Case Studies

Insurance Billing System

Insurance Billing System

Customer :Our client is a major Financial Services and Health Insurance player in the USA catering to insurance and wealth management businesses providing a range of advisory and brokerage services to the its clients. They serve corporate and high net worth individual clients throughout the United States and in Canada, with a focus on the middle market and entrepreneurs. They are committed to provide best healthcare to its members and enhance the competitiveness of companies.

Business Problem :The client had a many fold rise in their new enrolments contributed by their expansion mission into other US states and to further enhance on it and stabilize upon their business growth, they needed an electronic billing system that is robust in terms of operating efficiency, capabilities to support their customers via multiple channels, architectural competency for a robust and scalable payment related procedures like invoicing, updates & transactions and still able to bring down cost with end to end business critical engagements support.

  • Integrated Release Program for the final preparation of the strategic platform for Financial Management of the Billing system for the enrolments in new states of their business operation.
  • Integrated management platform for Enrolment Processing, Premium Billing, and Reporting to Carriers on the enrolments (EDI 834) as well as Payments (EDI 820) in compliance with the new Affordable Care Act.
  • Multiyear programs with focus on enhancing the applications within a member domain thereby building more Scalable Suite of Applications and also provide strategic support on Technology Infrastructure.
  • Building Financial Reporting Framework to all the carriers and Insurance exchanges that our client was working on.

Different payment reports essential for robust invoicing and internal audit documentation were needed to be integrated as per following.

  • Account receivable
  • Deferred revenue
  • Delinquency report
  • Account receivable for carriers
  • Account receivable aging
  • Credit balance report
  • Payment to carriers
  • Daily Deposit
  • WriteOff, etc.

Challenges: - The focus was to create a sophisticated premium billing system touching almost all the aspects of insurance exchange and complying with the regulatory requirements of the Affordable Care Act. To support billing & invoice accuracy the challenge was to process the precise information related to subscribers personal and payment data and other factors in a business constraint situation which was prone to vary at different times in a transaction cycle.

All of these difficulties needed a software that simplifies, centralizes data entry and management with inherent integrated features likes of Electronic Remittances, Pre-Billing Claim Checks, Claim Scrubber Edits, Contract Management, scanning and that facilitates to deliver targeted communication.

The Gunaatita Edge: - We completely revamped their existing software into a world-class premium billing system that resulted in auto-adjudication rate improvement by double digits while providing volume scalability and operational cost savings. Below are highlights.

  • We partnered with our client in technology migration to .NET and using SOA from a small Power Builder system, to allow IT systems to be scaled up at lower costs.
  • We provided business analysts scalability by augmenting the IT department and preparing domain training material to reduce knowledge transfer cost.
  • Being an integral part of operations, Gunaatita had built up the pool of subject matter experts who are being utilized as business analysts. This helped our client to scale up from a smaller team rapidly to accommodate projects from business users.
  • We supported the client in the development of management information system that helped reduce the time taken to provide detailed drill down capability to analyse data and pin point problems
  • We are still providing product support engineering capability through a pool of technology experts on our clients Core Premium Billing System to clarify system issues and take any technical issue in the product to closure in an efficient manner
  • We productized APIs in the Core Premium Billing System for enhancing our client’s capacity to add more small companies as its customers and minimizing time-To-Market for new Carriers and Insurance Exchanges

Technologies Used

  • .Net / Asp.net
  • MVC
  • WCF
  • C#
  • SQL Server 2012
  • XML
  • EDI
  • Systems content reporting interface (Industry standard pertaining to a billing system)
  • QuickBooks Integration (Financial reporting and audit)
  • Socks 2 complaint (For Data protection of users)
  • RSA (To protect user’s personal data)
  • New Relic and Pingdom
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