Cases

Requirement Scenario

One of the biggest challenges faced by the healthcare industry today is the need to reduce costs. Healthcare costs in the USA are increasing at the rate of 13 to 17 % every year. These increases are unsustainable. Increasing productivity and operational efficiency can help healthcare entities curtail these steep increases.

One way to reduce costs and improve efficiency is by replacing outmoded, paper-based methods with streamlined electronic documents. Today, approximately 70 percent of the healthcare transactions are paper-based, resulting in administrative costs of up to 20 percent of each dollar spent. In the U.S. alone, the yearly cost of processing and administering claims is about $90 billion. In addition to the cost of manually filling out all this paperwork, the process is often fraught with errors as well as with the risk of exposing confidential information. Improving the efficiency of these processes could dramatically decrease healthcare costs.

The key is to find ways to make complete information easily accessible, whenever and wherever it is needed. In the case of physicians, for example, having ready access to complete patient information including lab results, medication history, and specialists’ reports would significantly improve their ability to specify treatment plans that improve clinical outcomes.

Lilisoft Application was expected to work as a complete Clinical Information System where all medical records, reports, necessary documents would be managed patient wise. It was also expected to process the claims in the standardized manner as specified in HIPAA. The requirement mentioned achieving compliancy for 6 HIPAA modules, which are relevant to the line of business of Lilisoft Medical.

Solution

The Lilisoft Application provides a Two-way solution covering two major aspects of the healthcare industry in the following way:

Project Description:

The Lilisoft Application is essentially a Clinical Information System. It organizes and stores the medical records of a clinic in a very structured manner, enabling the doctors and clinic’s operation team to easily add and maintain patient records.

Lilisoft Application is divided into various functional modules on Patients, Providers, Nursing, Insurance, Transcription, Scheduling, System Admin etc. Each of them is broken down to various sub sections for better operational manageability. The E & M documentation and Document Archive segment acts as the record storehouse for documents, mainly on History of Present Illness, Past Medical History, Patient Social History, Medications and Prescriptions, and various Lab Reports etc. The application gives the flexibility to select a patient and manage his entire documentation and functionalities. Moreover, in most cases, PDF reports get generated and stored into the application for future references. The application also has a feature-rich Scheduling module for both Patients and Doctors. This scheduling takes care of the appointment scheduling part in a very user friendly way.

All the modules in the Lilisoft Application are tightly integrated and powered by the Admin panel. This module not only handles huge sets of Master entries required for both the application and the Claims processing functionality, but also takes care of automated backups. The Report section is quite extensive and enriches Lilisoft Application by generating various types of clinical reports.

Claim Processing & HIPAA Compliancy

As the Lilisoft Application achieves HIPAA compliancy for its Claims processing, a large part of the application deals with the data capture and processing of claims. Managing Patient Subscription including the dependents part, different Service Charges, Payments and Billing etc. are the major sections in the claim processing functionality. Keeping in mind the security aspect of the claims and financial data, PGP Software’s Encryption tool has been integrated with the application. Further, EDI conversion tool from Redix has also been integrated with the application. WebMD, the Compliancy Service Provider is providing the Clearinghouse (Receiver) services for claims’ compliancy check before forwarding the data to insurance parties. While processing claims, all the services like data conversion, encryption, format checking as per respective HIPAA Modules (837/835/270/271/276/277), and file transmission using FTP, work seamlessly from Lilisoft Application to make the entire cycle a fully automated process. A brief idea on HIPAA and its compliancy challenges follows:

What is HIPAA?

On August 21, 1996, President Clinton signed the Health Insurance Portability and Accountability Act, known as HIPAA. This law impacts all areas of the health care industry and was designed to improve the efficiency of health care by standardizing the exchange of administrative and financial data, and to protect the privacy, confidentiality and security of health care information.

A major concern in the law was the security and privacy of electronic health records and their transmission between health care entities. HIPAA includes provisions for Administrative Simplification the purpose of which is to improve the efficiency and effectiveness of health care transactions, by standardizing the electronic exchange of administrative and financial data, as well as protecting the privacy and security of individual health information that is maintained or transmitted electronically.

Why is HIPAA required?

HIPAA was enacted to address the deficiencies in business processes within the U.S. health care system. One of the deficiencies that the HIPAA legislation addresses is the transaction standards among healthcare entities such as providers, payers, employers, and clearing houses. The following are some of the HIPAA compliancy challenges:

Users submit claims in HIPAA EDI 837 transaction formats or proprietary formats over the Internet through secure communication. Data is sent after proper encryption. After users are authorized by the Web site, they can upload and download files in HIPAA EDI.

Users can also download HIPAA EDI 835 Remittance Advice, EDI 277 for both Acknowledgment Receipts and Pended Notices, and remittance advice for claims. The HIPAA EDI 835 and EDI 277 documents are generated in EDI format. The Claim Eligibility is also checked by HIPAA 270 and 271 processes.

Benefits

Lilisoft Application, with its HIPAA compliancy, positions itself as a cut above in the niche market of healthcare segment in USA. The application makes an effective usage of electronic documents rather than spending a huge amount on paper based documents, thus cutting down the operating expenses to a great extent. Document management had never been easier than the way it has been addressed in the application. The Scheduling module also adds value in order to keep track of the Appointment calendar.

Achieving HIPAA compliancy was a giant step for the software application. It brought Lilisoft Medical to an elite group of HIPAA compliant healthcare service providers. The application helps cut customers’ operating costs, boost efficiency, speed and responsiveness, meet compliance deadlines, and develop new market opportunities. This application in healthcare segment combines deep domain knowledge, proven methodologies with integrated 3rd party tools that enable the client’s IT-intensive organization to conquer the unique challenges of healthcare industry and compete on a higher level.

What is HIPAA?

Platform: Windows 2003 Server with IIS 6.0
Development Tools: VS.NET using ASP.NET & C#
Database: SQL Server 2000

Additional components/tools:
EDI Conversion: Redix
Compliancy Service provider: WebMD
Encryption: PGP
Reporting: Web Crystal Reports
File Transfer: Standard FTP