Business Value
The Healthcare Transaction Lifecycle
Healthcare transactions typically flow through many different systems and processes as they complete the transaction
lifecycle. In the case of a claim, the lifecycle may start with a billing provider generating a claim transaction (837)
which then flows through a clearinghouse, is manipulated and then is sent over the internet to a payer.
Next, the payer might validate it or edit it against multiple sets of rules before acknowledging it and then sending
it on for translation and loading into one of multiple adjudication systems. The process may finally reach completion
when the reverse happens and the original billing provider receives payment. In a more complex case, one or more
inquiry or response transactions may be sent to the provider to obtain additional information necessary to process
the claim or provide status, or a secondary claim may be routed to an additional payer for further adjudication.
Edifecs Transaction Management provides visibility and accountability across these complex processes, enabling business
managers at your company and at partner organizations to capture intelligence about critical transactions as they
proceed through the lifecycle, and to act upon that intelligence immediately.
Edifecs Transaction Management works by integrating with your middleware infrastructure, messaging system or enterprise
service bus to automatically audit the content of the transactions at each point in the process and to record key
events raised by your solution components. This information is then analyzed and the appropriate associations between
related transactions are created so that a complete picture of the entire process is obtained. Finally this information
is presented through a rich web interface that tracks key performance indicators, provides business views and drilldowns
into the data, allows customized dashboards and reporting, and allows the setup of notifications to alert users when
exceptions occur.
Achieve Accountability Across the Entire Lifecycle
Obtaining the complete picture of the transaction lifecycle is critical to assuring that each transaction ends
up where it’s supposed to. For example, this means knowing that every line-item in a batch claim submission
request was responded to by a corresponding payment or other response, even if the payments or responses were
spread across multiple transactions. Edifecs Transaction Management meets such needs by consuming events from each
of your transaction processing components, correlating the events, aggregating them and then reconciling the multiple
transactions that make up a given lifecycle to provide a complete, unified picture that can identify any problems that
exist or trends that may occur.
Leverage Transaction Lifecycle Insight to Make Better-Informed Decisions
Having the complete picture not only leads to accountability, it can also lead to better-informed
decision making. Unlike after-the-fact business intelligence systems, Edifecs Transaction Management’s dual-source
repository provides fast reporting on real-time data activity as transactions come in the door, with seamless
access to historical data when needed. Key performance indicators (KPI) can provide information such as the number
of hospital claims being processed per day, the total claims charges in the door per day, the number of claims
by type, error rates, and the number of claims by provider type and region. Transaction-based KPIs provide a
mechanism for managers and executives to gain awareness of changes in critical business patterns, empowering
them to make better decisions in areas such as staffing, risk management, and financial planning.
Improve First Pass Rates
Resubmission of healthcare transactions such as claims and enrollments due to errors in EDI transactions results
in increased cost and frustration for both you and your trading partners. Getting transactions through on the first
pass is a goal shared by all participants exchanging data. By providing visibility into why errors are occurring,
Edifecs Transaction Management provides a valuable tool to help you and your trading partners fix whatever system is
impacting throughput and eliminate errors.
Help Your Submitters Troubleshoot Their Own Problems
Submitters have an incentive to submit clean files that will move quickly through your processing systems.
However, many submitters do not have sufficient EDI skills to grasp concepts like loops, segments, elements,
qualifiers and other terms specific to EDI. Edifecs Transaction Management hides the complex EDI logic when
troubleshooting issues and presents an easily understandable set of business-normalized data elements that
enables submitters to understand why a submission has failed without the need to understand technical EDI rules.
Eliminate IT Bottlenecks by Empowering Business Users
As electronic sharing of data becomes a bigger part of the payer and provider business environment,
your business staff needs to have more control of the interaction with less involvement of your technical
EDI staff. The Transaction Management allows both payer and provider staff who may be unfamiliar with EDI
technology to track status and troubleshoot problems around electronic submissions. Users can see inbound
and outbound EDI data as individual business documents, such as eligibility requests, claims status requests,
claims and referrals, using either EDI terminology or business terminology. You decide what can be viewed and
how you want to control access.
Reduce Operating Costs Through Management by Exception
Empower stakeholders both inside and outside the enterprise to view and resolve exceptions. As transactions
proceed through the transaction lifecycle, problems inevitably occur, either as the result of a single processing
step, or because something that was expected to happen does not occur, or because of an error in the interdependencies
that exist between multiple steps or multiple transactions. Because Edifecs Transaction Management maintains a complete
view across the entire transaction lifecycle, it is able to report errors in real-time and error trends over
time — alerting you to problems before they have a serious impact.
For example, you can monitor throughput rates, error rates, and end-to-end latency rates through online charts
and dashboards. And you can configure alerts to warn for a variety of exceptions or conditions such as an unexpected
number of high dollar claims, if the percentage of failure rates for a specific submitter passes a defined threshold,
or if an expected file does not arrive.
Reduce Transaction Errors and Rework
Transaction errors result in substantial delay and re-work for all trading partners. Traditionally,
there is considerable finger-pointing and little resolution about the type and source of errors that result
in transaction failure. Edifecs Transaction Management’s error analysis capabilities provide cross-transaction
views of compliance problems to overcome these issues. Find the root cause of problems through drilldown from
high-level summary analysis to individual error occurrences that link back to the EDI and business views of
the transactions. By empowering internal business users and trading partners to view and troubleshoot problems
you reduce the chance they will happen again. |
