How low-code powered solutions solve high-risk problems in healthcare
Friday, June 4, 2021
Challenge
A leading specialty benefits company was looking for new ways to improve quality of care and reduce costs for today’s most complex tests and treatments. They managed the pre-authorization process for health plans and found that their clients were approving and paying claims incorrectly and had providers performing unauthorized procedures.
They needed to quickly design and build a system to match claims to authorizations and identify scenarios driving up the cost curve. The challenge was further compounded daily with high volumes with wideranging variability. The system had to be scalable and handle a broad set of claim-to-authorization scenarios.
“I have been so impressed with you and your whole team. [Macedon and Inspirant] helped us tremendously... I am thankful for all that you have done for my team and me.”
— Vice President, Healthcare Service Provider
Solution
Inspirant and Macedon partnered together from the proof of concept to the custom agile build. An initial analysis determined ROI, gaps in their currentstate matching logic, and the appropriate architecture and integration needs. We took an agile methodology approach focusing on incremental builds for both the proof of concept and the entire solution, allowing us to catch errors and make modifications quickly and early in the process.
We divided the solution into a rules engine, dashboard, reporting, and administration. For example, the rules engine contained all the business logic to process a claim and supported four general ideas that our client needed: modularity, auditability, transactionality, and fault tolerance.
The Appian platform provided a ton of tools that helped us speed up development. Our rules engine leveraged scalable, flexible process models that had configuration and auditability built in. Business logic was encapsulated and reused in expression rules that were easy to understand and quick to write. Appian’s modern UX for dashboard and reporting features made a very positive impression with the client who remarked on its ease-of-use and intuitive navigation.
Due to the complexity of this application, it was essential to have a testing tool for repeatable and reliable system testing. We built a testing system called the Scenario Builder, which allowed a QA user to test the engine and dashboard at scale. The client loved the tool and tasked us to build out a more full-featured solution that enabled them to perform the same highquality QA that we delivered for all their future projects.
Result
We successfully launched the solution on time and went live with one of our client’s customers. Our client’s opportunity savings from just this one solution is ~$26M over the last nine months. We processed over 375,000 transactions with over 98% of them requiring no human interaction.
The solution goes beyond just solving their initial challenge and provides additional benefits including:
Provides the option to sell pre-authorization solutions to other health plans
Allows them to take direct control of matching prior authorizations to claim lines for payment
Expands their market through new risk offerings
Reduces their implementation & maintenance costs with a new enterprise testing tool
Our client is extremely pleased with the solution and the process by which we got there. Building it iteratively and showing results to them on a biweekly basis made the go-live anti-climatic, which is just the way we like it.
From costly and disjointed to cost efficient and intuitive
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