Insurance network improves CX with standardized EDI processes
Insurance network develops internal tool for plan member enrollment and eligibility electronic data interchange files to standardize client experience and internal processes.
Client background
A member organization of a network of dental and vision coverage operating in all 50 states, Washington D.C. and Puerto Rico.
The business challenge
As the insurance organization grew and took on new customers, they were able to set up one-off special handling rules to accommodate non-standard eligibility files because they owned the source code for their system. Over the past 5 years they have been modernizing their business and have transitioned from their legacy system to a new claims and benefit administration platform.
As the organization mainly does group business, they don’t receive unique member identifiers on incoming Electronic Data Interchange (EDI) files. Their new administration platform relied heavily on unique identifiers and required the introduction of custom lookups and member matching logic for the client to be operational. While this was an acceptable solution in the short term, the organization continues to struggle with properly identifying members and creating duplicate member records in their system. This reliance on custom logic has led to increased cost and manual work for the company.
As a result, the insurance organization engaged Baker Tilly to help standardize their client experience and internal processes specifically related to EDI for plan member enrollment and eligibility data.
Strategy and solution
Baker Tilly worked with the insurance organization on a dual workstream approach to standardize client data and internal processes.
The first workstream focused on defining data standards for client files and properly communicating and enforcing those standards. This required analyzing both industry best practices and unique company and administration platform capabilities to develop a standard rulebook for distribution to the organization’s customers. Baker Tilly provided change management support in coordination with the development of these materials to educate the organization’s outreach resources and promote customer compliance.
The second workstream was an internal initiative to account for the differences across customer data. The goal was to determine the best solution for preprocessing data to ensure accurate data load and require minimal manual intervention. Baker Tilly assisted the organization with a vendor selection process for an integration engine which included vendor demonstrations, capability analysis and price comparisons before comparing vendor options to the feasibility of developing their own internal data processing engine.
After consideration, the organization decided to develop their own internal tool for data processing with support from Baker Tilly. This continued effort involved defining requirements for successful data processing, testing and validating various data formats and potential scenarios and providing strategic guidance for implementation.
In addition to these two strategic workstreams, Baker Tilly also assisted the organization with production support during high volume time periods, specifically during open enrollment. Significant effort was put forth to keep the company operational during their busiest production season while long-term solution and communication strategy planning were underway for the following year. This included:
- Launching a coordinated, proactive client outreach program to standardize incoming file processes from the organization’s customer base
- Refining, testing and implementing an interim file transformation processing solution (which had been utilized the previous year with limited success) to bridge the gap between the current-state and the desired, internally developed preprocessing engine
- Logging issues, investigating and solutioning file failures and executing frequent company-vendor and company-customer communication throughout the open enrollment period
Baker Tilly added tremendous value to the organization’s operational viability as they continued to iterate through their struggles to implement an efficient, successful EDI file intake process.
As a result of these combined efforts, this insurance organization was able to modernize and standardize their EDI processes as well as:
- Improve customer experience
- Structure data intake and load
- Reduce manual intervention
Similarly, another member group also faced obstacles in EDI file handling and member data processing. Learn more about the solutions implemented here.
