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Health Insurer Integrates Multiple Claim Systems into One Coherent View Using Service Oriented Architecture
The Challenge
Calling your insurance company to discuss benefits and claims can be a frustrating experience for health insurance customers. Claims processing is typically done through a variety of claims software solutions from a multitude of vendors, making difficult the task of dealing with a member's claim records in a holistic manner. Often companies will find that their customer service representatives require complicated and lengthy training in order to discern the correct claims history from information returned by multiple claim systems.
A government employee program managed by a large national Health Insurance company had just this problem. The customer service representatives were required to access multiple systems in order to retrieve the entire claim history for members that called in with questions. As part of an enterprise plan to continually improve customer service, the decision was made to utilize a single tool for all claim inquiries.
Pulling together information from disparate sources into an integrated view requires very complex business rules to resolve data inconsistencies and duplications. Ideally, customer service representatives should not be aware that the information is coming from multiple sources, but rather, the needed information is presented in a coherent and effective manner from one interface. All of this has to happen in real time to maintain a high-level of customer service and to control costs.
Aggregating claims information from five different data sources that utilize different technology presented a challenge for the solution team. The final status of a member's health claim information required the application of sophisticated business rules to ensure consistency.
The Solution
The Heath Insurer chose Netsoft USA specifically for the skills and experience required to understand the complexities of healthcare claim systems, as well as the technical prowess to integrate the solution into the internal Enterprise Service Bus (ESB). Netsoft worked across over a dozen teams covering end users to outside vendors, and by following our disciplined management processes, Netsoft was able to bridge the gap between the various technical systems that stored the data and thereby create a coherent view. In the final solution, Netsoft designed and built 19 business services to connect the Health Plan’s strategic customer service applications with multiple membership and claim systems.
Netsoft leveraged their Enterprise Business Service Framework (using Microsoft Enterprise Library) to deliver a Service Oriented Architecture (SOA) that made this data available to any applications that utilize the ESB.
The Bottom Line
A single customer service application can now provide a holistic view of a member's claim record history. Customer Service Representatives are able to quickly pull up the entire claims history for members, answer questions, and resolve issues.
And an added bonus: By basing the solution on an SOA design, Netsoft provided the mechanism by which future business applications that need to access this information can easily do so.
"Netsoft USA met the objectives in an exemplary manner. The subject matter expertise that was displayed by all of your team members whether it was the project manager, the tech lead, or a business analyst, everybody... all of the talent you brought to the table was immediately able to make a contribution to the project." Project Lead and Sr. Technology Manager for the Health Plan
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