Blue Cross and Blue Shield of North Carolina

There’s a Blue Cross and Blue Shield organization providing health insurance in every U.S. state, and frequently it is the largest health insurance provider in the state. With the tremendous volume of business they deal with, the “Blues” are often at the forefront of developing new IT solutions to onboard rapidly growing numbers of members, handle large volumes of claims and deploy new products and enhancements.

Blue Cross and Blue Shield of North Carolina (BCBSNC) is a prime example. The largest health insurance provider in North Carolina, the Chapel Hill-based company has 3.7 million customers and pays approximately $9.4 billion in claims. It has 4,700 employees, and it received approximately 4.4 million customer service calls in a recent year, for which CSRs had to produce complete information in a timely fashion.

Fixing the morning crash

That is a challenge as BCBSNC grows, and it is growing at an exponential rate. Three years ago, the company’s systems processed 42,000 eligibility requests. As providers (hospitals, doctors, and clinics) manage their costs and reimbursements, they need to ensure patients are eligible for the services they request at the time the service is provided and not during overnight batch processing. This year, eligibility requests have risen to 60 million, an increase by a factor of 1,429. As volume increased, however, problems arose. For a while, systems were crashing every morning at 7 a.m. due to the volume and the lack of a suitable connectivity solution between the company’s internal systems and its external customers. Lack of agility in the connectivity space also adversely affected the company’s ability to turn out new products in a timely fashion.

“In the past, we would implement logic within our applications,” says Duane Adkins, enterprise architect, Blue Cross and Blue Shield of North Carolina. “At the perimeter, each application would do its own thing and access the data in its own way. We decided that, in order to streamline eligibility, benefits and claim data transmissions, we needed to create common repositories for data, and expose the data via services. We also had a lot of point-to-point messaging via batch processing, which we wanted to change.”

The company also wanted to enhance the interoperability between providers and payers, and reduce the amount of administrative time and resources that providers spent getting their transactions settled. The initiative to evolve started as a grassroots effort and soon got more momentum from an executive mandate to achieve certification from the Council for Affordable Quality Healthcare’s (CAQH) Committee on Operating Rules for Information Exchange (CORE).

Real-time eligibility responses

“We wanted to roll out real-time eligibility responses to requesters from the outside,” says Adkins. “CAQH CORE certification was a roadmap to get us to where we wanted to be. CAQH provides rules and standards. We would have to meet certain SLAs around data latency and response times. In order to do that, we integrated the data in a common data layer and then provided access to that data using services.”

BCBSNC has been using IBM® WebSphere® Application Server for the past decade, and two years ago it decided to use WebSphere middleware as the foundation for a service oriented architecture (SOA) called One View. “One View is helping us meet our goals, providing the common service development team and a common way to manage governed services across the company,” says Adkins. “And now, One View is also a team of people. Executive leaders and others have joined and created an integration of management practice. We’re trying to implement lean principles to develop services as fast as possible in an agile manner.”

Enabling 1,429-fold growth over three years

Because services are reusable across the enterprise, everyone can think about eligibility in the same way. “So we no longer have various groups using their own methods,” says Adkins. “This makes us much more efficient at what we do.”

One View is responsible for the company’s ability to achieve 1,429-fold growth in a period of three years. Specifically, it was the BCBSNC IT team’s connectivity solution using IBM WebSphere DataPower® Appliances as the enterprise service bus (ESB) solution that enabled the company to meet the challenge.

A number of the company’s traffic issues were caused by partners who used batch processing rather than real time processing, and were sending batch eligibility requests through BSBCNC’s real-time channels. “Everybody wants to do real time, but not everyone is converting to real time overnight,” says Adkins. “IBM WebSphere DataPower provides the runtime governance to manage usage.”

The WebSphere DataPower XI50 Appliances perform the governance function for internal message traffic and the XB60 Appliances work on the external message traffic.

More recently, BCBSNC implemented IBM WebSphere Message Broker in conjunction with WebSphere DataPower Appliances in a hybrid ESB. WebSphere Message Broker replaces Oracle Sun Java Complex Application Platform Suite (JCAPS) as the strategic platform for processing incoming messages and for making decisions on the tasks or steps needed to execute them. This generally involves delegating the execution of the incoming message to one or more back-end services which manage data repositories.

One-tenth the coding than with JCAPS

WebSphere Message Broker also works in conjunction with IBM WebSphere Service Registry and Repository, which functions as a dynamic look-up mechanism to provide metadata information on the back-end services. “With JCAPS we had to write about 100 Java classes to execute a governance service whereas with WebSphere Message Broker we need to write maybe 10 XSL files,” says Adkins. “We’ve used other products here, but we’ve definitely chosen IBM as a partner for integration.”

BCBSNC uses WebSphere Message Broker to mediate larger, more complex messages and perform transformation and end-point service routing. The company uses WebSphere DataPower Appliances to provide throttling and shaping for all traffic.

Both Message Broker and DataPower enable the user to develop prebuilt mediation patterns that help guide the decision-making process. The team uses Message Broker patterns for complex event processing and DataPower’s larger-grained patterns to direct messages at a lower level of complexity.

WebSphere DataPower dramatically reduced the time the team had to spend mediating eligibility traffic. “Who knows where we’d be today if we were still trying to control the traffic to our eligibility services by building our own point solutions?” says Adkins. “We would have had to build and enforce our own rules for each one of those end points."

"We’ve saved a lot of time and money with IBM WebSphere connectivity solutions―60 - 80 percent of the cost of developing and testing new projects,” says Adkins.

Data management and service management successes

In addition to driving down costs, implementing DataPower enabled the team to end the morning crashes and meet CAQH CORE requirements that certified BCBSNC’s real-time message processing capabilities. However, real-time integration did not happen through the IT team’s success with IBM ESB tools alone. Another half of the multiyear development project involved a master data management (MDM) initiative using IBM InfoSphere® products to establish a trusted source of data for member information. “With the help of IBM products in data management and service management, we have achieved the ability to grow at an amazing pace with fewer interruptions and lower cost,” Adkins concludes.

For more information

Contact your IBM sales representative or IBM Business Partner, or visit us at:

ibm.com/software/integration/datapower

ibm.com/software/integration/wbimessagebroker

For more information on Blue Cross and Blue Shield of North Carolina, visit: www.bcbsnc.com