Automating Claims Payment Improves Efficiency and Accuracy

Background and Challenge  

When Geisinger Health Plan (GHP), a regional payer in Pennsylvania, needed to upgrade an outdated, time-consuming claims payment system, its leaders engaged Tegria to help them select and smoothly transition to a new platform. The solution needed to save time and resources by automating claims payment and pricing for their Medicare, Medicaid, and commercial lines of business.  

Solution 

Tegria began with a detailed analysis of GHP’s existing claims system and processes, then conducted a comprehensive evaluation of several competing claims processing platforms. GHP used Tegria’s analysis and recommendations to select Cognizant’s TriZetto Facets and NetworX Pricer platforms. Transitioning to Facets would allow GHP to manage multiple fee schedules for a single provider and share pricing methodologies for multiple providers at one time. 

To ensure an accurate and timely transition to Facets, Tegria’s experts converted the existing Oracle database to Microsoft SQL through the data governance council. They also documented the existing Amisys and vendor data to be readable across multiple platforms. The Operational Data Storage (ODS) was created and configured to convert existing data into a cross-platform, central source of truth that would allow GHP to communicate with third party vendors such as pharmacy, radiology, and credentialing. 

Tegria successfully installed and configured Facets and NetworX Pricer to automate more of the claims payable process. The ODS was ultimately migrated to the Hadoop Distributed File System platform for expanded storage, scalability, and speed.