Case Study

Case Study

Managing Complex Healthcare Data

Customer Success Story: Adeptia streamlined the processing of information for Centivo, a health plan for self-funded employers

About the Company

  • Industry: Health plan for self-funded employers
  • Employees: 222
  • For more information: Visit centivo.com

Benefits

  1. AI-driven Data Mapping/Self-service:
  • Centivo business users can implement data integration without the need for IT data integration experts.
  1. Automation:
  • The process is simplified and templatized, making integration 80 percent faster.
  1. No-code Templates:
  • Reusable templates mean no coding is needed as new business connections are added.
  1. One-to-many App Connectors:
  • Business partners can easily and securely exchange data from their own cloud app instances.

The Challenge

In order to deliver on its mission to create and administer health plans, the Centivo team manages the data that is transmitted between healthcare-related companies in order to provide patient care. At a high level, these business entities include providers, payors, plan sponsors, participants, and regulators. The complexity of data standards, carrier-specific business rules, regulatory compliance requirements, and high stakes involved make this healthcare data very challenging information to manage and integrate.

There are many systems-of-record and databases among the various healthcare system entities, and the message, document, and data transaction set standards are extensive. The challenge is to digitally connect and exchange data between employers, payroll providers, insured participants, network medical providers, insurance carriers, pharmaceutical networks, regulatory agencies, claims processors, government benefit program services, care facilities, third-party insurance brokers and advisors, and a large number of internal company departments including actuarial, underwriting, compliance, accounting, billing, rating, policy management, product management, and much more. While this is a long list of data exchange endpoints, the actual list is actually even longer due to the variety of different types of documents and messages needed to support the operations of healthcare. The vagaries of data formatting, access methods, business rules, and exception management processes associated with external data exchanges add even more complexity.

Of course, this is not just any “data” that’s being exchanged. It’s important data. It’s sensitive data. Healthcare data must be exchanged using the best, most careful, and most secure methods. High quality data integration and data management support high-quality patient care and outcomes as well as affordability.

In order to ensure healthcare plans are affordable while providing the best in healthcare data management, Centivo must be able to connect with new employer plan sponsors, care providers, and pharma providers easily. The typical business-to-business data integration implementation that requires weeks (and sometimes months) of expert IT integration developer time is not sufficient.

And the ongoing management, maintenance, and troubleshooting of those B2B data exchanges is labor-intensive, with IT integration experts required to be on call. The status-quo in B2B data integration doesn’t help Centivo in its mission to deliver highquality affordable healthcare insurance plans.

“It’s really about maintaining the tool and getting it set up in the first place, and how easy and quick it is for your teams to do that. “
– Michael Mann Integration Architect, Centivo

Partnering with Adeptia

Centivo utilized Adeptia to streamline data integration, achieving faster cycle times, reduced costs, and simplified connections between employers, payors, care providers, and regulators.

The Business Value

For Centivo, the business case to take action and implement Adeptia data integration software was based on the significant productivity savings that Adeptia enables. Saved IT labor results in reduced costs while shortening the cycle time to implement new data connections. Additionally, because there was a significant seasonal demand for IT integration labor to support signing on new employer-sponsored plans, Adeptia solution’s helped Centivo reduce the spike in data integration labor demand that precedes new benefit plan years. Further, by automating and simplifying many of the more mundane data integration connections, Centivo’s expert IT integration staff are freed up from endless rote work. It’s boring and unfulfilling to establish the same kinds of connections day in and day out using very similar data domains and data semantics that have only slightly different field names and variations in business rules. These experts are needed in other priority projects at Centivo. Adeptia automates what can be automated and simplifies the remaining work into templates that can be implemented with less expensive business team resources.

The prior manual way of implementing B2B integration was more error-prone and required more rounds of testing for each connection. When reusing an integration template that’s working with dozens of other similar business connections, there’s a faster cycle time to completion with a higher quality connection.

Document Flows

B2B data integration is challenging in the healthcare industry because of the number of different document types and transaction sets that must be perfectly implemented between business entities. Here are a few key examples:

Benefits Enrollment/Management:
– Benefit Enrollment (EDI 834)
– Coverage Accepted/Rejected (EDI 999)
– Benefits Maintenance (EDI 834)
– Changes Accepted/Rejected (EDI 999)
– Premium Payment Advice (EDI 820)

Healthcare Claims Processing:
– Coverage Inquiry (EDI 270)
– Coverage Response (EDI 271)
– Provider Insurance Claim (EDI 837)
– Claim Adjustment (EDI 835)
– Claim Status Request (EDI 276)
– Claim Status Response (EDI 277)
– Claim Remit Advice (EDI 835)

Pharma & Dispensing Entities:
– Prior Authorization Response (EDI 278)
– Pharma Insurance Claim (EDI 837)
– Claim Adjustment/Response (EDI 835)
– Claim Remit Advice (EDI 835)

Partnering with Adeptia

To reach beyond the typical data integration platform capability set, Centivo drew upon Adeptia’s unique software capabilities to reimagine its approach to data integration and achieve business results including streamlined operations, improved productivity, and increased revenues. These product features include:

Self-service: Centivo business users are now empowered to implement data integration with business partners without the need for certified data integration experts. After implementing and rolling new connections into production use, these business users can subsequently monitor, manage, and extend their B2B connections.

Automation: Every automatable step gets automated, reducing complexity. By simplifying and templatizing the remaining integration steps, Centivo’s business users can implement data integration 80 percent faster than the cycle time previously required. Now onboarding new employers/plan sponsors, third-party benefits administrators, physicians groups and hospitals, pharmaceutical networks, and others is faster and easier.

AI-driven Data Mapping: With AI and machine learning providing data mapping assistance, some of the most tedious and error-prone aspects of B2B data integration get streamlined. Centivo has freed up IT experts from seemingly endless data mapping to work on more exciting, high-priority projects.

No-code: Simplified data integration means the hard work to establish flexible and reusable one-to-many templates and connectors is done once, up-front. After that, no additional coding and scripting is needed as new business connections are added.

One-to-many App Connectors: Adeptia’s NextGeneration App Connector approach enables thousands of applications to easily and efficiently connect to Centivo’s data ecosystem, where its hundreds of business partners can securely exchange data from each business’ own cloud app instances.

One-to-many Use Case Templates: Adeptia enables streamlined data integration and process flows with easy-to-use reusable templates that tame multi-enterprise workflow complexity.

Conclusion

By reimagining its data integration with Adeptia, Centivo has been able to streamline implementation of data integration connections while alleviating the labor-intensive work otherwise required of its IT teams. With faster connection set-up, surefire data transformation, higher-quality data exchanges, and better customer experiences, Centivo is growing and bringing its healthcare plans to millions more.

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