The client is an Australian healthcare insurance firm offering financial protection for medical expenses to policyholders. They approached Sparity with challenges related to the complexity of healthcare payer data, integration issues, delayed reporting, and stringent healthcare data privacy and compliance requirements, in accordance with the Australian regulatory framework.
Client: Healthcare Payer
Services: Data Visualization , Data Security and Data
Year: 2023
Key Challenges
- Client software faced data interoperability challenges when integrating data from sources like EHRs and claims due to non-standardized formats and coding systems.
- Data security and regulatory compliance, such as HIPAA, while enabling data access and sharing, particularly for Protected Health Information (PHI).
- Complex adjudication processes and a high claim volume can lead to workflow delays.
- Payer faced revenue loss from fraud detection challenges.
Technologies
Solution
- Data Integration Platforms with ETL capabilities ensure data consistency and accessibility by harmonizing diverse data sources.
- Encryption and strict access controls safeguard PHI, enabling secure data access and sharing for authorized users.
- Claims Automation, powered by RPA and intelligent algorithms, expedites claims processing and reduces errors.
- AI-Driven Fraud Detection continuously learns from historical data to enhance the detection and prevention of fraudulent claims.
- Azure Machine Learning enhanced decision-making with advanced analytics and maintained HIPAA compliance with robust data security measures.
Benefits
- Improved data interoperability in healthcare promotes collaboration, reducing redundant efforts.
- Efficiency is boosted with AI and claims automation, cutting costs.
- Advanced analytics prevent fraud, leading to substantial savings.
- Power BI aids in data visualization, aiding decision-making and transparency.
- Blockchain enhances data security and patient trust and regulatory requirements like HIPAA compliance .
