Navigate Health Plan Challenges and Reduce Claims Expenses with EDI

The Client

Our client specializes in human-centered, data-driven health plan administration, working to deliver customized solutions for self-insured employers. By combining compassionate care management with cutting-edge data analytics, they seek to educate and empower health plan participants to make informed and cost-effective healthcare decisions.

To help expand its marketplace presence, the client selected Chetu, a certified BigCommerce partner, to build a robust website for marketing a wide variety of offerings directly to manufacturers.

The Approach

Chetu’s client has the ambitious goal of offering personalized healthcare support to members and designing individualized health plans for companies and personnel, leveraging data engineering to implement effective solutions.

Our business intelligence experts and software specialists collaborated to streamline the client’s claims management processes, address claim denials, and enhance financial protocols to ensure a fully optimized Revenue Cycle Management.

Claims processing remains a costly endeavor for healthcare, with claims adjudication and administrative costs accounting for more than 40% of hospital budgets according to The American Hospital Association, a leading advocacy and research center for healthcare communities.

Chetu’s client wanted to reduce expenses while enabling a more efficient process to complete complex claims processing while maintaining strict data integrity.

The Solution

Chetu leveraged customized, AI-driven resources to implement automation, strict HIPAA compliance, and ultimately support the client’s Revenue Cycle Management with accurate claims processing and secure handling of Protected Health Information.

The HIPAA Journal, a leading healthcare industry journal, provides news, statistics and trends for healthcare professionals that reported the average healthcare data breach cost over $9 million.

Chetu’s business intelligence and software specialists enhanced Electronic Data Interchange (EDI) with Artificial Intelligence to present the client with an intuitive, powerful new resource to streamline data processing and monitoring and mitigate costly patient data errors.

Recent reports from the American Health Information Management Association state duplicated patient data, improperly denied claims and inaccurate patient identification costs the U.S. healthcare industry over $6.7 billion annually.

The Impact

EDI agents powered by AI were seamlessly integrated with Machine Learning (ML) and ultimately, automated the client’s workflow.

Tasks such as data entry, processing, and monitoring fully optimized operations, enabling the client to reduce claims and billing errors.

Customized EDI agents facilitate standardization of data to streamline claims submission processes and interoperability protocols adhering to evolving HIPAA and HL7 policies.