Published on 29-Jun-2011
Validated on 27 Feb 2013
"With its healthcare background and highly accurate matching capabilities, Initiate was the ideal fit for the problem we needed to solve." - Leading U.S. healthcare plan executive
U.S. healthcare plan
Information Governance, Master Data Management
Improving member and provider data accuracy with IBM Initiate Master Data Service
A U.S. healthcare plan maintains member eligibility information across 35 source systems. The lack of integration and inconsistencies in member and provider information were increasing manual claims processing time.
IBM helped create unified, accurate views of members and providers to improve processes and service, while reducing costs.
● Improved claims processing saving more than US$1 million annually ● Uniquely identified 167 million members from 300 million records ● Streamlined processes for managing member and provider information
This U.S. healthcare plan offers a broad spectrum of products and services through six operating businesses to millions of customers. As the industry moved toward a more consumer-centric healthcare model, the health plan focused on upgrading its IT infrastructure with solutions for tracking members over time, even if they transitioned among different benefit plans. The company also wanted to leverage its information and technology core competencies to improve operational efficiencies, such as claims processing.
Seeking a unified view of members and providers
As a result of several mergers and acquisitions along with continued business growth, more than 300 million member records from multiple lines of business and healthcare plans were managed in 35 different eligibility systems. There was a need to integrate information and streamline processes to support compliance and reporting requirements.
To improve customer service and reduce the requirement for members to repeat basic information, the company needed to uniquely identify members across systems and provide a unified view of accurate information to all operating groups across its enterprise. In addition, to reduce the time and manual resources required to process provider claims and improve auto adjudication results, the health plan wanted to accurately identify providers from its store of more than six million provider records.
Improving claims processing and reducing manual methods
The healthcare plan searched for a master data management (MDM) platform to provide a single repository for member and provider information, where all internal systems could query this repository to obtain complete information describing each member’s eligibility, as well as provider information.
The company selected the IBM® Initiate Master Data Service® software because of its proven superior accuracy in a proof of concept against other vendors. In addition, IBM Initiate® Inspector provides an intuitive data stewardship tool that enables quick error identification and resolution.
The first of two MDM initiatives was a m ember hub project that focused on the accurate resolution of 300 million member records, in 35 eligibility source systems, to create a database of unique member identities. Using IBM Initiate Master Data Management Service, the deployment process was rapid and non-disruptive, taking about six months.
After realizing significant benefits from the member hub project, the company launched a second project to accurately identify providers, which would improve claims processing. This project focused on the accurate resolution of 6 million provider records. Again, the deployment timeframe exceeded projections—four months from engagement to production.
More than US$1 million saved annually
IBM Information Management solutions have helped the company create a unified, accurate view of members and providers. The member hub comprises 167 million uniquely identified individuals from 300 million member records in 35 source systems. This number represents more than 97 percent of all member data. The provider hub uniquely identified 2 million providers from 6 million provider records.
In addition to faster than expected deployment, access to more consistent data reduced manual claims processing by 1 percent and resulted in a cost savings of more than US$1 million annually. Any additional reduction in processing times will only increase the savings.
Improved customer service
With new capabilities and more accurate information, claims processors are able to improve the coordination of consumer benefits and billing. In addition, reducing bottlenecks has improved claims processing. The solution also was deployed seamlessly without disruption to ongoing business processes.
Streamlining processes for collecting and managing member and provider information also provides the necessary support for compliance and reporting requirements. Another welcome result of the IBM Initiate Master Data Service solution is a reduction in the cost of compliance with the California law SB853, which requires the capture, storage and utilization of each member’s written and spoken language preferences. The company significantly reduced efforts and costs associated with compliance by collecting and storing language information in a central member repository. Instead of accessing the data from 35 different systems, the data can be easily accessed for compliance and reporting purposes, once quarterly.
There are many additional benefits that can be derived from the IBM Initiate Master Data Service member and provider hubs. Advanced search capabilities will help prevent duplicate entries at the point of creation, when providers are awarded new contracts. It is also possible to apply analytics to member data to glean more meaningful information about overall consumer populations. For example, a longitudinal view of the member health records will help drive trust and completeness for Accountable Care Organizations (ACO) initiatives.
For more information
Contact your IBM sales representative or IBM Business Partner, or visit us at: ibm.com/software/data/infosphere/master-data-service
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Products and services used
IBM products and services that were used in this case study.
IBM Initiate Master Data Service, IBM Initiate Inspector
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