Provider Dispute Resolution

Our Client Says

We have been very pleased with our experience with Summa Solutions. When we looked for a partnership for our development needs, Summa had the skills, process and procedures that mapped well into our environment.
We have been very impressed with not only the development talent but the architectural expertise as well. We look forward to continuing our strong working relationship.

Eduardo Don Jr.

President

Lumen21

Rectify a Dispute Resolution application for a Healthcare provider company to comply with DHMC requirements. [05-2010]

Our client, a Healthcare provider company, is a multi-state managed care organization that arranges for the delivery of health care services to persons eligible for Medicaid, Medicare, and other government-sponsored programs for low-income families and individuals. The client has nine licensed health plan subsidiaries throughout the U.S and more than 18 healthcare clinics it runs. It has 2500 employees and 1.2M subscribers.

Business Requirements

Our Client has been given a directive from DMHC to modify procedures related with the Dispute Resolution application in California. The internal Dispute Resolution department has identified some enhancements to the existing application to enable them to comply with DHMC requirements, as well as to increase user productivity and reporting capabilities. The internal IT department has proposed some technology changes to upgrade the Dispute Resolution application to use the latest Microsoft Technologies for Web Applications to replace the legacy architecture.

Due to the nature and urgency of this problem, there was an immediate need to enhance the current Dispute Resolution application to accommodate the suggestions made by the Dispute Resolution and IT departments. The proposed enhancements have several benefits:

Accuracy and Risk Reduction.
- New Determination (Upheld, Contested, Misdirected and Overturned) letters with proper verbiage.
- New Annual and Health Net reports for DHMC.
Improved User Efficiency.
- Enhanced filtering capabilities to search for Claim and Cases.
- Capability for an agent to assign a Case to personal mailbox queue.
- New report capability to allow the staff to go from the reports directly into a Case.
- New functionality to alert individuals of non compliant Cases on their queues.
Improved Administration.
- Enhanced reporting capabilities for all functional departments.
Improved Workflow.
- To manage SLA between internal departments.
- To acknowledge multiple like Claims.
Security Enhancements.
- New audit function to track user changes or modifications on the database.
Improved application maintainability.
Improved application scalability.

Solution

In a strong partnership with Lumen21, Summa Solutions developed a specific solution by following the SCRUM methodology, an agile development methodology to early and continuous delivery of value, daily working side by side with Business people and responding to change for the client's competitive advantage even in late development.

The Dispute Resolution application was rewritten in 5 months, 10 sprints of 2 weeks each, using the latest Microsoft Web Technologies at that time. It is designed as a multi-tier solution where the presentation was developed on ASP.NET MVC v2.0, the middle tier holds several services to communicate with different data sources such as Microsoft SQL, Microsoft SharePoint and other external legacy systems and data access layer was developed using EntityFramework. Everything glued up using Microsoft Unity.

Benefits

Cost avoidance of $ 1.000.000 by avoiding a DMHC fine due not being complainant with their resolutions.
Admin cost reduction of $ 240.000 per year by reducing the temporary staff.
Improved timeliness of Dispute Resolution turnaround time.