Requirement Scenario
One of the biggest challenges
faced by the healthcare industry today is the need to reduce
costs. Healthcare costs in USA are increasing at between 13
percent and 17 percent each 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 will be managed
patient wise. Also it was expected to automatically do the
claims processing 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
for Lilisoft Medical.
Solution
The Lilisoft Application provides
a Two-way solution covering two major aspects of the healthcare
industry in the following way:
Clinical Information
System
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 has also 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 handles not only huge set of Master entries
required for both the application and the Claims processing
functionality but also takes care of automated back ups. The
Report section is quite extensive, 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.
Here it would be very justified to give a brief idea on HIPAA
and its compliancy challenges:
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:
- Standardize data interchange
- Privacy of patient information
- Security practices
- Leverage existing proprietary systems to support HIPAA
transactions
- Speed of implementation to support HIPAA transactions
by deadline
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 was never been so easier like
the way it has been addressed in the application. The Scheduling
module also adds value in order to keep track of the Appointment
calendar.
It was also a giant step for the software application in
achieving the HIPAA compliancy, hence bringing Lilisoft Medical
to an elite group of HIPAA compliant healthcare service provider.
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.
Technology
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
“All I can say is Wow. It’s really beautiful to
see it (the application) working together so nicely.”
- David Hayes
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