4-page Case Study - Posted 3/14/2006
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Leading Health Insurer Speeds Transactions and Affordably Meets New Business Demands
Horizon Healthcare Services, Inc. (Horizon), the independent licensee of the Blue Cross and Blue Shield Association in New Jersey, automated its claims and referral transactions in 2001 using off-the-shelf integration software. This linked the transactions to its mainframe systems. The integration solution required considerable manual intervention, was hard to adapt to new types of transactions, and often failed to meet required transaction-processing speeds. To address those challenges, Horizon switched to Microsoft® BizTalk® Server to link claims and referral transactions to its mainframe. The transition increased transaction-processing speed by more than 30 percent, simplified integration with mainframe systems, added flexibility for future development, and helped reduce costs by a projected 40–50 percent. It also expedited customer support response from minutes or hours to seconds.
Situation
Since 1932, Horizon has offered high-quality healthcare products and services to New Jersey residents. As the independent licensee of the Blue Cross and Blue Shield Association in the state of New Jersey, Horizon provides health insurance coverage—including managed care, Medicare, and traditional indemnity health plans for individuals, families, and groups—to more than 3.1 million people throughout the state.
As a healthcare insurer, Horizon must comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, which requires privacy of patient information, increased security for information storage and transaction activity, and a single standard electronic format for all transactions. The requirements resulting from that legislation began to take effect in 2002.
Horizon, like many insurers prior to HIPAA, handled many of its claims and referral transactions manually. This was very time consuming and prone to error. HIPAA requires healthcare facilities to assign standard HIPAA transaction codes to charges and requires insurers to process claims according to clearly defined procedures that are verified each step of the way. In anticipation of the HIPAA requirements, Horizon decided to automate those tasks and enable providers to submit claims and referrals online through a trading partner connectivity application.
 | We turned on BizTalk Server and turned off our old EAI tool, and the messages flowed through the new connection…. We could always flip a switch and go back to the old system, but we never had to. |  | | Ken Plotnick,
Manager of Software Development–EDI, Horizon Healthcare Services, Inc. | |
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To facilitate that process, Horizon installed enterprise application integration (EAI) software on a Microsoft® Windows®–based server in 2001 to automatically route claims to its mainframe system through electronic data interchange (EDI) transactions. After using the EAI tool for a while, Horizon found that the solution required extensive administration. For example, manual monitoring activities had to be done four times a day to ensure that the systems operated properly. Each round of activities took 45 minutes, which resulted in 180 minutes lost per day.
“When the transactions came in, we needed to have very clear controls and be able to balance the number of claims we had received with the number of claims processed,” says Raj Shekaran, Enterprise Architect for Horizon. “We had problems doing checks and balances through our old integration solution.”
In addition, the EAI tool was expensive to maintain because the IT staff spent a significant amount of time monitoring and troubleshooting it. These factors persuaded Horizon to look at other alternatives. By that time, the Horizon development group had moved almost entirely to the Microsoft .NET Framework as its development environment. The .NET Framework is an integral component of the Windows operating system that provides a programming model and runtime for Web services, Web applications, and smart client applications. Because the EAI tool Horizon was using was not built on open-architecture, it was difficult to integrate with new systems.
The new integration solution needed to be easy to implement and manage. It also needed to be scalable and able to be modified to meet changing requirements.
Solution
Because Horizon had standardized its development on the Microsoft .NET Framework, the insurer decided to examine Microsoft BizTalk® Server and the BizTalk Accelerator for HIPAA to support its provider claims and referrals applications. In September 2003, Horizon’s EDI department tested BizTalk Server with hundreds of thousands of transactions that it had collected from trading partners.
“We ran thousands of files through BizTalk Server 2002 and compared our results with the expected results for transaction speed,” says Ken Plotnick, Manager of Software Development–EDI for Horizon. “The transaction speeds with BizTalk Server exceeded our expectations and ran approximately 40 percent faster than with our previous EAI tool.”
Because of the increased performance and the ease of integration and interoperability with its existing systems, Horizon decided to deploy BizTalk Server to provide translation and orchestration services for its provider portal claims and provider portal referrals applications. Working with Microsoft Services, the Horizon IT staff deployed BizTalk Server 2002 on a two-server cluster running the Microsoft Windows Server™ operating system. BizTalk Server and Windows Server are both part of Microsoft Windows Server System™ integrated server software. In addition, they used the BizTalk Accelerator for HIPAA to expedite setting up and processing the necessary HIPAA transactions.
| Because of BizTalk Server integration, we were able to write an application in a couple of weeks that would have taken months using our old integration tool. | | | Raj Shekaran,
Enterprise Architect, Horizon Healthcare Services, Inc. | |
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Horizon also built a series of dashboards on the .NET Framework that give its EDI customer support specialists access to its transaction data as well as to transactions using the Blue Exchange application. The Blue Exchange application enables other Blue Cross licensees across the United States to seamlessly submit HIPAA transactions for Horizon subscribers who receive healthcare while traveling outside their home plan network. It also enables Horizon to submit HIPAA transactions for traveling subscribers of sister plans who receive treatment within the Horizon network.
Healthcare providers, billing services, and transaction aggregators submit electronic transactions to the Horizon trading partner connectivity application. To conform to HIPAA transaction, privacy, and security regulations, transactions are encrypted at the trading partner site and decrypted when they arrive inside the Horizon firewall. The transactions are then passed to BizTalk Server, which translates them into HIPAA-compliant transactions. They are then routed to the appropriate mainframe system for processing. Every aspect of the process is recorded in Microsoft SQL Server™ 2000 databases. (SQL Server is also part of Windows Server System.)
The dashboards also provide administrators access to system information—including a count of all transactions—and gives the Horizon customer support staff a near-real time view of the entire process. As a result, customer support representatives can review transactions in detail to respond to customer inquiries about claims or referrals, and proactively identify and troubleshoot potential problems.
Horizon moved its trading partner connectivity application to BizTalk Server in three phases over 18 months, migrating three HIPAA transactions at each phase. Mapping the HIPAA transactions took about a month at each phase. Rerouting those transactions to BizTalk Server took just a few hours.
“It was just a matter of pointing things to a different place. We turned on BizTalk Server and turned off our old EAI tool, and the messages flowed through the new connection,” says Plotnick. “We watched the process for a while to make sure it was okay, and then repeated the procedure for the next trans-action. We could always flip a switch and go back to the old system, but we never had to.”
By January 2005, Horizon had completely replaced its old integration tool with BizTalk Server and the .NET Framework for all local and Blue Exchange HIPAA transactions. By the end of 2005, BizTalk Server was processing approximately 100,000 roundtrip transactions per month for Horizon.
Benefits
By moving from the old EAI solution to Microsoft BizTalk Server to integrate its trading partner connectivity application with its mainframe systems, Horizon increased transaction speed by more than 40 percent, exceeded transaction speed requirements, improved visibility into transactions and customer service, and expects to reduce cost of ownership.
Expedited Transactions
As an independent licensee of the Blue Cross and Blue Shield Association in the state of New Jersey, Horizon must meet strict performance guidelines. As of October 2005, failure to meet those guidelines could result in financial penalties. One of the requirements specifies that transactions must be processed within 20 seconds. With the insurer’s previous integration solution, that time limit was achieved by only 70 percent of transactions. Plotnick estimates that with BizTalk Server the company processes transactions approximately 40 percent faster than with the previous integration software. That increased performance has resulted in many transactions processed in less than 20 seconds and 95 percent of transactions being processed within the required 20 seconds. Currently over 75 percent of Horizon’s transactions are handled electronically.
Improved Visibility into Transactions
The dashboards, supported by BizTalk Server integration and the .NET Framework, give Horizon administrators a near-real-time view of how many transactions came in, how many failed, and why they failed. “Before, it was like sending transactions into a black box and hoping they came out,” says Plotnick. “Now we can see at any point in time where a single transaction is in the process and what its status is.”
Increased First-Call Resolution of Support Requests
In addition to expediting transactions, BizTalk Server and the .NET Framework have helped to significantly improve customer service. The ability to access near-real-time information through a dashboard has significantly increased first-call resolution of customer inquiries overall. As a result, support professionals rarely have to pass calls on to other individuals, who formerly had to search through thousands of files and scattered logs to resolve customer issues.
One dramatic example of improvement is demonstrated by the Blue Exchange application. “Before the dashboard, level-two and level-three support for Blue Exchange would get several calls per day,” says Plotnick. “Now that the dashboard has been installed, 99 percent of the calls regarding Blue Exchange are handled during the first call.”
Call length has also been reduced. Previously it could take 20 minutes or more to locate a batch file within the thousands located on the server to answer a healthcare provider’s question. Now support staff members can simply enter the provider’s identification number and the date or range of dates for the file transmission, and find what they’re looking for in seconds.
Projected 50 Percent Reduction in Cost of Ownership
The BizTalk Server solution has decreased claims discrepancies by 35 percent, which reduces transaction-troubleshooting time by 20 percent. In addition, BizTalk Server is based on an open architecture, which makes it easier to integrate with various systems. This simple integration helps Horizon extract value from mainframe systems and meet new business demands, while reducing complexity and development time.
For example, Horizon wrote an enhanced eligibility application using BizTalk Server to transform data for submission to and responses from the mainframe. By turning the application into a Web service, the insurer made the application accessible to every access channel without writing a separate interface for each channel. “Because of BizTalk Server integration, we were able to write an application in a couple of weeks that would have taken months using our old integration tool,” says Shekaran.
BizTalk Server also requires less administration time. “We had to do more babysitting with the old tool,” says Plotnick. “It was very sensitive to changes in the environment. If there was a network disruption, the EAI tool might shut down, and you wouldn’t know it for an hour. The BizTalk Server implementation basically runs itself.”
With the decreased transaction discrepancies and reduced development and administration time, Horizon projects that the BizTalk Server solution will reduce its cost of ownership by 40 to 50 percent.
“Some of our people initially weren’t happy that we were switching because they were used to what they had,” says Shekaran. “Now that BizTalk Server is in place, they are singing its praises because it makes it easier for them to get their jobs done and serve our healthcare providers and their patients more efficiently.”
Microsoft Windows Server System
Microsoft Windows Server System is a line of integrated and manageable server software designed to reduce the complexity and cost of IT. Windows Server System enables you to spend less time and budget on managing your systems so that you can focus your resources on other priorities for you and your business.
For more information about Windows Server System, go to:
www.microsoft.com/windowserversystem
For More Information
For more information about Microsoft products and services, call the Microsoft Sales Information Center at (800) 426-9400. In Canada, call the Microsoft Canada Information Centre at (877) 568-2495. Customers who are deaf or hard-of-hearing can reach Microsoft text telephone (TTY/TDD) services at (800) 892-5234 in the United States or (905) 568-9641 in Canada. Outside the 50 United States and Canada, please contact your local Microsoft subsidiary. To access information using the World Wide Web, go to:
www.microsoft.com
For more information about Horizon Healthcare Services, Inc., products and services, call (973) 466-8755 or visit the Web site at:
www.horizon-bcbsnj.com
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This case study is for informational purposes only. MICROSOFT MAKES NO WARRANTIES, EXPRESS OR IMPLIED, IN THIS SUMMARY.
Microsoft, BizTalk, Windows, the Windows logo, Windows Server, and Windows Server System are either registered trademarks or trademarks of Microsoft Corporation in the United States and/or other countries. All other trademarks are property of their respective owners.
