your reputation as a provider focused on quality care.
  • Claims Processing — BPM can help you smoothly handle claims, compliance and reporting activities. You can issue invoices and receive payments in a more timely manner.

If you think BPM could help your healthcare organization unwind a few knots, you have a lot of options. However, if you find you’re short on time or personnel, consider contacting TxMQ. Our capability partnership means that we offer an initial analysis to determine your needs and then develop and deploy the right BPM solution. We also have access to highly-trained technical professionals that you can contract to maintain your solution or even train your employees on how to use it efficiently.

Hacking into Healthcare: Why hackers want health data and how healthcare SMBs can protect their patients

As I was reading about Cedar Sinai’s recent implementation of Bottomline’s Healthcare Data and Security Solution, I couldn’t help but to wonder – why is patient data at risk in the first place?
Clearly, we can all understand why big box shops like Target and Home Depot were hacked; credit card numbers are better than cash. Siphoning electronic funds is the digital age’s form of Bonnie and Clyde-style bank robbing. So, realistically, what could a hacker possibly stand to gain from breaching healthcare data security and gaining access to my records?
After consulting with a few colleagues in the healthcare industry, I realized there is one extraordinarily valuable piece of information that all U.S. residents have – a social security number. With that 9-digit treasure chest, individuals with more nefarious tendencies can open a line of credit under your SSN, file for a fraudulent tax refund and open financial accounts. But, that’s not all.
Medical identity threat was up 40 percent in 2013. Stolen health credentials go for about $10 each, double and sometimes triple the black market value for credit card numbers. This information can be used in hundreds of ways, but what they’re really after is your identity.
In some cases, only a few that I found, are hackers ever really interested in your maladies. Social security checks, yes, credit lines, yes… your latest blood pressure reading? Not so much. But it does happen. Mostly, though, they’re breaching healthcare data security so they can pretend to be you, convincing a bank they are you, which is much more valuable than health history.
So that’s why protecting patient data is extremely important to healthcare organizations. It isn’t just about not having the world know about your heart condition, although that certainly is one reason. It’s about what people are capable of doing once they get ahold of all the information that they need to take control of your financial credibility. Cedar Sinai’s decision to implement Bottomline puts them one step farther away from a reputation-damaging data breach.
That being said, what can smaller companies do for healthcare data security? Bottomline has a price tag that could bankrupt small specialty providers. What are the security options out there for the healthcare SMBs?
While there are many options out there, IBM has a whole arsenal of data, application and integration security options – many of which are scalable for both size and budget. Fortune 500s all the way to private locally-owned practices can benefit from a number of these solutions. These security products are packaged to meet individual organizations’ needs, ranging from identify protection to fraud prevention, from encryption to vulnerability assessment. How do you know what’s right for you? As an IBM Business Partner, TxMQ assists companies with the selection, deployment and maintenance of enterprise security options. As experts in securely integrating solutions in the cloud, we can not only help make your patient records more secure, but we can help you digitize them, as well. We’ll stay with you for as short or as long as you need us.
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Do health-tracking wearables actually make us healthier?

When I’m not writing all about the health IT world, I am a personal trainer, and it never ceases to amaze me how often these two worlds collide. The other day one of my training clients said to me – “I’ve gained almost 10 pounds since I got my <insert name of popular health-tracking device here>. Isn’t it supposed to do the opposite?”

 I thought about it for a minute.

 “Well,” I began, “Do you wear it every day? Have you forgotten it any?”

 The client shook her head. “I only take it off to shower and to charge it.”

 I thought a little more.

 “How have your behaviors changed since you started wearing it?”

 Now she looked at me strangely. She shrugged. I asked her to keep wearing her health-tracking fitness band, but to also go back to keeping a journal where she logs in her activities and her food. In addition, I asked her to also log in how often she consults her wearable.

 When she came back to me the next week, she handed over the journal. It didn’t take long to see what the problem was. In the evenings, when my client had consulted her health-tracking device (which she does about a billion times a day), she would then consume the exact amount of calories she had remaining in order to come in right at her daily goal. However, sometimes these snacks consisted of highly processes carbohydrates and sugars. In addition, her fitness band had no way of knowing her muscle mass or the speed at which she metabolizes specific types of food.

 Technology plays an enormous and essential role in the detection, diagnosis and treatment of many life-threatening diseases. Digital devices monitor heartbeats and blood pressure, all able to be analyzed by the amazing connectivity of the Internet of Things. We can cure and prevent more illnesses than ever imagined before with digestible sensors, hybrid operating rooms and 3D printed biological materials. However, as a fitness professional, I’m not talking about that kind of technology. I’m talking about the kinds of health-tracking gadgets, like wristbands, apps and trackers, that have become as common place as the timeless Timex. Can these wearables really stop, or even reverse, the American obesity epidemic?

The answer is — it depends. In my client’s case, no. Or, not exactly. She was using the fitness band to justify eating poorer quality foods more often. For some people, however, they do work amazingly. I regularly meet marathon runners who worship the Garmin watches that help them track speed, as well as fitness band enthusiasts who saw the fat melt away from the moment they plugged in. The crux is this – in order to live a healthier lifestyle, you have to change human behavior. While these health-tracking devices cannot force behavior change, they can make us more aware of our actions and choices. 

Interested in using health & fitness tech to kickstart or continue your healthy lifestyle? Check out CNet’s review of top wearables under $200: