Rheal Software

  Client Background

This client is an innovator born from the experience of its leadership team who have deep domain expertise in the fields of clinical medicine, provider reimbursement, health economics, software development and employee benefits. They use this unique skill set to crack the code on shopping for health care. They have applied years of experience working with medical claims to determine medical service and prescription drug prices for both in-and out-of-network providers. They convert these findings into an actionable consumer health care shopping service delivered as an employee benefit.

  Challenges

The client has their many clients for which they processes the data that produce a defined output and provide different kinds of services. The data is received by the client as raw data files in the form of text/csv files. This data needed to be processed and stored into the database system and is then needed to be presented in the required formats based on the different requests.

Further, client has employed a call center that provide online help to their members. However, there was no automated system in place that kept a record of the details of the call, maintained its status or tracked their progress. A member would simply call in and ask for help and the call center agent would simply verify the caller and then proceed with the call. The call center staff simply used an adhoc Excel and paper based solution which was extremely slow and cumbersome to maintain.

There was also a requirement to develop a system that would validate the Medicare eligibility of a member. This entailed generating encrypted 270 formatted requests as per HIPPA guidelines, communicating these encrypted requests with Medicare and retrieving the response in the 271 format. It was then required to decode the response, process it and then save the information in the database.

  Solutions

Rheal helped this client to process the data using SQL scripts, SSIS packages, and stored the data in the SQL Server database. We then built several SSRS reports as per their requirements that presented the data back to the user in required format as and when needed.

We built a web based system that provided with all the CRM functionality they required for their call center. The system recorded detail of the calls, maintained their status and provided instant information for the call center agents.

We also developed a utility that generated the encrypted 270 request, sent the request to the corresponding Medicare provider, retrieved the response, processed it and stored the results in the database. This utility could be called independently or from within the application. It store the results in the database so that all the members could view it from within the application.

  The Result

With the implementation of the data processing routines and SSRS reports, all the data that is required is available online as and when needed. The call center application made it very easy for their staff to maintain call records, track calls, and generate reports. The Medicare eligibility data was now dynamically available in the database thereby streamlining the validation process. Rheal has played an important role in keeping day-to-day processes on schedule and has helped the client to save developments costs and grow their business.