Modernizing the Platform to Enhance Claims Processing

Industry: Healthcare & Life Sciences

Delivery Center: India

Modernizing the Platform to Enhance Claims Processing

Industry: Healthcare & Life Sciences

Delivery Center: India

Industry Context

In the context of the 340B program, which aims to provide discounted medications to eligible patients, efficient claims processing and order management are crucial.

By collaborating with the right technology partner, organizations can leverage their expertise, advanced software solutions, customization capabilities, integration expertise, and ongoing support to achieve efficient claims processing and order management. This, in turn, enables compliance, cost savings, improved patient access, revenue generation, and data integrity, leading to the successful operation of the 340B program and improved patient outcomes.

Client Challenge

The client is a prominent medical administrator in the 340B Drug Pricing Program.  They offer a comprehensive platform and services that support covered entities and pharmacies participating in the 340B program.

The client struggled with rampant errors within their processes, which were impacting business efficiency and profitability. Their legacy system lacked the functionalities to adapt to its evolving business needs. Lack of integration capabilities created data silos and increased manual work. The absence of robust data analytics and visualization capabilities hindered their ability to gain valuable insights from the business data.

The client was seeking a strategic partner for the implementation of novel technology and automation tools for enhancing the administrative efficiencies in their 340 Program.

Approach

Product Roadmapping services for collaboration on the strategic development and planning of the 340B Program solution, ensuring that it aligns with the client’s business objectives.
Product Engineering & Development services to build a web-based application tailored for the 340B program. Incorporated billing development feature for their contract pharmacy application. Developed management screens for contract pharmacy systems and split billing functionalities.
Product Support services to support process improvements in terms of project management & QA. Extended ongoing production support to ensure operational efficiency.
Platform Modernization services for migration from legacy system to modern architecture with improved charge files processing and starting development with TPA integrations.
Data Modernization & Engineering services for integrating  PowerBI reports into the client's system, providing them with powerful data visualization and analytics capabilities.
Implemented DevSecOps services for Continuous Integration (CI) and Continuous Deployment (CD), leading to increased productivity and higher software quality.
Integration services for integrating multiple wholesalers into the client’s system. This integration enhanced the client's ability to streamline their supply chain processes and manage multiple suppliers effectively.
Implemented Automation services to introduce auto reprocess functionality, enabling users to complete reprocessing tasks at a faster rate. Implemented notification emails to alert users in case of data failure, ensuring timely awareness and response to critical issues.
Cybersecurity services for enhancing the user convenience & security through implementation of Single Sign-On (SSO) integration.

Results

The client witnessed enhanced revenue generation with improved 340B claim capture logic. Enhanced regulatory compliance, improved processes, and reduced errors ensured an elevated customer experience and cost savings for covered entities.

Configurable management screens for the contract pharmacy system and split billing empowered the users to tailor the system to their unique requirements, enhancing overall usability and flexibility. Split billing capabilities within the system allowed seamless and efficient handling of billing processes across various entities.

With the implementation of advanced auto reprocessing capabilities, users can now complete reprocessing tasks in a matter of hours, a significant improvement over the previous time-consuming process that could take up to a day.

The file processing time was optimized from 1 day to 20 minutes. Introduction of Redis Cache into the claim processing logic increased the number of claims processed per hour from 31k to 110k+.