SYBASE Healthcare Solutions
A Presentation For TheSybase Users' Group of Texas Tuesday, September 16, 2003
Catherine SchultenHealthcare Business Development [email protected] 6, 2003
Lisa Rasor, Acct MgrMax Sanchez, SC
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AgendaAgenda
• Sybase’s Healthcare Vertical• Overview of Healthcare Issues• Overview of Healthcare Solutions• Q & A
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The Sybase Healthcare HeritageThe Sybase Healthcare Heritage
CenturyAnalysis Inc.
EAI for Hospitals
MicroScriptEAI for Hospitals
PaperFreeEAI for Payers
New Era of Networks
19971998
19992000
20012002
Sybase, IncDatabase, Mobile and Wireless for Hospitals
1983
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• Top six U.S. managed-care organizations
• 29 of the 47 Blue Cross Blue Shield plans
• 1,250 payer and provider organizations worldwide
• Sybase teams with more than 95 application partners, offering clinical, financial, administrative and medical management solutions
Sybase Powers Major Healthcare Solutions
Sybase Powers Major Healthcare Solutions
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Healthcare CustomersHealthcare Customers
Partial Listing
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Healthcare CustomersHealthcare Customers
• MVP Health Care• NASCO• Nationwide Health
Plans• OAO Healthcare• Ochsner Health Plans• Ohio Medicaid• Oxford Health Plans• PreferredCare• Quest Diagnostics• Sagamore Health
Network• Trigon BCBS• TriZetto• Union Labor Life• Wausau Benefits• WPS Insurance
• EDS/Connecticut Medicaid
• EDS/EBX• EDS/Indiana Medicaid• EDS/North Carolina
Medicaid• EDS/Rhode Island
Medicaid• EDS/Vermont Medicaid• Fortis Benefits• Fresenius• Health New England• HealthNow NY• Independence BC• L.A. Care• Mayo• Massachusetts
Medicaid
• American Medical Security
• AmeriGroup• BCBS of Arkansas• BCBS of Arizona• BCBS of Illinois &
Texas• BCBS of Minnesota• BCBS of South Carolina• BCBS of Tennessee• CareFirst BCBS (Incl.
FEP)• CDPHP• CIGNA• CSC Healthcare Group
Partial Listing
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Healthcare CustomersHealthcare Customers
• Tenet Healthcare Corp.
• Kaiser Permanente • HealthNow New York• BCBS Minnesota• BCBS Michigan• BCBS Texas and
Illinois• NASCO• John Muir/Mt Diablo• Universal Care• University of
Colorado Hospital• Cole Managed Vision• Quest Diagnostics
• Hospital Sick For Kids• Arkansas Children's
Hospital• Children's Mercy
Hospital• Children's Healthcare
of Atlanta• Nemours Children's
Clinic• Children's Hospital -
San Diego• Lee Moffitt Cancer
Center• Stanford Medical
Center
• Methodist Hospital Memphis
• Baptist Hospital Memphis
• Johns Hopkins Health System
• Carilian Health System
• UCSD Medical Center• Mayo Clinic• Loma Linda University
Medical Center• Group Health• Univ. California – San
Diego
Partial Listing
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Healthcare CustomersHealthcare Customers
• Quest Diagnostics• HealthNow New
York• BCBS Minnesota• BCBS Michigan• BCBS Texas and
Illinois• NASCO• John Muir/Mt Diablo• Universal Care• Commonwealth of
Massachusetts• Oxford Health Plans
• Mayo Foundation• Holy Redeemer• Sutter Health• Catholic Healthcare
West• Union Labor Life• Conseco – Bankers
Life• Health Alliance• Partnership Health
Plan – CA• L.A. Care• LA County
• St. Luke’s Hospital• John Hopkins • Wake Medical
Center• Kaiser Permanente• Carilion Health
System• UCSD Medical
Center• Research Medical
Center• Detroit Medical
Center
Partial Listing
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• Trizetto – Embedded solution for EDI
and Process Management
• HSD/Perot – Embedded EDI solution for
Diamond 725/950
• OAO MC400 – Embedded EDI solution
• CSC PowerMHS – Recommended solution
Channel PartnersChannel Partners
Payer Vendors
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Commitment to the Healthcare IndustryCommitment to the Healthcare Industry
• AFEHCT membership, co-chair ASPIRE workgroup (CMS 1500 and UB92 print image gap analysis/demonstration project)
• HL7 membership, ASIG workgroup (claim attachments)
• WEDI Board of Directors, ’02-’04
• X12N membership, TG3 WG3 (HIPAA Implementation and Modeling)
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• Testified on HIPAA issues to NCVHS
• SNIP Transaction workgroups, Co-chair Translations sub-workgroup
• NCPDP membership• HIMSS NHII Task Group
Commitment to the Healthcare IndustryCommitment to the Healthcare Industry
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• Costs for healthcare will continue to increase.
• Overall efficiency needs to be improved to be in business.
• Better customer satisfaction needed.
• HIPAA mandate.
• Healthcare fraud.
Healthcare Industry IssuesHealthcare Industry Issues
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Sybase Healthcare SolutionsSybase Healthcare Solutions
• Enterprise Application Integration– Revenue Cycle Enhancement Solution– Sybase Secure Server Solution– HIPAA Compliance Solution– Sybase / PeopleSoft Solution
• Business Intelligence– Centralized Data Management Solution– Sybase Fraud Detection Solution
• Enterprise Portals– HIPAA Security / Privacy Solution
• Mobile / Wireless
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Online Claims CorrectionOnline Claims Correction
• Web-based collaborative case management applications for both payers, providers and service bureaus. Allows processing for:
– Fraud investigation– DDE and claims correction– Customer complaints management– Privacy management– Customer service
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Temporary cache vs. Very long term storage requirements
Temporary cache vs. Very long term storage requirements
• Operational Data Store used for temporary cache of data needed in order to complete an operational process
• Long Term Data Storage Requirements for ongoing analytics, research and to comply with data retention regulations
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ProprietaryFile
Structure*EDI Map
Valid X12
ComplianceMap
HIPAA Compliant
HIPAA
REPOSITORY
Maps
HIPAAData
Repository
TRANSLATION
837 Claim
Remit Trans
835 Data
Claim
Adjudication
System(s)
HIPAA RepositoryHIPAA Repository
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Dat
a A
cqu
isit
ion
Lay
er
Sybase IWS
Data Warehouse
Sybase IWS
Data Warehouse
CRM AnalyticsCRM Analytics
• Patient Demographics• Effectiveness of
Treatments and Procedures
• Disease Management• Etc. . . . .
• Patient Demographics• Effectiveness of
Treatments and Procedures
• Disease Management• Etc. . . . .
Business AnalyticsBusiness Analytics
• Fraud Detection• Government Reporting • Claims Analysis• Facilities Mgt• Insurance Risk Mgt• Etc. . . . .
• Fraud Detection• Government Reporting • Claims Analysis• Facilities Mgt• Insurance Risk Mgt• Etc. . . . .
So
urc
es o
f C
ust
om
er D
ata
Patient EncounterPatient Encounter
SybaseHIPAA
Repository
Lab andTesting
Applications
Lab andTesting
Applications
Claims and Billing
Claims and Billing
R&DR&D
InsuranceInsurance
IndustryEvents
IndustryEvents
CustomerCustomer
ProductProduct
AnalyticalViews of
Data
Automated ETL
Industry Warehouse Studiofor Healthcare
Industry Warehouse Studiofor Healthcare
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Fraud DetectionFraud Detection
• Healthcare fraud is approximately one-seventh of the national economy, or $80 billion annually. Healthcare fraud represents about 10 percent of $1 trillion in annual healthcare revenues.• Types of Healthcare fraud:
• Ping-ponging – the use of a single patient ID to generate billings across multiple providers• Unbundling – false inflation of provider billing in which a single patient procedure is represented as a series of separate treatments• Duplicate entrie and the billing of more hours than feasible for patient services• Inappropriate or inapplicable cost center charges• Over-billing, either in man hours or at a higher-than expected rates• Unusual changes in transactions or amounts over short periods of time• Unusual changes in patient activity or care profiles• Unusual provider billing or treatment patterns
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SYBASE and SPSS:Predictive Fraud Detection for HealthcareSYBASE and SPSS:Predictive Fraud Detection for Healthcare
• Consists of• SYBASE Adaptive Server IQ Multiplex D/W engine• SPSS Clementine Data Mining Workbench with fraud-specific Clementine Application Templates (CATs)
• Enables organizations to• Profile and segment claimants, identifyng those most likely to commit fraud• Predict medical practices among provider base most likely to be subject to fraud• Identify service and product combinations most likely to be out of compliance with claim regulations• Prioritize providers and consumers for enhanced scrutiny and auditing• Detect claim fraud between practices and from region to region within an entire market• Identify duplicate claims, unbundling, and ping-ponging• Take proactive steps to prevent fraud in the claims process
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Security ServerBusiness Case
Security ServerBusiness Case
• Maintaining VPN is expensive and communications via dial-up is slow and unreliable
• Remote connection points not technically sophisticated• Large number of connection points• Need to perform data transformation before sending message over the network• Meeting compliance with HIPAA Privacy rules requires that exchanging
protected health information (PHI) during transmission between trading partners be secure
• Adding, deleting, and modifying trading partner profiles and exchanging data quickly in a secure way is challenging and cumbersome
• There is a need to move to a real-time processing environment from batch orientation in order to integrate with the Internet and WWW
• To stay competitive, organizations must improve quality of service to their constituents
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SYBASE Secure Communications Server
SYBASE Secure Communications Server
• Secure bi-directional communications mechanism between you and trading partner• Firewall-supported queuing technology that automatically deploys satellite queues along with
the digital certificates• Integrate a new trading partner into a transaction network economically ( low cost of ownership)• Ability to centrally monitor and manage all satellite queues and hosts• Guaranteed Transactional Messaging
– Designed for the Internet• Portable – small footprint, pure Java• Only pre-requisite software JVM• Complete and self-contained
– Guaranteed Delivery• “Once and Only Once”
– Transactional at both client and server– High performance – real-time messaging
• Data exchanged between sites are encrypted (RSA Encryption & authentication)• PKI• SSL3
– Automated set-up and administration• Own certificate authority or integrate with trusted third-parties
• Integrate a new trading partner into a transaction network economically ( low cost of ownership)– Automated deployment, release management, and un-installation
• iMercury• Adapters/applications deployed to the client
– Automated installation, configuration and scheduling– Remote client monitoring & management– Automated firewall tunneling
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Example Configuration Example Configuration
Deployment, Integrated Distributed Security, Guaranteed DeliveryDeployment, Integrated Distributed Security, Guaranteed Delivery
SYBASEEDI
Server
Hospital
SYBASE SCSClient
INTERNET
INTERNET
EAIEAI
Provider Ad
ap
ters
Ad
ap
ters
Leg
acy
Syst
em
sLe
gacy
Syst
em
s
Doctor’s Office
SYBASE SCSClient
SYBASE SCSClient
SYBASE SCSServer
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SYBASE HIPAA Privacy PortalSYBASE HIPAA Privacy Portal
• Business Need:– Per the HIPAA privacy rules, enhance patient’s control over their own protected health
information (PHI)– Enhance a covered entitie’s obligation to protect this PHI
• SYBASE HIPAA Privacy Portal Value Proposition:– Reduce cost of meeting privacy compliance by automating the implementation of the key
requirements
• Includes:– SYBASE Enterprise Portal– Pre-Built Portlets for management of
• Disclosures• PHI Access• Authorization• Complaints• Notices
– BPI Suite for Healthcare (Optional for integration)
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Provider ChallengesProvider Challenges
• Reduce Accounts Receivables (AR)
• Decrease Days Outstanding in AR
• Reduce Claims Denied
• Reduce Claims Reviewed and Resubmitted
• Resource Reduction/Realignment of FTEs focused on “fixing claims”
• Direct Submit EDI transactions, avoiding ClearingHouse costs
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Objectives of SYBASE HealthcareRevenue Cycle Enhancement
Solution
Objectives of SYBASE HealthcareRevenue Cycle Enhancement
Solution
• Generate “clean” transactions in the first place, avoiding costly delays with time spent correcting and resubmitting down the road
• Cut out the “middle-man” to reduce costs• Speed up the process to get claims paid faster• Study reimbursement trends to avoid pitfalls in the future
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Streamlining the Revenue Cycle ProcessStreamlining the Revenue Cycle Process
• Immediacy and Accuracy of Charge Capture• Eligibility Checking prior to procedure• Point of service charge capture
• Speed of Revenue, getting the $ in faster• Clean Claims (scrubbing, apply business rules, HIPAA
validation)• Transaction Exception Handling and Resubmission• Automatic Claim Status Checking for claims outstanding > x
days
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QUESTIONS?