Case Study – HMS

Canada-based Company collaborates with New Tier Technologies to Modernize & Improve its

Legacy Healthcare Management System

  • Healthcare
  • Insurance
  • Corporate Insurance
  • Employee Benefit Programme
  • Claim Settlement
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Healthcare Spending Account

Overview

New Tier Technologies’s Healthcare Management System (HMS) benefits the admins, employers, and employees by offering a digitized, modern, and dynamic system to provide quick access to the healthcare spending account. Our end-to-end enterprise software offers swift employee enrollment, automated member management system, billing, and claims workflow, for efficient and fast claim approvals and settlement, according to the organization’s policies. The Adjudication engine checks that no false claims pass through.

Our Client

Based in Canada, our client supports various businesses, ranging from large enterprises, SMBs, to start-ups, for more than 30 years. The company offers innovative & flexible Employee Benefit solutions, and Group plans for medium to large businesses and individuals and sole proprietors for dental, medical, life, vision, and disability insurance. They process thousands of claims in a year worth millions of dollar.

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client

Challenges

Our client’s legacy system was more than two decades old and was based on out-dated technology. The existing system was not dynamic, scalable, and did not offer quick data visualization access for accurate decision-making. The company wanted a revamped system designed with the new-age and advanced software platforms to offer best-in-class User Experience. An automated and strategic report generation system for a variety of health claims was required to design the most-suited plans at affordable costs for various businesses.

Our Strategy & Solutions

Legacy Modernization

The continued process of transforming Legacy Systems aims to reduce IT environment complexity and costs, while increasing data consistency, enabling collaboration across platforms and improving process flexibility. We studied the existing system to retain and extend the legacy investment value through migration to new media. One of the major challenges was to ensure that the modernized system has similar capabilities with compatibility with existing data formats. Our developers successfully transformed the old IT system into a new digitized environment and improved business agility using the latest technologies, contributing to rapid results with reduced costs. It also added more flexibility across diverse organizational processes, according to their client requirements.

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Paperless Claim Processing

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  • Faster Turn-around Time

    Processing claims becomes more comfortable with New Tier Technologies’s HMS, and claim processors can easily manage and track different claims. The claimant can also communicate effortlessly any information that is required for the processing of claims. The online repository of documents aids in faster multi-level approvals.

  • Improved Efficiency

    Original receipts can be attached electronically and for better verification and authenticity checks, whereas a paper-based portion can still be retained for those who require original receipts.

  • Easy to maintain records

    The HMS leads to easy access to health spending account and provides quicker access to getting approvals from managers, anywhere, on any device, at any time. The Accounts and Finance Departments have complete visibility and control over the information flow.

  • Bullet Features

    • Initiate claims through Phone
    • Handling Claims through e-mails
    • Interconnectivity of Companies and Service Providers

  • Flexible Plan Design

    HMS offers complete flexibility as business owners can choose a standard plan design or create a customized program to ensure that their organization’s unique needs are met. Customizable plans allow them to set their own set of coverage for different groups of people.

  • Calculations Based on Specific Plan Selection

    Depending on the client’s needs, New Tier Technologies’s HMS provides a customized plan that works and strategically incorporates some or all the elements of different algorithms like, Sliding, Tiered co-pay, Annual Deductibles, Customized Formulary Creation, and Maintenance.

  • Specialized pre-calculated Plan Design Options

    There are specialized plan design options for varied fee guide options for dental, vision, health, and drug fee guide options. HMS also offers grouping of various categories with variable maximums, deductibles, and time definitions.

  • Bullet Features

    • Creation of Customer Specific Plans
    • Covers all major Healthcare benefits
    • Supports On-the-Go Plan alterations
    • Tailor-Made process for customer satisfaction

Right-Fit Benefits: Customizable Plans

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Multiple Claim Secure Benefits

The HMS offers easy and quick access to claimsecure login that provides claim benefits on your health spending account, vision care, dental care, prescription drugs, etc.

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  • Interlinking of Provincial Fee Guide

    HMS is capable of automatically identifying the employee’s province and calculates the fee accordingly. The Latest Fee Guide linkages are dynamic, and the employee need not make changes every year, even if a new fee guide is prepared.

  • Rule-based Algorithms

    The system validates all the pre-defined rules set before making any commitments to provide to the customer. iHMS allows admins to make as many rules as crucial to define the diverse trigger points, including the input-output parameters.

  • Dynamic Tree Structure

    New Tier Technologies’s HMS allows a hierarchical allocation of services under different sets of benefits. It helps in easy identification of services/benefits relation, and the employees/admins can select or unselect any benefits of their choice or customize as per requirements. The Adjudication engine ensures that no false claims pass through.

  • Coverage Maximums

    Our system provides full flexibility to the user so that the Maximum Coverage Limits can be specified on an individual and/or family level. It helps in capping payouts and can be defined at various levels, depending upon the requirements.

  • Bullet Features

    • Cover Major Health Categories
    • Integration with Rules Engine
    • Sync with the latest Universal Fee Guide
    • Provision to allocate customizable benefits to customers

  • Other features

    • Capping of pricing based on the customer plan.
    • Allocation of benefits based on Card
    • selection. Track and manage change requests for benefits.

  • Customized Fee Guide

    Define suggested fees that serve as a guide for each province; Add dental codes corresponding to every guide. Create a fee guide using the previous year’s fee guide or create a new one from USCLS (Universal Fee Guide).

  • Import Proc. Codes

    It is a simple yet essential function that lets you import Proc. Codes list corresponding to provincial guide, Sample Proc. Code list is already provided for you to help with the import process and template.

  • Update Proc. Amounts

    Next time when Federal/Provincial fee guide rates are updated, simply open Fee Guide and update proc. Codes amount in no time by clicking any line entry and update the amount. For cases when full series amounts are updated, use the Bulk update operation.

  • Bullet Features

    • Add Customized Fee Guide for different Provinces/Cities
    • Effortlessly add amounts for each proc. Code.
    • Import list of Proc. codes in fee guide
    • USCLS – Setup to add Universal Fee Guide

Fee Guides

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Rule-Driven Adjudication – Customizable Rule Engine

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  • Add Rules

    Operators who have limited programming languages can also easily add rules. Defining rules for different benefit coverage categories, contributes in setting of inputs and dependent parameters.

  • Define Rules to Plan

    HMS allows the admins to define rules as per the requirement, and attach rules to respective plans. The “Rules Screen” allows attaching rules directly, without the need of visiting every plan repeatedly, for designing new rules.

  • Attach Rules to Plan

    Attach Plan specific or universal rules as defining rules is easy with the Rules engine. Choose trigger points for all rules – as you might be interested when these rules should be called and what should be their action.

  • Bullet Features

    • Defining Rules made easy
    • Customized Rules for any benefit category
    • Define Plan specific / Universal rules
    • Attach rules directly to company’s plan

  • Automated Reporting

    Generating Reports automatically, at the end of the day, helps in sharing the details of the claims which are approved/ unapproved to track the daily progress.

  • Improved Workflow

    Sending claims back to the claim processors or supervisors when additional information (like X-ray or Medical) reports are required, improves workflow.

  • Add Doctor Comments to EOB

    The system allows adding EOB (Explanation of Benefits) and internal comments to the claims. EOB comments are made available in the EOB form for detailed analysis.

  • Bullet Features

    • Allow Doctors to review claims which claim operators can’t handle.
    • Add the Doctor’s comments to EOB
    • Improved Doctors’/Operators’ workflow

Doctor Review Mechanism

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Online Plan Administration

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  • Manage Beneficiaries online

    Once a customized plan is developed to the employer’s satisfaction, our client provides an option to add benefit cards for their employees. Smartphone users will also register and receive electronic health cards from their secure Member account, which they can store electronically for display upon purchase. All this can be done online, and Plan members are now ready to submit claims.

  • Notifications

    Our clients count on us to save on time and money, and we prove this by sending timely updates and critical information in the form of notifications. The software informs Plan Administrators on all the approvals required and information to be transferred using the Plan Administrator Portal and allows administrators to quickly respond to that online.

  • Change Maximums

    We put together a customized plan on the agreement of the right approach, strategically incorporating some or all of the elements required. However, there can always be a need to change things like maximums; and the Administrator portal will allow you to manage this online easily

  • Customizable Taxes

    Taxation in Canada is a prerogative, which is shared between the federal government and the various provincial and territorial legislatures. Hence, there are many taxes and rules. Our software allows setting as many taxes for different states; and our Tax engine allows you to add and change taxes in the simplest of ways.

  • Set “What the Tax Applies On”

    The shared prerogative between federal and provincial governments allows provinces to set different rules for taxing the principal amount. Our Tax engine enables the admin to define new taxes and select one or more transactions from the Benefit Process to choose as the principal to be taxed.

  • Set Applicable Address

    Our Tax engine allows you to set which province’s tax is applicable on a transaction if it has taken place in the region or the beneficiary was of the area, or the benefit provider company belongs to the province. We allow multiple rules to be set and hence admins and employees are comfortable handling these scenarios.

Taxations – Customizable Federal and provincial Taxes

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Real-Time Claim Submission and Pluggable APIS

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  • Real-Time Claim Submission

    The HMS allows Cardholders to submit claims online by having free access to our Cardholder Online benefit Tool, powering the submission of new claims, viewing compensation statements and available benefits.

  • Direct Submission by Providers

    The HMS allows providers to connect to their Benefits Program in real-time and have the pre-authorizations, inquiries and claim processing done in real-time, letting providers and Cardholder know approvals and rejections.

  • Cashless Claims

    Direct Submissions by providers allow real-time approvals enabling Service providers to allow Cashless treatments. The system allows real-time payments via Electronic Funds Transfer pay Service Providers, without delays.

  • Developing Custom Applications with our pluggable APIs

    Our unique benefits’ management system allows providers and Benefit management software to use our services; Third-party can request data using our APIs and get the specified response hence making them use our services without doing custom coding.

Technical Specs

Why New Tier Technologies?

New Tier Technologies, a CMMi Level 5 Certified Company, offers a bouquet of services to automate, digitize, and modernize your business network. An authorized partner of Hewlett Packard (HP), and Google, we are a global leader in providing next-gen consulting and digital services for business transformation. Our strong clientele across 50+ countries leverage our wide range of customized services to suit their business needs. At New Tier Technologies, we are committed to delivering high-quality solutions to build a long-lasting alliance. Our clients trust us as we empower them by:

  • Creating Business Value
  • Minimizing Implementation Risk
  • Accelerating Go-to-Market
  • Boost the Revenue Growth of our Partners
  • Maximizing value realization for business owners
  • Optimization of business process
  • Effective organization change management
  • Reaching out to broader markets & demographics
  • Addressing their Specific Needs & Problems
  • Transparency in Strategy & Approach

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