Challenge

The EDIC is a leading US-based insurance company serves customers in the State of California. The Company offers claims for injured workers, as well as provides medical support services. They aimed to create a web application providing all in one service to multiple businesses. Their primary objective was to create centralized business software that can access every single business process. This included handling multiple entities such as Insurance company (Payor), Injured worker (Patient), service providers, and client's internal operations.

Critical challenges faced by the client

• Process eligibility (claim) files of different file formats (Flat file, spreadsheet, EDI) extracted from multiple Payors from BizTalk
• Single interface to manage Payor, users like agents, providers and their subsequent details, services, and billing information and rules
• Referral (appointment) interface to manage all details of transportation/translation service on a single platform
• Dedicated queues to work on for different teams like Service, Operations, Quality, Billing
• Maximum automation features to increase productivity, quality and reduce human errors in areas such as Operations and billing
• Comprehensive UI and automated report generation using graphs/charts for easy data management

Solution Provided:

Considering the requirements of the client, Techupai's .NET development team created a web-based solution using C# and React that supports multiple backend services and manages all internal and external processes of the client.

Enlisted are some of the desirable features provided by Techupai's web app:

• Centralized interface to manage multiple entity information such as Payors, users, third-party providers, and their intricate details, state/county wise pricing, service number, billing cycle details, and more.
• Provides BizTalk EDI solutions to download claim details from the Payor's network, import into database, and interface to display claim details associated with Injured Worker (IW).
• A single platform to manage the applintment life-cycle from creation, reconciliation to final receiving of payment from the Payor.
• This interface specifically manages Transportation services like Ambulatory services, Wheelchair, Air ambulance, and Translation services like Onsite (regular, certified, legal), conference call specific details
• Techupai implemented a number of automation process that improved productivity and reduced human dependency

Solution Benefits

• Automated mileage calculation (Google APIs) based on destination and travel time.
• Automated cost-effective solution to book ride from Lyft, Uber, and other local providers.
• Automated communications at different stages of the appointment using generic email templates
• Different task queue interfaces dedicated to a team like intake, service, care, operations, billing etc. to work on and smart task assignment rules
• Interactive voice response (IVR), dial/receive calls over browser to reduce hardware dependency and create dynamic call routing
• Automated Calls/SMS/Fax using Twilio with IW for various purposes like confirmation/reschedule an appointment, talk to representatives, surveys, etc.
• Interface to load emails on-screen using office 365 Graph APIs and related actions
• Automated invoice generation in various formats like PDF, spreadsheet, XML, tab-based txt, etc., Auto reconciliation and Auto follow-up process
• Following US health standards to generate EDI 837, 277, 999 files through BizTalk
• System generated management reports to review quality, productivity, sales, services, accounting in real-time
• Dedicated provider portal where they can log-in and review services assigned to them, accept pending or assigned tasks, payment check status, submit queries, etc