Case Studies

Transforming Hospital Claims and Payments

Delivering IT Transformation

Envisian’s vision and experience persuaded a major health insurer to change how it worked with the hospital industry, and helped it become a leader in hospital claims and payment processing.  Today $2 to $3 billion in hospital claims are processed and paid each year, untouched by human hands. 

Yet, when Medicare set up the Government’s ECLIPSE platform in early 2007 to process electronically all health related claims, it was not being used for hospital claims and payments. This was due to the complexity and depth of the multi-level hospital claim content and the inability of patient management systems to send information electronically.  It was further hampered by the lack of a working and agreed B2B format within the industry.  As a result, hospital insurance claims continued to be processed manually.

To take on the challenge of leading the industry to develop a standardised hospital claiming process, our client needed a leadership team with the knowledge, experience, and drive to secure industry wide commitment – insurers and hospitals – to a uniform message content and structure.

We put together a small team of professionals, skilled in diplomacy, stakeholder management, project management, B2B and technology.  This team was part of the ECLIPSE industry working group, comprising health insurers, major hospitals, and selected software developers.

We started with two hospitals, one from each of the two largest groups, and worked to align their systems with those of the insurer and ECLIPSE.  We used an iterative process to continually refine content and structure to cater for the wide variety of claim scenarios.   Once we achieved a level of confidence, we started processing real claims and gradually rolled out the ECLIPSE hospital claim to more hospitals in the two groups (around 150), nationally, adjusting and refining to handle non-conforming claims, no matter how unusual.  In some instances, the hospitals would adjust their systems to our industry standards, as needed. We then took the roll out further, to bring other hospitals and hospital groups on board, until we achieved a tipping point in the industry.

Our team also worked with internal teams to successfully integrate the new system and processes into the business, managed IT incident and problems, put in place a contingency process and regularly briefed the Senior Team and the Board on cut over and implementation activities and progress.

It was a three year process, with three stages of business roll-out to over 300 hospitals. The benefits and cost savings to our client were visible, immediately.  As the program rolled out, it was able to deploy staff to other areas, and overtime reduce approximately 150 manual operators to just 10.  Our client continues to be the leader in hospital claim processing.  We continue to provide valuable input into health insurance industry transformation projects.




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