DocFinity® and IBM On Demand:
Collaborative Business Solution Drives Work Management for Statewide Insurer

Background

View printable PDF (opens in new window)

A major regional health insurance company in the southeast faces challenges common to insurers nationwide: creating a seamless flow of information that provides their 13,000 employees and industry regulators with the tools they need to ensure top-quality healthcare and service to their customers. Although the company is a large insurer, the problems they encounter in their business are faced in many companies, both within and outside of the health insurance sector.

The challenge: centralizing work management

As a health insurer that also processes a large volume of Medicare and TRICARE claims for the federal government, the company is subject to unusually large amounts of paperwork, as well as the government-mandated service level agreements (SLAs) with which insurers have to comply. The SLAs, which carry large penalties when insurers fail to meet the mandated requirements, have made timely processing an urgent matter. With a vision to simultaneously improve processing in all areas while tackling the processing challenges posed by SLAs, it was clear that automated workflow built around their valuable electronic records was the best solution.

One of the concerns this insurer faced was the large financial investment that had already been made in their IBM mainframe On Demand 390 image repository (OD390), which stores multiple types of images in database tables. It was critical to the company to be able to build efficient and effective automated workflows around the systems without having to abandon OD390 or convert images from the database into another system. Many layers of controlled-access security were already in OD390 because of the insurer’s needs to comply with HIPAA and other regulations; the financial and staff resources required to convert the system were prohibitive and undesirable.

Ideally, OD390 would remain a critical part of this insurer’s operations: this powerful mainframe application stores well-organized indexes of billions of documents, in many formats, pdf files, tiff images, jpeg images, electronic facsimiles and much more, which are critical to the organization’s operations. Coupled with automated workflow that would push valuable documents from their OD390 system to parties requiring the images and documents, the insurer could facilitate claims processing, even from remote locations and with third parties, without the complication of moving paper.

The company analyzed its needs carefully, and recognized five common “work management” needs within a variety of areas within the organization: 1) efficient processing of memos, letters, and forms from multiple locations; 2) timely processing of documents that are handled by multiple parties; 3) matching records with multiple receipts; 4) prioritizing and processing calls at help desks; 5) and timely check deposits for financial control. Mandatory government service level agreements further complicated the scene, making it difficult to comply with the mandates when working long distance with Medicare and TRICARE.

One of the most basic needs was for the chosen work management system to be able to retrieve files from their OD390 system and index them properly for quick retrieval. A series of behind-the-scenes commands would need to be built to determine automatically whether or not a user had the permission to see a given file or was permitted to query the database and get the desired result set. The vendor would need to be equipped with a highly sophisticated Web services application programming interface (API) in order to provide the information needed from the vault, while conforming to the safeguards that were designed to protect the system.

Planning: creating a blueprint for success

Instead of working to create a solution for each of its departments, the company leaders had a vision: to build an electronic structure with the five major work management projects that were found within the company, centralized around OD390, their electronic vault of information. By integrating their five business solutions to OD390 and the more than four billion documents within it, they envisioned building five gateways to and from their most critical information. These gateways would be the starting point for flowing critical correspondence, forms, receipts, claims, and other materials to, from, and within these business units.

OD390: building a structured treasury around the vault

The visionaries within this company had the wisdom to recognize that their most critical asset was the information stored in OD390, which needed to be at the center of their new structure, and carefully secured. Sensitive information could only be viewed by people who were given the “keys” to the vault, and the security had to be well planned. While it was complex to conceive, the structural strength and beauty would be in the ability of the 3,000 users from each of the five business units to access the vault simultaneously and perform sophisticated searches of the contents, then subsequently view, edit, annotate and process only the information each person would be permitted to see. Such a structure would require a vendor with a flexible, innovative, and scalable solution that could provide this information gateway while safeguarding their records in OD390.

DocFinity: activating the information flow to the surrounding chambers

After the needs assessment and the insurer’s blueprint were complete, Optical Image Technology (OIT), Inc.’s DocFinity suite of document management products was chosen, and implementation began in the fall of 2003. OIT was chosen as the vendor because of the flexibility and scalability of its product line, competitive pricing, and integration capabilities, as well as their ability and willingness to provide professional services and custom integration as the solution grew and was rolled out across the company. A paperless mailroom was developed to enable digital processing of forms and correspondence from remote locations; the other four solutions that were developed helped them to address property & casualty application processing, matching medical record requests with receipts, technical service center help desk task prioritization, and timely check deposits.

Connecting the walls: creating an interconnected, cohesive structure

While the pieces of the solution were not unique (an information repository, corporate scanning, fax and image management software, workflow, and more), the challenge lay in connecting the pieces and creating a structure with a seamless flow that operated as one cohesive unit. Another key element was the desire for users to remain comfortable with the inevitable changes. By utilizing DocFinity Web Services, the company was able to add “power tools” to their solution behind the scenes, allowing users to pull the information they required with the click of a button added to their screens, with all of the work being performed behind the scenes, unknown to the user. This meant that users’ learning curves were short, not requiring them to learn entirely new software, and allowing them to continue to work with systems and processes that were familiar.

The solution they required was complex: integration with Esker Fax™, Oracle, other existing tools was also essential in order to ensure the company could manage its data efficiently in the paperless mailroom project. The DocFinity solution (including the Core imaging and IntraVIEWER products, Barcode Indexing, Email Manager, Full Text Server, HSM (Hierarchical Storage Management), Print/Fax Server, XML FormFLOW™, and Workflow) was the mortar needed to fuse the elements together and create a smooth flow of information. The prerequisite integration with the OD390 database required 3-4 months, and each of the five major business areas was operational within several months as well.

Visiting the chambers: five distinct operations

The first project to become fully operational was the paperless mailroom, which enabled processing of all of the incoming mail for one of the major business units, such as requested authorizations, to be directed to one location on the east coast of the United States. The work is electronically distributed to the appropriate people in California, and the operation is completely paperless. The project imitates the tasks and paperwork involved in manual processing, including paper-based memos, letters and forms, but with the far greater efficiency allowed by electronic processing. This business solution of paperless processing has dramatically increased productivity and made it possible for the company to meet the government-mandated service level agreements, which was difficult when papers had to be processed manually from multiple locations in a short period of time. As a result of their success, this digital mailroom is being replicated throughout the company in all areas, since the need is similar in every department.

The property & casualty application processing utilizes the same engine, enabling Word and Excel documents and e-mails to be copied into the data repository and indexed. Workflows are then automatically initiated for applications and renewals, as well as cancellations, reinstatements, endorsements, and general correspondence. The challenge was to process voluminous material and delegate tasks in a timely and efficient manner, and the solution has enabled the company to reduce costs and increase productivity considerably. Since the distribution of workflow tasks and related processing is required within all departments to some degree, the business solution to application processing is being duplicated enterprise wide.

The matching of medical record requests with receipts enables users to image and index the information contained within medical records so that the records can be automatically and properly matched when requested. The solution enabled this tedious process to be handled quickly and efficiently. While the type of information that needs to be matched differs in each department or business area depending upon the specific need, many departments need to match papers and receipts with documents, and the company is benefiting from replication of the process in other areas.

The technical service center help desk prioritization enabled the service center to process 500,000 calls effectively in 2004. By tapping into the DocFinity Web Services Application Programming Interface (API), the company was able to drive the needed work through the insurer’s local contact management system (Inform), where all calls are logged. Large volumes of information and materials have to be prioritized in all areas of the business, regardless of the type of data. As a result of the project’s success, more deployments of this nature, where large volumes of information require prioritization, are planned in other areas within the company in the near future.

The fifth business model was in the area of timely check deposits, managing bank accounts and addressing two types of returned checks: corporate and personal/business. The challenge was to create an efficient workflow that would deposit the money within 24 hours and simultaneously determine the source of the money so that the funds are allocated to the proper account. The solution has enabled this insurer to do this quickly and efficiently, and since timely check deposits are a concern in all areas of business across the enterprise, this model will also be replicated for all departments.

Installing the windows: end users see the benefits

Although management knew that electronic document management was the only viable solution to meet their needs, convincing end users was not easy, since they were happy with their paper-based processes. The company invested time and resources early on in the planning process so that users’ needs were considered and their processes were thoroughly understood. Managers “looked through the window” into the daily processes of their users, and end users were able to look through the window into the technology. This helped both parties to understand how each of their needs would be addressed through a technology implementation, which helped them to buy into the benefits of the solution from the beginning. Two years after the initial implementation, management and end users benefit today from faster delivery of work to the people who need to do it; assistance with managing tightly monitored government SLA timeframes; a significant decrease in lost documents; more automation of key processes with greater standardization; and reduced processing costs. A member of senior management commented, "Our leveraging of the OIT solution and our image repository is just beginning. When the project spans the enterprise, there will be no paper-initiated workflows in our organization. When you eliminate passing the paper, you realize significant quality and cost improvement."

Construction completed: looking forward

This enterprise-wide solution is a significant process innovation within the field of insurance because of the comprehensive integration with OD390 and other systems, its usability by very different areas within the company, and the ability to replicate the business solutions across all departments within the enterprise. As a result of careful planning, the company was able to draft a blueprint which Optical Image Technology was able to refine and implement to meet the insurer’s complex needs. DocFinity Imaging, Workflow, Print/Fax Server, Hierarchical Storage Manager (HSM), Barcode Server, and Full Text Server software are all tied into the DocFinity Web Services API, the OD390 and other in-house applications. This benefits all departments, and the company anticipates expanding the applications to every area within the company in the near future. The end result: the company was able to leverage their existing enterprise document/content management investments to achieve greater efficiency and reduced operational costs, as well as having happier customers. What more could anyone ask for?