U.S. healthcare plan – a case study

Improving member and provider data accuracy with IBM Initiate Master Data Service

(Summarized from IBM.  View full case study here.)

Overview:  Improving member and provider data accuracy with IBM Initiate Master Data Service

  • Business need:  A U.S. healthcare plan maintains member eligibility information across 35 source systems. The lack of integration and inconsistencies in member and provider information were increasing manual claims processing time.
  • Solution:  Implementing Initiate Master Data Management HUB created unified, accurate views of members and providers to improve processes and service while reducing costs.
  • Benefits: ● Improved claims processing saving more than US$1 million annually ● Uniquely identified 167 million members from 300 million records ● Streamlined processes for managing member and provider information

Seeking a unified view of members and providers
As a result of several mergers and acquisitions along with continued business growth, more than 300 million member records from multiple lines of business and healthcare plans were managed in 35 different eligibility systems. There was a need to integrate information and streamline processes to support compliance and reporting requirements.

Improving claims processing and reducing manual methods
The healthcare plan searched for a master data management (MDM) platform to provide a single repository for member and provider information, where all internal systems could query this repository to obtain complete information describing each member’s eligibility, as well as provider information.

The company selected the IBM® Initiate Master Data Service® software because of its proven superior accuracy in a proof of concept against other vendors.  The member hub project focused on the accurate resolution of 300 million member records, in 35 eligibility source systems, to create a database of unique member identities. The provider hub focused on the accurate resolution of 6 million provider records.

More than US$1 million saved annually
IBM Information Management solutions have helped the company create a unified, accurate view of members and providers. The member hub comprises 167 million uniquely identified individuals from 300 million member records in 35 source systems. The provider hub uniquely identified 2 million providers from 6 million provider records. In addition to more consistent data and reduced manual claims processing time, the project resulted in a cost savings of more than US$1 million annually.
Future plans
There are many additional benefits that can be derived from the IBM Initiate Master Data Service member and provider hubs. Advanced search capabilities will help prevent duplicate entries at the point of creation, when providers are awarded new contracts. It is also possible to apply analytics to member data to glean more meaningful information about overall consumer populations.