BCBS Association Monitors Transaction Quality With Bristol Technology

For the BlueCross BlueShield Association (Chicago), the decentralized structure of its nationwide services created a challenge when it came to managing stalled inquiries from healthcare providers and their patients. Newly implemented transaction-monitoring software from Bristol Technology Inc. (Danbury, Conn.) is helping it improve the quality of how inquiries are handled.

Within the association of Blues plans, individual BlueCross BlueShield plans operate independently with their own negotiated rates with local healthcare providers. However, sometimes a portion of the claims that come to a local plan involve subscribers covered by another plan. National Account Service Co. (NASCO, Atlanta) was set up to do some of the processing for those accounts. The systems of local BlueCross BlueShield plans recognize when a claim is associated with another plan and automatically forwards those claims to NASCO.

In addition to processing insurance claims, the insurance company is likely to receive follow-up inquiries from healthcare providers and patients on claim status or eligibility for additional services. Patients frequently wish to change their physicians, check on their benefits, or receive new identification cards, and these inquiries may also come to NASCO when the patient has moved outside the ring of healthcare providers associated with a regional plan.

A doctor from one state who has treated a patient from another state will submit a claim, then "eight days later he wonders what the status of (the claim) is," says Doug Simpson, director of production support at NASCO. "That inquiry is processed ultimately" by the company. The company's systems receive and respond to inquiries, which are monitored by Bristol's TransactionVision. The monitoring application watches the message traffic through IBM's WebSphere MQ and identifies the sequence of steps that completes the message transaction.

Sometimes a healthcare provider's inquiry doesn't use the correct terminology for a treatment and the message stalls. TransactionVision uses sensors placed in WebSphere MQ to track inquiries and can drill down to follow an individual message, helping pinpoint the step where it failed.

Such identification saves the time of systems and network managers and database administrators, who in the past would have to pore over system logs looking for the step that failed. It also improves customer relationships by reducing response time to healthcare providers and patients.

At other times, an inquiry makes it from the local plan's system to NASCO, then stalls somewhere on the network on the return trip to the local plan. "There are a number of points of failure with an inquiry," Simpson says.

Simpson also uses a feature in the tracker, the TransactionVision dashboard, to get real-time indications on performance, letting his staff know how well BlueCross BlueShield customers are being served. NASCO's systems administrators can readily see whether response times for submitted inquiries are in line with expected norms or unaccountably slow. "A regional plan may say, 'I sent you a bunch of messages and your response time is terrible,'" Simpson says.

Or the monitoring system can provide proof that the problem isn't with NASCO's message processing but in another area. That proof can put to rest arguments over where responsibility lies for bad performance or lost transactions. "We humans expect instantaneous answers," Simpson says.

The application also tracks incoming messages that take a heavy toll on the IT infrastructure, which assists with capacity planning. Says Simpson: "That helps you right-size your environment while still providing superb services."

EDITOR'S NOTE: This article originally ran in InformationWeek, a sister publication of Insurance & Technology.