empowering the business of healthcare€¦ · tailoring edi workflow optimization for clients greg...

EMPOWERING THE

BUSINESS OF HEALTHCARE

Automate Your EDI Transactions

for Significant SavingsAutomate your EDI transactions and achieve significant savings through

reduced investment in management and support

KEY TAKEAWAYS FROM TODAY’S SESSION

What does EDI automation mean? What is Administrative

Simplification?

Why does it matter and where can

it be applied?

What are the easiest ways to

achieve automation?

How do you put it all together to reduce EDI administrative effort, improve

operations and lower transaction costs?

EMPOWERING THE BUSINESS OF HEALTHCARE.

Dean Hill 25 years in healthcare

systems

Leads client delivery

team for EDI

transactions

Over > 450 X-12 client

implementations

Responsible for

conceptualizing and

tailoring EDI workflow

optimization for clients

Greg Sparhawk 27 years in IT Systems

Architecture/Management

14 Years in IT/EDI

Operations

Bob Kraus 24 years in info-security

and availability and

enterprise platform

Jamie Chesak 20 years of designing,

developing, and

supporting database

applications

Devotes professional

time to the architecture

of an integrated X-12

transaction engine for

healthcare PLEXIS

EDI Specialist Team

PLEXIS is trusted and built on partnership


With years of experience developing and implementing EDI

solutions – we understand you and your business

KEY TAKEAWAYS FROM TODAY’S SESSION

What does EDI automation mean? What is Administrative

Simplification?

Why does it matter and where can

it be applied?

What are the easiest ways to

achieve automation?

How do you put it all together to reduce EDI administrative effort, improve

operations and lower transaction costs?

Let’s first start with

Administrative Simplification

then move to EDI automation

1


WHAT IS ADMINISTRATIVE SIMPLIFICATION + WHY DOES IT

MATTER?

HIPAA was enacted in part to

reduce administrative overhead 1 2 EDI was the driver to achieve

savings

3Savings is realized by

completing all of the steps Implementing EDI

Defining the complete EDI workflow

process

Optimization: Identifying and removal of

bottlenecks

Automating Processes

Managing the exceptions and responses

4Automation is lifecycle process

workflow from beginning to end Accurate and consistent information

Faster error identification and remediation

Improved availability of systems

Increased usage and scalability

Measuring performance and results

Service Levels met or exceeded

Continuous process improvement

ROI/Cost

Savings for

automation of

EDI workflow


1. End-to-end digitizing of the value chain

2. Eliminating paper across the whole system

to reduce errors and cost

3. Significantly speed up transaction

processing throughout the entire system

4. Cost transfer/reduction from full time

employee to platform automation

5. Deflection of customer support calls to

web-based self-service

6. Increased service levels to 24x7 via web-

based self-service

7. Reduce current EDI processing cost by

30-40%

SO WHAT DOES EDI

AUTOMATION

REALLY MEAN?


WHAT DOES EDI AUTOMATION REALLY MEAN?

Defined work flows

– cannot automate what is not defined

Technology Discipline

Communication - EDI is a two-way

Street

Performance Monitoring / Management

Code Files, Business Rule Maintenance

Visualization of the workflow

– cannot manage what you cannot see Rapid recovery of anomalies in the process

Automated Workflow

Secure FTP

Correct/Resubmit Encounter Data

Run ReportsAdmin Portal

Plexis Data and

Transaction Repository

Plexis EDI Transaction

Rules Engine

EDI X12 Encounter Data

Plexis ScheduledCMS Extract

CMS (Medicare)EDI Processing

Engine

EDI X12 Pended Encounter Data

CMS Accepted Encounter Data

CMS Accepts Encounter

Data?

Plexis CMS Job: Process

Encounter Data

Secure FTP

Payer

Update Database

EDI X12 Success Response

Secure FTP

CMS Encounter Data Processing

YesNo

Pend Encounter DataReply to Plexis

Accept Encounter DataReply to Plexis

MAO Reports

+


WHAT DOES EDI AUTOMATION REALLY MEAN?

Defined work flows – cannot

automate what is not defined

Visualization of the workflow –

cannot manage what you cannot

see

Technology Discipline

Communication - EDI is a two-way

Street

Performance Monitoring

Maintenance of Code Files,

Business Rules

Automated Workflow

Secure FTP



Plexis Data and



Rules Engine




Engine

EDI X12 Pended Encounter Data



Data?


Encounter Data

Secure FTP

Payer

Update Database

EDI X12 Success Response

Secure FTP


YesNo

Pend Encounter DataReply to Plexis

Accept Encounter DataReply to Plexis

MAO Reports

+

Workflow Scenario: Encounter Data

Automated Workflow

Automated Workflow

Secure FTP



Plexis Data and



Rules Engine




Encounter DataResponse

Secure FTP

Payer

Update Database


Yes

EDI 999, 277, Other

Response Files



Data?No

Pend Encounter Data

Accept Encounter Data


Engine

Send Report File

Job #1: Scheduled Extract @ 1:00am. Log Event Start, Stop, Outcome

Job #2: File verification Run communication scripts to send file Log event Start, Stop, Outcome

Job #3: Monitor above, log reports and exceptions (check)

Job #4: Fine tune process based on results (adjust/improve)

3 HIGH IMPACT AREAS FOR

ACHIEVING EDI AUTOMATION

Customer

Service

EDI

DepartmentMonitoring

+

Reporting


AUTOMATE CUSTOMER SERVICE

Implement workflow to support

automated portals – using X12

Example: Provider Portal

visibility to X12 Transactions

Main Ingredients Submit - Claims

Inquire - Claim Status

Verify - Eligibility and Benefits

Submit/Change - Authorization

for Service

Receive/Lookup - payment files


AUTOMATE CUSTOMER SERVICE

Implement workflow to support

automated portals – using X12

Example: Provider Portal

visibility to X12 Transactions

Main Ingredients Submit - Claims

Inquire - Claim Status

Verify - Eligibility and Benefits

Submit/Change - Authorization

for Service

Receive/Lookup - payment files

Benefits of Automation:

Show workflow for automation of steps to

pull out Claims, Payments, Enrollment,

Messages

Provider Portals Automate a phone call

for status to customer service versus EDI

Identify the top 10 calls to customer

service

Transfer FTE expense to automation

investment

Portals: Provider; Member; Employer


AUTOMATE YOUR EDI DEPARTMENT

Focus on highest impact transaction

volume - Encounter Data

Automate your external interfaces

for exchanging files

Show Workflow on Encounter Data

Submission and response handling

Introduce the EDI Gateway Solution

for automating EDI workflow


AUTOMATE MONITORING +

REPORTING

Describe the specific tools that

need to be monitored in an

automated environment. Why it is

different.

Notification Management

Visual monitoring and remediation

of the response

Enabling the ability to see and track

submittals and response

Real-time and batch measurement

of EDI workflow


AUTOMATE MONITORING +

REPORTING

Describe the specific tools that

need to be monitored in an

automated environment. Why it is

different.

Notification Management

Visual monitoring and

remediation of the response

Enabling the ability to see and

track submittals and response

Real-time and batch

measurement of EDI workflow


Key Questions to Ask:1. How confident are you in understanding your EDI workflow?

2. Have you defined your complete workflows and documented them?

3. Do you utilize a solution to visualize EDI data workflow?

4. Have you identified your efficiencies or obstacles to full automation?

5. What is your fall-out on transactions submitted?

6. Do you have a performance management process?

7. Do you have additional questions or want to explore some ideas?

8. Would you be interested in follow-up 1:1 session with our subject matter

experts from today’s call?

AUTOMATING EDI: KEY QUESTIONS TO ASK


FREE ASSESSMENTLet our EDI Specialists at PLEXIS help identify roadblocks

with your EDI workflows. Our free assessment includes:

Identifying common

symptoms of process

deficiencies

Prescribing best practices

for maximizing the value of

your data

THANK YOU FOR YOUR TIME

QUESTIONS?

If you have any additional questions or would like a 1:1 demonstration of PLEXIS EDI, please

send an email to [email protected] or send an inquiry through www.plexishealth.com★

empowering the business of healthcare€¦ · tailoring edi workflow optimization for clients greg...

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