A healthcare insurer with more than two million members is bound to feel growing pains as membership expands, while at the same time the company tries to reduce costs.
To complicate matters, Trigon Blue Cross Blue Shield ($2.4 billion in assets) aims to provide "hassle-free, world class service," says Breck Hall, director, document management services (DMS), Trigon.
However, in order to provide great customer service, Trigon (Richmond, VA) had to automate and streamline processes that had become unbearable staffing hogsnamely the processing of nearly 250,000 claims per week.
Designing and building an imaging and workflow system that connects to many of the company's systems is not an easy taskespecially with a growing reliance on outside technology help. To do that, a good project management structure needs to be in place. "All IT purchases are based on business goals," says Phil Crowder, director, information technology. "When the goals are identified, business and IT leaders develop the operational strategy to achieve them. Each part of the strategy usually becomes a separate project."
The joint business/IT team considers criteria such as the future of the technology, the future of the vendor, flexibility of the vendor and the technology, maintainability, value and whether the technology satisfies the business goals, according to Crowder.
When it came to upgrading the existing Eastman Software imaging system in '95 because Trigon's DMS employees were becoming swamped with paperwork, the joint project development team brought in outside help. Imerge Consulting (Warrenton, VA), an imaging consultant, helped Trigon find a system that would tie into the Eastman product.
"After sorting paper claims into batches by type, the claims were scanned for archiving purposes," according to Hall. When possible, imaged claims were run through an optical character recognition program (OCR), but only one-third of the documents could be scanned. As a result, the remaining two-thirds of paper claims were rekeyed into the system. "A backlog developed, and outside service bureaus were contracted to pick up the balance of the work," Hall adds.
Imerge helped Trigon choose Recognition Research, Inc. (RRI, Blacksburg, VA) and the forms processing vendor's FormWorks, an image-based solution used for automating claims data capture.
According to Louis Rolan, Trigon DMS team leader, "RRI understood our need to get claims quickly and accurately into our system." The FormWorks system has given Trigon huge productivity gains, Hall adds.
"Rather than being scanned twicefirst for archiving, then for OCRclaims are scanned only once," according to Hall. "The three days it previously took us to get our claims into the system has been reduced to just one day. Batching of paper claims in the DMS has been reduced."
Efficiency has also improved. According to Hall, with the old Eastman system, data entry productivity was fewer than 150 claims per hour, per operator in the OCR application, and only 50 claims per hour, per operator, in the manual keying environment. Today, with FormWorks, the numbers have increased to "300 claims per hour for HCFAs, and are averaging more than 200 per hour when combined with ADA American Dental Association claims," he adds.
Trigon's focus on efficiency and cost reduction with the workflow system has also been expanded to other areas. In mid '99, Trigon and RRI expanded the use of the workflow system to include the automation of the Interplan Teleprocessing System (ITS), responsible for processing out-of-network claims.
Chris Thompson, RRI executive vice president, says ITS was automated after "a thorough review of some very complicated rule sets. We saved Trigon almost half a million dollars in labor and improved the accuracy of the process," Thompson adds.
In 2000, the OCR Enhancement Project was launched. "An advanced rules engine now provides an unprecedented level of accuracy from paper claims, on top of the six-fold increase in efficiency," Hall notes. "Thousands more claims are adjudicated without human intervention."
The fact that Trigon had so much success with RRI means it will increase its use of external vendors in the future. "Five years ago it was about 70 percent built/30 percent bought," Crowder says. "Today it is reaching 50/50. We believe our five-year horizon will have it about 20 percent built/80 percent bought."
By leveraging external sources for technology development, Trigon can expand and launch new initiatives, Crowder says. Some of the most recent initiatives include a browser-based physician application at the point of care and ongoing development of the infrastructure to support e-commerce applications. "Further extention of our services to the end user" and "the expoitation of our data to continue increasing the quality of health services" will be two results of the initiatives, Crowder says.
With the increasing percentage of external IT development, Crowder says that managing vendors is critical. Trigon has a "careful vendor selection process," which makes sure each vendor has "comprehensive contracts."
COMPANY NAME: Trigon Blue Cross Blue Shield, Richmond, VA, $2.4 billion in assets under management.
LINES OF BUSINESS: Insurance/Managed Care. Trigon is Virginia's largest managed healthcare company, providing a broad range of health, wellness and healthcare financing programs and services.
KEY EXECUTIVES: Phil Crowder, director, information technology; Breck Hall, director, document management services; Louis Rolan, team leader, document management services.
KEY INITIATIVES: A claims imaging, optical character recognition and workflow system designed to handle 250,000 weekly member and provider claims. Also, a browser-based physician Internet application for use at the point of care.
KEY TECHNOLOGY/VENDORS: Recognition Research, Inc. (RRI, Blacksburg, VA) image-based forms processing solution; Imerge Consulting (Warrenton, VA); Eastman Software (Billerica, MA) imaging system.
WHAT IS YOUR GREATEST BUSINESS CHALLENGE?
BRECK HALL: "Providing hassle-free, world class service while continuing to reduce costs."
HOW IS TECHNOLOGY SUPPORTING THAT CHALLENGE?
HALL: "Technology is allowing us to automate many business processes. This helps us to process our documents quickly with improved accuracy and consistency. This frees up our associates to spend their time on more value-added functions like resolving complex cases and being advocates for our customers in meeting their healthcare needs."
Greg MacSweeney is editorial director of InformationWeek Financial Services, whose brands include Wall Street & Technology, Bank Systems & Technology, Advanced Trading, and Insurance & Technology. View Full Bio