Customer Solution Case Study
/ / Integration Solution Helps Organization
Meet Federal Insurance Requirements
Overview
Country:/RegionUnited States
Industry:Healthcare
Customer Profile
Based in Roseville, California, PacAdvantage is a nonprofit organization that pools health insurance plans from major carriers for use by small businesses.
Business Situation
PacAdvantage needed to find a solution to replace an antiquated system for transmitting enrollment information to its insurance industry partners.
Solution
PacAdvantage worked with Accenture to deploy an integration solution that uses Web services and XML technologies to convert and transmit insurance information.
Benefits
Meets federal requirements for health insurance information
Fast deployment of integration solution
Creates potential for integrating new business partners / “The [BizTalk] accelerator [for HIPAA] helps us cut the risks associated with achieving HIPAA compliancy by helping us achieve transactional accuracy.”
Kathy Souza, Director of Information Technology, PacAdvantage
PacAdvantage is a nonprofit organization that pools health insurance plans from various carriers and offers them to small businesses. The California-based company, which works with major insurance carriers such as Blue Shield, Kaiser Permanente, Health Net, and regional healthcare insurers, relied for years on an antiquated system for transmitting customer enrollment information to its partners. To help streamline the data-transmission process, reduce data errors, and come into voluntary compliance with federal health insurance regulations, PacAdvantage worked with Accenture to architect, design, and deploy an integration solution. Using Microsoft® BizTalk® Server 2002, PacAdvantage is now able to transmit important insurance-enrollment information faster, more accurately, and within the guidelines established by the U.S. government for protecting the privacy of health records.
Situation
PacAdvantage is a health insurance purchasing pool that provides affordable health insurance plans to small businesses in California with up to 50 employees. A subsidiary of Pacific Business Group on Health—a nonprofit coalition of employers working to improve healthcare while containing the associated costs—PacAdvantage pools insurance coverage and matches it to the purchasing power of thousands of small businesses. This provides small-business employers with attractive insurance products and coverage that normally are available only to large corporations. The full-service products available through PacAdvantage include medical, dental, vision, and chiropractic insurance plans. PacAdvantage’s partners include a range of national and regional insurance carriers, such as Blue Shield, Health Net, Kaiser Permanente, Chinese Community Health Plan, American Specialty Health Plans, HumanaDental, SafeGuard Health Plans, and Vision Service Plan.
Since it was founded in 1992, PacAdvantage has installed disparate technology for sending enrollment information to its trading partners. As the organization grew in recent years—PacAdvantage now helps provide insurance to about 10,000 small companies—its IT systems became increasingly inadequate for efficiently processing member and policy information.
In particular, PacAdvantage had been using an enrollment information process that used antiquated technology and was not compliant with the Health Insurance Portability and Accountability Act (HIPAA), federal legislation that was passed by Congress in 1996. The HIPAA Administrative Simplification provisions require insurance entities to adhere to national standards for electronic healthcare transactions. The goal of these provisions is to improve the efficiency and effectiveness of the nation’s healthcare system by encouraging widespread use of a standardized Electronic Data Interchange (EDI) format, a globally accepted method for exchanging business documents.Although PacAdvantage is not, by definition, a covered entity, the organization decided to convert to the HIPAA format, which would help PacAdvantage interact more effectively with its trading partners.
Solution
PacAdvantage worked with Accenture, a Microsoft® Gold Certified Partner, to deploy an integration solution that converts documents based on XML into HIPAA-compliant EDI files. The solution was built by using Microsoft Windows® 2000 Server operating system and Microsoft BizTalk® Server 2002, both part of the Microsoft Windows Server SystemTM integrated server software. Each file is configured for each insurance company trading partner. The resulting EDI files are encrypted and then transmitted to the trading partner according to the partner’s preferred FTP transmission process.
Benefits
PacAdvantage managers say that the new system, which Accenture designed and deployed in about four months, is helping reduce or eliminate any compliance issues involved in transmitting sensitive customer information. Accenture was able to produce the new system in a relatively short timeframe due to the power of the Microsoft development tools. Because it is relatively easy for PacAdvantage to integrate its enrollment system with external insurance businesses, the solution offers PacAdvantage the opportunity to more easily add trading partners.
Power and Flexibility to Meet HIPAA Requirements
In the past two years, PacAdvantage’s insurance trading partners—particularly the larger ones—have requested that the company implement industry-standard methods of dealing with customer enrollment data, according to Ira Rothman, PacAdvantage Vice President of Operations and Chief Information Officer. Additionally, the company was dealing with the issue of data accuracy, which sometimes was affected by the lack of integration. Both problems needed to be addressed.
“We had been using EDI/EDGE, but it could not provide all the features and functions we needed to meet the HIPAA requirements. We needed a more powerful and flexible software solution that could also help us meet the ANSI X12 requirements,” Rothman says, referring to the uniform coding system that is used to communicate information through EDI. “The ANSI format for transmitting records has very complex layouts—there can be thousands of characters and conditional fields.”
Kathy Souza, PacAdvantage Director of Information Technology, says that in addition to being the most cost-effective integration software that was considered for the new solution, BizTalk Server also provides vertical industry accelerators. These help companies quickly adapt the solution to specific needs—in this case, PacAdvantage used the Microsoft BizTalk Accelerator for HIPAA.
“The accelerator helps us cut the risks associated with achieving HIPAA compliancy by helping us achieve transactional accuracy,” Souza says. “It also helps cut the costs of ongoing maintenance and will help us adapt more quickly to future rules.”
Rich Development Tools Expedite Integration Solution
PacAdvantage also benefited from the rich development environment that Accenture used to create and deploy the new integration solution in the latter part of 2003. Accenture, relying on its extensive Windows-based development expertise and using the Microsoft .NET Framework development tools, came up with several innovative components for the solution. The Microsoft .NET Framework is an integral Windows component that supports building and running the next generation of applications and Web services.
One innovation was a Web Service Test Harness, a custom, stand-alone Windows-based application used for exercising and testing the Web service that runs on BizTalk Server. Through this component, Accenture was able to manually submit a generic 834 document—the code for an enrollment document exchanged among insurance companies—and verify the BizTalk Server translation process. Accenture was also able to easily test a Web service–based retransmission feature as well as access details of documents that wound up in a BizTalk Server suspended queue. When documents end up in this queue, alerts can be sent to the appropriate PacAdvantage personnel so they can take the appropriate action to resolve any transmission problems.
“This provides us with the ability to track the transmission of a document, and it gives us the information we need immediately if there is a problem,” says Souza. “The daily transmission of enrollment information is the single most important thing we do. We needed a solution that we could rely on and, if we have to transmit, we can do that knowing that the transmission can be brought to a successful completion.”
Accenture also created an Application Interface Component that determines the intended target EDI file receiver, accesses the correct system registry and configuration items, and encrypts the file by using the receiver’s public key. Additionally, Accenture created a process that splits EDI documents into small chunks that can be handled rapidly by the BizTalk Server document mapping system, helping to expedite the handling of enrollment information.
“The power of the Microsoft development tools helped us create an effective, powerful solution to integrate the PacAdvantage system with its external partners,” says Michael Mojaver, Accenture Account Manager and Chief Solution Architect for the PacAdvantage project.
XML Support Creates New Opportunities
Rothman says the tools and technologies provided by and supported in BizTalk Server also create the potential for building new partnerships with other insurance carriers.
“The XML capabilities in BizTalk Server are very important to us,” he says. “They give us the flexibility to add new features in the future and have those features mapped correctly to the corresponding fields in our enrollment documents. We believe it will also be relatively painless and a lot easier to integrate our business with new partners in the future.”
The work described in this document was previously performed by professionals who were part of apractice that Accenture acquired in 2005.
Microsoft Windows Server System
Microsoft Windows Server System integrated server infrastructure software is designed to support end-to-end solutions built on the Windows Server™ 2003 operating system. It creates an infrastructure based on integrated innovation, Microsoft’s holistic approach to building products and solutions that are intrinsically designed to work together and interact seamlessly with other data and applications across your IT environment. This allows you to reduce the costs of ongoing operations; deliver a more secure and reliable IT infrastructure; and drive valuable new capabilities for the future growth of your business.
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