The focus here is using 2 Microsoft technologies and this solution is aimed for the payer and 3rd party claim auditors. As you read through, the automation process will allow for less “human” involvement when checking and scrubbing for claim accuracy. We are a ways out from the actual conversion deadline, which I kind of 
wonder about myself as far as being met and everyone being ready, but planning is in the works to move toward the goal.
One of the 3rd parties mentioned here is Trizetto which is owned by a private equity firm in the UK, Apax Partners that does a lot of the analysis and claim scrubbing work for the insurers and they offer their own flavor of a payer based PHR. With the use of 3rd parties, as a consumer it may take a while for you to perhaps find out why claims have been reduced or denied due to insurer use of third parties. BD
Press Release:
REDMOND, Wash. — June 9, 2010 — Microsoft Corp. today announced that multiple payer, provider and partner organizations, including Molina Healthcare Inc., EmblemHealth, Edifecs, Evolute, Neudesic LLC, The TriZetto Group Inc. and Washington Publishing Company are standardizing on Microsoft’s integrated, standards-based platform, with Microsoft BizTalk Server 2009 at the core, to support HIPAA 5010 and ICD-10 compliance. The platform also enables health plans to reduce costs and accelerate and automate processes and workflows to achieve administrative simplification.
BizTalk Server 2009 is a scalable electronic data interchange and messaging solution that helps payer and provider organizations meet the challenges of integrating diverse systems. It provides out-of-the-box support for HIPAA 5010 messaging schemas, trading partner management and integration components, while also enabling payer and providers to make better use of existing technology to support growth and reduce costs.
“Our business needs were two-fold. We wanted to use existing technology to reduce administrative costs and simplify customer interactions and also needed a way to meet new guidelines related to security and transaction standards in HIPAA 5010,” said Amir Desai, chief information officer, Molina Healthcare. “Working with Microsoft, we chose a fixed-licensing solution based on BizTalk Server 2009 and Microsoft Office SharePoint Server 2007. Now, in addition to many other benefits in line with our organization’s business goals, we will be HIPAA 5010 compliant at a fraction of what we would have spent on building a system.”
Microsoft and leading partners, including The TriZetto Group Inc., Neudesic LLC, Evolute, Washington Publishing Company and Edifecs, are collaborating to help payers and providers embrace a service-oriented approach to HIPAA 5010 while creating a longer term IT strategy to support administrative simplification, health reform, ICD-10 adoption and new health IT models.
“In light of the switch to HIPAA 5010 and the replacement of ICD-9, payers and providers throughout the country are struggling to find a cost-effective approach to meet these deadlines,” said Dennis Schmuland, director, U.S. Health Plans Industry Solutions, Microsoft. “By allowing healthcare organizations to get more out of 
their existing investments and minimize the cost of integrating new pieces of technology, the Microsoft platform helps payers and providers easily meet HIPAA 5010 compliance while achieving administrative simplification.”
Furthermore, to meet the new medical loss ratio minimums that, under health reform, compete directly with profit margins, health plans must find innovative ways to quickly drive down administrative costs, fraud, process waste, and the complexities of doing business.
By using BizTalk Server to convert HIPAA 5010 transactions into electronic documents that are human- and machine-readable, health plans can redesign and automate labor intense and error-prone processes by tightly coupling administrative transactions with customer service, medical management and financial processes — including claims auditing, investigations, authorizations, referrals, fraud and abuse, utilization management, appeals/grievances, online sales, enrollment, and customer service.
Coupled with platform technologies, such as Microsoft SQL Server 2008 and Microsoft Office SharePoint Server 2007, the Microsoft platform provides straightforward ICD-10 compliance so that it can be sent and received in time for the October 2013 deadline. It also integrates with the entire suite of Microsoft tools and interoperates with legacy applications and Java-based platforms, so the organization’s legacy systems can be integrated into the platform.
About Microsoft in Health
Microsoft is committed to improving health around the world through software innovation. Over the past 13 years, Microsoft has steadily increased its investments in health, with a focus on addressing the challenges of health providers, health and social services organizations, payers, consumers, and life sciences companies worldwide. Microsoft closely collaborates with a broad ecosystem of partners and develops its own powerful health solutions, such as Amalga and HealthVault. Together, Microsoft and its industry partners are working to advance a vision of unifying health information and making it more readily available, ensuring the best quality of life and affordable care for everyone.
About Microsoft
Founded in 1975, Microsoft (Nasdaq “MSFT”) is the worldwide leader in software, services and solutions that help people and businesses realize their full potential.
“We are positive that our BizTalk 2009-based solution will certainly help us meet our 5010 and ICD-10 compliance objectives and deadlines as it eliminates obligation of augmenting or enhancing legacy solution to accommodate HIPAA 5010/ICD-10 requirements. Out of the box capabilities of BizTalk 2009 has provided our architects and engineers quick headway through designs.” - Nitin Gotmare, Director IT, Molina Healthcare
“The Microsoft and Edifecs technologies will solve a serious set of challenges that we were facing with our legacy systems with regard to performance, product support and transaction standards support. Being “ahead of the curve” is a hallmark of First Medical Health Plan, and our new system will ensure we maintain our leadership status as we move into migration to the HIPAA 5010 standards in our community. The visibility into errors, status and states of transaction business documents will give First Medical Health Plan and its valued provider partners the means to collaborate in a cost-effective manner.” - Melvin Vélez, Information Technology Director, First Medical Health Plan Inc.
“By enabling the BizTalk Server 2009 to accept 5010 transactions, Microsoft has simplified an important first step of 5010 compliance for payers using .NET. With this covered, payers can focus on upgrading their core administration systems to accept these transactions and prepare for ICD-10. TriZetto’s QNXT 4.7 core administration platform, which is built on Microsoft .NET and accepts BizTalk transactions, provides the path for payers to meet the January 2011 5010 level 1 compliance date and focus on becoming ICD-10 compliant before the 2013 deadline.” - Marty Newton, Vice President of Product Management, TriZetto QNXT product.
0 comments :
Post a Comment