To address this challenge, Anadolu Sigorta joined with IBM Business Partner JFORCE to create its new Anadolu Sigorta Medical (ASMED) portal, an integrated health claims management solution that automates processing according to established business rules.
Now, hospitals or other medical offices can submit their health insurance claim provisions to Anadolu Sigorta through the centralized portal, which automatically identifies:
- If the submitter is eligible for payment
- If the patient has a valid policy
- If the identified policy covers the recommended treatment
With each claim, ASMED is designed to evaluate the submitted information against thousands of rules and policies in under one second and make a determination regarding payment. At the same time, the system monitors for irregularities that might indicate a larger issue.
“It looks at the timing of the treatment,” clarifies Abaci, “particularly if its near the beginning or ending date of a policy. Or it notifies us if a suspiciously large volume of treatment requests for a condition are being requested by the same physician. If something seems strange, it lets our staff know to take another look at the claim.”
For the new ASMED portal, Anadolu Sigorta and JFORCE assembled a joint solutions team comprised of five doctors, four data analysts, 14 developers, four line of business experts, three scrum masters, one project manager and one technical consultant.
“We looked through all of Anadolu Sigorta’s policy information, extracting, grouping and rationalizing all of these rules,” explains Umit Sile, Business Development and Software Director at JFORCE. “Altogether, we organized around 300,000 medical claim codes into 14,000 services on the portal. And we synchronized the codes for all of these services with an expanded version of the government’s health catalog, helping to simplify compliance.”
The JSure Health Insurance Platform serves as the heart of the ASMED portal, managing the automation and authorization of the incoming claims. And the team used IBM Business Automation Workflow software to develop two rule-testing suites that track compliance with the insurance company’s ever-shifting policy adjustments. In addition, the JFORCE team created a Microsoft Excel-based scenario tool that Anadolu Sigorta can use to vet conflicting rule sets.
And to promote security-rich communication between the claims automation portal and its greater network environment while also overseeing business-to-business web service integration, Anadolu Sigorta deployed an IBM® DataPower® Gateway device.