Blue Cross NC
Trizetto Facets Implementation Remediation, Staff Training and Project Management
SUMMARY
Blue Cross and Blue Shield of North Carolina (Blue Cross NC), the state’s largest health insurer, needed to rapidly assess and adjust their approach to how they handled provider data from myriad sources across all 50 states. The size and scope of Blue Cross NC’s provider network required a deep audit of their system architecture and a critical look at how their processes and system could be made scalable and effective.
Discover how Mediant Health Resources was able to exceed Blue Cross and Blue Shield of North Carolina’s expectations once more.
BACKGROUND
Since 1933, Blue Cross and Blue Shield of North Carolina has provided high quality health insurance at a competitive price. Among Blue Cross NC’s initiatives has been a charge toward better health and more consumer-focused healthcare in their state. Blue Cross NC employs more than 5,000 North Carolinians and serves more than 4.3 million customers. The Blue Cross and Blue Shield of North Carolina’s PPO network includes 95% the of medical doctors and 98% of all general acute-care hospitals in the state.
Previously, Blue Cross NC turned to Mediant Health Resources for immediate remediation and training after a third-party vendor error and system failure led to a very public breakdown and widespread customer billing issues. This arose two years into their multi-stage implementation of Cognizant’s TriZetto® Facets® core administration and billing/claims processing platform. Pleased with Mediant’s performance and service with their previous emergency needs, Blue Cross NC partnered with Mediant once more for an assessment of provider data.
CHALLENGE
Blue Cross and Blue Shield of North Carolina’s network spans the globe. Blue Cross NC’s in-state PPO network of healthcare providers includes 95% of the medical doctors and 98% of all general acute-care hospitals. When outside the state, members have coverage with doctors and hospitals in all 50 states and nearly 200 countries and territories.
Before Blue Cross NC could continue converting any additional groups to TriZetto® Facets® core administration, provider data needed to be reviewed to assess its scalability and health as well as its effect on members, providers, and internal teams.
SOLUTION
Blue Cross NC consulted with Mediant Health Resources, a leading healthcare IT support and staffing company who had already demonstrated their exceptional ability to provide expert consultants and meet tight deadlines under pressure. Mediant was able to rapidly provide five consultants, each of whom boasted more than 15 years of experience in both TriZetto® Facets® and healthcare architectures.
Mediant’s experts were allotted a 12-week timeframe to assess provider data in order to identify key pain points and problematic data sets before performing root cause analysis and providing solutions based on industry best practices. Five deliverables were established as key to the project’s success at this stage:
- An in-depth provider data audit
- A detailed process assessment
- A thorough systems architecture determination
- Quality assessment
- A provider data roadmap, or “manifesto”
RESULTS
Once again Mediant proved their performance and value to Blue Cross NC. They rapidly understood the provider architectures and delivered the in-depth provider data audit ahead of the scheduled 12-week deadline. This audit discovered data anomalies, including duplicate records, which negatively impacted claims matching and correct payment processing.
Mediant then conducted a detailed process assessment which brought to light the extensive manual workload required of Blue Cross NC teams in order to keep two systems in sync. Prior to Mediant’s involvement on this project, Blue Cross NC relied on six and a half full-time equivalent staff members in order to accomplish this task. From there, Mediant reviewed the payer’s system architecture.
Mediant’s assessment of Blue Cross NC’s architecture highlighted inefficiencies. Additionally, this assessment illuminated both the lack of and need for a data quality process to ensure the system’s “health” moving forward. Accomplishing this along with the other assessments led to the creation of the final deliverable.
Mediant’s experts pulled together the information from the four initial assessments to create a “Provider Manifesto.” This document was a roadmap and common set of rules, known issues, and best practices for provider data developed to meet Blue Cross NC’s specific needs.
Throughout the engagement Mediant managed the project successfully and with high efficiency. Leadership was able to communicate the urgency of the issues uncovered as well as the necessary outcomes across the organization. Not only was Mediant able to initiate phase two of the project two weeks ahead of schedule, but the quality insights provided to Blue Cross NC gave the organization a clear and confident path forward. The project was completed on time and on budget.
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