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Case Study: Integrating Healthcare EDIs

Electronic data interchanges (EDIs) were created to replace paper processing, decrease human error, and automate data entry. Today, EDIs are found across industries, including government, retail, and healthcare. For healthcare companies moving from paper to electronic processes, integrating EDIs between entities is an essential part of the project. However, EDIs are written in archaic code, lack adequate documentation, and aren’t as easily integrated as modern APIs.

A habilitative for-profit healthcare company came to Ventive ready to streamline its insurance claim process and improve its workflow. Their previous processes were entirely on paper, and the company couldn’t collect the data they needed to see how effective their services were. They wanted more data, a faster insurance process, and reduced errors in insurance claims. Unfortunately, standing between the company and a streamlined insurance claim process was Molina Healthcare’s distinctive and esoteric EDI.

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Healthcare EDI Prevents Project Integration

A major priority for the Idaho-based company was improving its health insurance claim process. Running a habilitative for-profit company using pen and paper was hampering their scalability. Since the average error rate for insurance paper claims is 28%, the company’s growth was blocked by human errors and processing delays. As part of their business process overhaul, the company prioritized switching from paper claims to an EDI format to securely transmit protected health information (PHI).

With a patient population entirely reliant on the same kind of health insurance, the software that Ventive was building for them needed to seamlessly integrate with Molina Healthcare. Unfortunately, the project quickly hit a snag. The Technical Project Manager realized that even though the EDI integration was only one part of the project, the difficulty of integrating healthcare EDIs could hamper the client’s move away from paper processes.

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“Even though this project was really complex, development-wise this has been one of the best teams we’ve ever put together. There were never any regression bugs, and the team was incredibly efficient.”
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Ventive’s Custom-Built Solution

It’s not unusual to have delays in healthcare EDI integrations. That’s one of the reasons entire firms specialize in this type of integration. For smaller companies though, using specialty firms is often cost-prohibitive. As the Ventive team started to automate the company’s insurance claim process, the Technical Project Manager knew he needed to understand the process enough to direct the EDI developer.

Even though the information about integrating with Molina’s system was scattered across technical manuals and online developer forums, the Technical Project Manager decided to learn enough about EDI integration to work closely with the Lead EDI developer. They were able to navigate the vast configurations of EDI attributes and apply the correct service codes to the proper plan of care.

The Result: Seamless EDI Integration with Molina Healthcare

This EDI integration was only one step in our client’s business transformation, but the difficulty of integrating a system like this could have stalled the project’s progress. Instead, the Ventive team’s ability to adapt and rise to the project’s needs has kept the entire process running smoothly. 

The next stage of digital transformation for this company includes building out scheduling, payroll management, and time tracking management for their clients and employees. In the meantime, our client is able to immediately improve how quickly they receive insurance reimbursement, thereby streamlining their processes and improving their cash flow.

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