Competing in a growing market, insurer Anadolu Sigorta teamed with IBM Business Partner JFORCE Bilisim Teknolojileri A.S. to launch an automated health claims processing platform that could easily adapt to shifting rules and industry standards. Backed by IBM Business Automation® Workflow technology, the system provides fast, accurate answers to insurance claim requests.
Concerned with its levels of claims leakage, Anadolu Anonim Türk Sigorta Şirketi wanted to improve the accuracy and reliability of its health claims processing solution.
With a new submission portal in place, the business can automate the investigation, review and payment of health insurance claims.
The health insurance sector in Turkey is growing quickly.
Over the past two decades, a series of governmental reforms established a universal healthcare system that was managed by the nation’s Sosyal Güvenlik Kurumu (Social Security Institution). However, in recent years, additional legislation was passed, opening up the market for supplemental coverage and empowering citizens to secure plans that helped cover charges received from private medical institutions.
With such a young and growing market, customer expectations, government policy and even system requirements are in a constant state of flux, making it challenging for insurance providers, like Anadolu Sigorta, to keep pace.
“There’s a lot of competition,” explains Mehmet Abaci, Chief Information Officer at Anadolu Sigorta. “And we have built our business and our reputation on the principle of paying claims quickly and in full. But that speed can sometimes lead to difficulties.”
In particular, the business was concerned about claims leakage—improper payments being issued. With so many changes occurring with its backend processes, far too often the conditions printed on official policy documents did not match the rules being followed by the insurer’s automation system. And each time one of these mismatches occurred, the issue had to be arbitrated by a third party, which delayed resolution and final payment often by weeks.
“It was a shortcoming that we couldn’t tolerate in such a competitive market,” adds Abaci.
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:
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.
With the IBM technology and ASMED portal in place, Anadolu Sigorta streamlined its claims processes, with roughly 80% of incoming claims now being handled without human intervention. And the bulk of these determinations are calculated in less than a second, encouraging faster payouts, greater user satisfaction and an improved market standing.
At the same time, the new solution cuts leakage in half, yielding a 40% drop in operations costs. And these savings quickly added up, achieving a full ROI for the project in just the first year of use.
“It also makes life easier for our staff,” notes Abaci. “We can add new products and health policies to the platform in a matter of hours—that used to take us weeks. And now that our process documents and policies are stored online or via web services, we don’t have to manage and track so many physical documents. You’d be surprised how much time that consumes. In addition, with the help of the new ASMED fully digital health insurance claims portal, all our people could work from distance during COVID-19 pandemic lockdown.”
Beyond these new capabilities, the insurance business is pleased with its choice to work with JFORCE.
Abaci adds: “We chose JFORCE because of their experience in healthcare insurance automation. They understood the issues and industry pressures that we were facing, and they helped us navigate around the pitfalls of updating our claims systems. We had a common language and a common understanding of goals, and that let us achieve an almost perfect implementation.”
Established in 1925, Anadolu Sigorta (link resides outside of ibm.com) was the first national insurance company founded in Turkey. Today the business offers a broad array of insurance coverage—fire, transportation, personal accident, engineering, agricultural, legal, health and credit—catering to a range of consumers and businesses. Anadolu Sigorta is headquartered in Istanbul, Turkey, and it employs roughly 2,500 professional agents across the country.
Founded in 2003, IBM Business Partner JFORCE (link resides outside of ibm.com) offers technology solutions, predominately focused on needs in the financial sector—like claims handling, risk evaluation, renewals automation and fraud detection. The business is presently headquartered in Istanbul, Turkey, with additional offices in Ankara.
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