As part of a new business initiative, Dental Benefit Providers (DBP), a division of UnitedHealth Group, created a service for the re-pricing of dental claims from insurance companies. DBP was able to deploy a BPM solution from Fuego to create and implement a new automated claims re-pricing system within 30 days.
James Robins has been Vice President and CIO at Dental Benefit Providers since 1999. Robins has over 20 years experience working in information technology.
DBP is the largest dental wholesaler in the US. The mid-size company is owned by the UnitedHealth Group and provides healthcare services including claims and payments to other companies in the health care industry. The challenge DBP faced was the need to reduce costs and find better ways to conduct business. Robins was tasked with creating a claims re-pricing capability for a new customer that needed to be in production within eight weeks. The new customer would provide member and provider information and procedures performed with a dollar value for each one. DBP’s present system could not do this. The solution needed to be HIPAA compliant and be able to match all the dentists both inside and outside their database with the new rules and be highly automated. On top of all this, there was a new project in the works to replace all the DBP legacy claims systems, which meant that any solution had to be portable to the new environment. It was a CIO’s nightmare.
One of the options Robins had was to build a re-pricing capability with the development tools DBP already had in place. But this solution required more manpower than DBP had and the solution could not be leveraged against the future claims environment. Also, there wasn’t enough time available to complete it. The second solution considered was to buy a stand-alone claims re-pricing package. This option would take months to install, configure, and integrate. The cost was disproportionate to the value and there wasn’t enough time to do this either.
Then Robins looked at the problem within a process context. The processes included data coming from the client, being transformed to a format DBP can use, checking some data values for rates and rules for the network they were in, then getting the data back to the client. The question was how could DBP model these few processes in a graphic design. Robins needed a way to capture the business rules and logic and move the data along while auditing and monitoring the work as it was being done. Robins had been talking to Fuego about some of their IT problems, and saw that Fuego might be able to help with the above problems. He described what DBP needed and asked if Fuego could do and complete the work in eight weeks. Fuego said they could do just that. Looking at the problem in a Business Process Management context, what DBP needed was:
- A process modeler
- The ability to capture the business rules and logic
- Integration
- A process engine
- Monitoring and audit capability
- A work portal
- Reporting and analysis capability
Robins and Fuego created a joint team to create the solution. Robins sees Business Process Management as sitting on top of the business processes such as verifying claims and making payments. A number of technical processes have to occur and Fuego created a conductor to harmonize these processes within the IT environment.
Robins emphasized that Fuego is not a middleware tool. It doesn’t connect things as middleware does. It ensures that the processes that have to happen at each step get done, whether it has to go through Windows, Unix, an Oracle database or any other system at DBP.
The solution would take a process-centric approach by:
- Accepting files
- Translating them
- Applying business logic and rules
- Integrating to DBP applications
- Sending files back to external partners via B2Bi
In the solution, clients aggregate claims and submit them electronically for re-pricing. DBP re-prices the individual claims then the re-priced claims are consolidated and transmitted with summary reports. The Fuego BPMS platform is used to orchestrate claims re-pricing by confirming receipt of valid files based on client-specific material, then re-prices the line items, manages the turn around time (less than 24 hours) and the consolidation and distribution of the re-priced claims. All of this is done in compliance with HIPAA and other requirements that are necessary in the insurance industry.
The solution was tested with the client four weeks after they began. The total production time was eight weeks. Only two full-time employees were used for a total of 21 days. DBP was also able to identify numerous uses for BPM within the company based on the results.
According to Robins, the major lesson learned was integration needs exist solely to support your business processes. Any integration requirement points to a larger process problem. Addressing the process problem first goes a long way to reduce the complexity and scope of the solution. “It is really important to start small. Pick something that has a defined scale. In this case, we almost made it seem to the senior executives that it was their idea. We presented a BPM concept, explaining to the senior executives that we would involve the claims department, the client services and IT departments and work together to define this at the business level. It was simple enough and in a short enough timeline for them to see and understand. Plus we made our financial objectives.”
Robins said that DBP has taken this approach to other parts of the company and automated several all-manual processes using the Fuego solution. Productivity is up, quality is up, and the customers are happy. Robins said the whole process was a wonderful experience.
