Securing approval for healthcare appointments requires rigorous application of business rules to determine patient eligibility. The greater the degree of automation in the process, the faster business can be done and the happier healthcare providers will be.
Eden Prairie, MN-based CIGNA Behavioral Health (CBH)a wholly owned subsidiary of CIGNA Corp.works with a network of 40,000 therapists serving a pool of about 13.5 million covered individuals. Before therapists can schedule sessions for a covered individual, they must first submit an approval form to CBH. This was a burdensome process historically, since accompanying clinical and administrative information was mostly sent in written and telephonic format, according to Jodi Aronson, vice president, clinical operations, CBH.
Feedback from providers resulted in the implementation of an electronic submission application that involved sending Microsoft (Redmond, WA) Word documents through the carrier's Web site, but problems remained, according to Aronson. Business rules for approval were scattered throughout many software applications and accessing and changing them was difficult and slow.
"Since we had such interest among the providers, we looked for ways to give providers greater ease of administration," Aronson says.
After determining basic requirements and design, CBH pondered over solution options, according to Dave Carl, director of data warehouse and e-commerce development. "We asked ourselves, 'Do we look at a tool that will provide a knowledge engine-type capability for us, or do we code it like we've coded stuff in the past?'" he relates. "The decision came pretty quickly that we would like to have a more sophisticated tool to handle all the rules the system would be executing."
CBH undertook an RFI process to identify candidates and invited them in to present demos and to give CBH's IT staff the opportunity to evaluate their systems. In February 2001, CBH selected The Haley Enterprise's (Sewickley, PA) Authorete graphical, speech-driven interface and CIA Server, which were to be supported within a home-grown Web application called eCare. "Authorete is the tool we used to establish the rules that would be used by eCare, and CIA Server executes those rules," Carl comments.
"One of the key differentiators from other products was that Haley had an interface that enabled a non-technical person to understand what was going on with the application," Carl says, adding that price, support and ability to integrate with the Java-based Web site were other factors. CIGNA consulted the clinicians for purposes of rendering the approval rules into English, using Authorete.
Starting in October 2001, "we ran a pilot involving 25 providers targeted on various ISPs, computer platforms, locations, and having varying degrees of technology knowledge," says Aronson. "We had them use the tool for a number of weeks so we could get their feedback, on things such as ease of log-in, system response, movement from page to page and the time it took the system to process what they loaded.
User response to the capability the Haley tool brings to the eCare solution has been very positive, says Aronson. "There's no software they had to purchase, no cost for using the system, and they get immediate feedback to approval requests." Built-in rules inform clinicians if any needed information is missing from the request, meaning no days are wasted returning forms for correction.
The process speeds approval for the 65 percent of cases that need more CBH involvement; 25 percent result in immediate approval, according to Aronson, who calls that figure "a very good start."
The solution enables the carrier to handle more requests with present staff, enables rule changes to be made easily using ordinary language, and has potential for re-use in other applications. "Right now it's only touching one portion of our business, but there may be others, such as our employee assistance program business," Aronson says, adding that CBH is currently studying that possibility.
CASE STUDY CLOSEUP
CIGNA Behavioral Health, Eden Prairie, MN, subsidiary of CIGNA Corp., Philadelphia, $88.7 billion in assets.
LINES OF BUSINESS:
Healthcare products and services.
Haley's (Sewickley, PA) Authorete software and CIA Server.
Speed care request approval.
Anthony O'Donnell has covered technology in the insurance industry since 2000, when he joined the editorial staff of Insurance & Technology. As an editor and reporter for I&T and the InformationWeek Financial Services of TechWeb he has written on all areas of information ... View Full Bio