Executive summary
Fresenius Medical Care, an insurance company specializing in end-stage renal patients, had the task of automating the Medicare/Medicaid claims submission process with CMS (Centers for Medicare & Medicaid Services).
The process was primarily manual, difficult and had a high error processing rate of around 70%.
The project solution required patient data extraction from a Microsoft SQL patient database and mapping the data to CMS specifications and building a web portal for claims processing submission using Microsoft BizTalk.
The final solution improved the predictability and timing of Medicare & Medicaid claims payments and reduced the claims error rate to under 2%.
"Xemble built a HIPPA compliant EDI integration solution allowing us to automate the process of extracting information from our MS SQL database and map the data to CMS compliance requirements which allowed Frenius the ability to scale Medicare and Medicaid payment processing with an error rate of less than 2%."
~ Patricia Anderson,
Senior Director - Data Architecture Group
Challenges
The task at hand was very important to the company because of the financial impact and timing of claims processing.
The data used was stored in a patient medical database which required considerable care to not reveal any patient medical data but rather just extract the information required for the claims billing process.
This was a very new process for both teams which required a considerable amount of time for researching hot to map the data needed to the CMS submission specifications.
CMS would often take days to report errors which then required a very quick response time for correcting errors and resubmitting corrected data to ensure payment.
HIPAA guidelines also required protecting client information and avoiding a reveal of sensitive client information.
The solution
The solution required analyzing the data from Microsoft SQL to extract only the data necessary for claims submission, while protecting patient privacy rights under HIPAA.
The team wrote the code for the data extraction routine and mapped all the data for submission with Microsoft BizTalk Server according to CMS submission specifications and then built a web portal to accomplish the claims submissions and communications.
The building of this solution improved the submission error rate from 70% to approximately 2% .
There is now a predictability to claims processing payments previously not available and errors are now more clearly defined and are immediately corrected and resubmitted.
This solution is saving Fresenius approximately $160,000 per year in staffing costs previously incurred in the manual claims submission process.
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