by Jon Sund & Jim Roach

This paper is based on the knowledge and experience gained while providing consulting services to the health care insurance market sector over the last ten years. During this ten-year period the health insurance market has gone through radical change, customer expectations have expanded, new legal requirements imposed, and technology made quantum leaps. The pace of change offers opportunity for the nimble, while challenging their ability to exercise cost containment.

In this paper existing data is consolidated then applied to the area of Media Independent Publishing (MIP), in this case the dissemination of provider information, is a strategy that offers implementers an opportunity to:

Leverage exiting data

Consolidate major process segments

Implement new technologies in incremental steps

Change with the market demands

Meet or exceed customer expectations

Decrease impact of legal requirements

Currently within most health insurance companies there are three major initiatives being
supported to meet marketing demands:

Provider Directory Publication

WWW Site Development

Customer Service Support

Each initiative is treated as a separate business function with its associated work process and final products. Each is considered to have significant impact on the ability of the company to meet legal, customer and competitive requirements. Viewed from the traditional functional paradigm convergence of the individual workflow processes is not a consideration. Compounding the apparent disparity between the initiatives is the addition of multiple insurance products distributed across multiple systems. Yet, convergence of major segments of the workflow yields substantial benefits to the implementers.

The basic data that supports each initiative resides in the same database, on a product by product basis. The three initiatives identified all represent the publication of data for human consumption. To be effective the data must be presented in a manner that meets customer requirements while providing future flexibility to meet future demands.

The objective of this paper is to provide the reader with an overview of the parallel work process functions, how these can be combined to meet current and future market requirements and how the process can be automated to increase efficiency and accuracy.

Major Initiatives – Current State

Provider Directory Publication

The publication of Provider Directories is a time consuming manual process that normally involves an outside provider of services. Each Directory produced is a separate production process that involves unique business units. The request for data, required for an individual directory publication, is normally handled by the same IS department but can vary if data for provider directory production is contained on multiple systems. The supplier of typesetting services can be from a single service or multiple services depending on the elements of time, quality, and price.

There are potentially two common points in the workflow process for Provider Directories, IS and the service provider. The requesting department within most health insurance companies varies by product. Work process review is not encouraged under these conditions since the consistent providers of service, i.e. IS and the outside service provider, are not impacted by the cost of production. There is very little incentive to address a process at the requesting department level since the printing of provider directories is an infrequent process.

The result of fragmentation of Provider Directory production is a manual time consuming process. Production times for most directories range from 4 to 6 weeks after the data has been provided by IS. The customer requirement for electronic versions of Provider Directories is causing many companies to evaluate their work processes. The staffing of teams is a challenge due to the fragmentation of the process, but there is a significant opportunity for savings in time and money making the effort attractive.

To properly address the workflow for Provider Directories, team members would come from:

The IS community

The individual requesting departments

The service provider.

The team would be unique to the functional areas of the process and would have little if any cross function synergies.

WWW Site Development

Most major health insurance companies have a presence on the World Wide Web (WWW) or are in the process of developing this critical marketing tool. The planning for the initial site is normally led by the Information Systems (IS) business segment because of the security, technical, and operational elements. Once these elements have been addressed the content of the site is developed and it is at this point the individual business units become involved.

The request for content goes out from the IS community to the business units for content that should exist on the companies WWW presents. One of the major items that business units desire to place on the Web is a form of Provider Directories. The options most often considered for this process are:

Placing images of current product on the site

Providing a searchable interface

Since neither of these options is supported by the current work processes, they are viewed as unique process and a development team is assigned. The team, armed with its new charter, proceeds to develop what it considers the most elegant solution to meet the Web presents requirement. The resulting work process specifically supports the Web element and becomes another ongoing work process that represents a form of data farming

The short-term need for Web content is meet, but the process stands alone. Efforts are not made to include the process in other work processes for many reasons. For example the original development people return to their normal jobs or support of the Web falls to a specialized group. The resources involved with development of the Web content are not included in other business projects that deal with the Provider Directory and thus their experience and ability to link work processes is lost.

Customer Service Support

Customer Service is a major business element in any health insurance company and is charged with many roles. While the charter is clear the development of the support infrastructure is not always viewed as a high priority. This lack of emphasis tends to result in a make do process that while not necessarily efficient does get the job done.

Competition within the health insurance industry is causing many companies to reevaluate their cost of doing business. Combined with an ever increasing demand by customers for service, focus is being placed on the Customer Service Representative (CSR) and ways to make them more effective.

To meet the challenge for effectiveness and efficiency, teams are charted and formed to meet specific needs of the CSR community. Most participants are either those in the current customer support organization or from the IS organization. Since most support functions are provided to the CSR come from the mainframe we have a different subgroup of IS participating than for the development of the Web site, thus reducing the opportunity for cross project synergies.

Work processes are developed to meet the needs of the CSR community and like the Web process become separate support requirements.

Conclusion

The three areas, i.e. provider directory publishing, web site development, and customer service support appear to be unique work process elements in many health insurance companies. While there may be opportunities for synergies between the process, independent vertical team structure makes the occurrence unlikely.

Media Independent Publishing (MIP)

Illustrated on the next page is a concept of data farming as an enabler to media independent publishing. The three processes, i.e. provider directory publishing, WWW site development, and the customer service support function, are pulled together under a common work process. The diagram deals specifically with provider directory data and its application across multiple functions.

The illustrated concept is the result of a collaborative effort between a Xerox team and a Group1 team. The concept as presented has been partially prototyped by the team using Group1 Software. All software utilized in the prototyping process is mature and in many cases is already installed on insurance company sites. The fact that it is already installed means implementers are familiar with it decreasing the slope of the learning curve as the project moves forward.

Common Work Process Elements

Provider directory publishing, web site development, and customer service support share many common areas in their work processes. It is the areas of commonality that are leveraged to achieve synergies that result in an effective solution.

Primary Data Source

All three elements are dependent on the provider data that normally resides within Certification systems. There may be more than one database as illustrated above by System 1 through N Provider files which often require additional processing before they can be used by external processes.

During the prototype development of MIP the Data Designs software product was utilized to combine individual databases into a database of the desired content and structure. The process requires an in-depth understanding of the data available from all sources and the data requirements of the individual processes being supported.

The advantage of extracting data from an existing database is the maintenance of data integrity. The new process is not required to maintain the underlying data, only access it in a batch process. Once the desired data has been extracted from Certification systems the MIP process continues with the batch address hygiene.

Address Hygiene

Mainframe systems, for the most part, maintain data in all upper case, which is effective, but not the format required for MIP. In addition to the upper case issue, the nature of database maintenance allows the entry of incorrect addresses that result in errors during the geographic coding process.

The hygiene process modifies all names and address to upper and lower case then determines if the address is valid. In the event there appears to be an error between the street address and the zip +4 code, an attempt is made to determine the correct zip +4 coded based on the address. In the event that the conflict can not be resolved, the record is placed in an exception report for human review.

The hygiene process is run in a batch mode when database updates are scheduled and as an iterative process when individual request are being process from either the CSR community or Customers from the WWW. Address hygiene is a necessary step because the geographic locations applied in the next step are determined based on the zip +4 field.

Geographic Coding

Geographic Coding is used to support publishing of provider information that is relevant to the subscriber community. The batch processed provider information from the address hygiene step is geographic coded and stored in the Geographic Provider Database for future reference by the three work processes.

Geographic Provider Database

The geographic provider database becomes the central repository that supports the three work efforts. The process to maintain current information can be automated for a monthly, twice monthly, or weekly refresh. Human intervention in the process is limited and replaces what has traditionally been a labor-intensive process.

Provider Directory Publication

Provider directory publishing can be accomplished at its current level of support or down to the audience of one. The MIP drawing contains a CSR/Administrator workstation, on the right side of the MIP diagram that represents access to the automated publishing system. The CSR/Administrator can receive request by written correspondence, the WWW, or telephone. The request can be for one directory or hundreds of thousands with little change in the process.

The CSR/Administrator submits a request for a specified directory based on plan, location, and quantity required. The process in the example is a batch process that stores the requests until off peak hours for processing. The data from the Customer Request for Information Database is used to activate an automated query to the Geographic Provider Database to compile the records required for the specified directory.

Data coming from the Geographic Provider Database is then sent to a Data Prep for Publishing step to be paired with an electronic mold that will dictate the structure of the directory. Individual plans and/or customers can have their own unique mold for the look and feel of the published product. The data and the electronic mold are then sent to the Demand Publishing process for production.

Output from the Demand Publishing process can be for production printing on laser printers, PostScript for use on offset presses, or PDF for use on CD ROMs. One process supports output in multiple media formats determined by the requesters requirement.

WWW Site Development and Customer Service Support

The advent of the WWW and the use of the same technology to support an intranet configuration make these two alternatives almost identical. The exception being the type of information that access is provided for and how the physical connection is made.

Looking at the left side of the MIP diagram the interface into the provider directory data is through a CGI Application Interface. In the example it is assumed that the requester whether a customer or a CSR will enter a reference address to request information and the area of search limited based on the users preference. To provide a geographic location for the requester it is necessary to convert the entered address into a zip +4 code. Like the batch address hygiene process the enter address must be valid for the zip code to be assigned.

The requesters input is then applied to the Geographic Provider Database to supply the requested information. The results of the search can then be sent back to the requester for view on their screen, faxed, or printed on a specified printer.

Summary

Media Independent Publishing (MIP), is an opportunity that deserves exploiting to leverage corporate resources. Taking the three areas:

Provider Directory Publication

WWW Site Development

Customer Service Support

As examples it has been illustrated that an opportunity exists to:

Leverage exiting data

Consolidate major process segments

Implement new technologies in incremental steps

Implementation of the process will result in an increased ability to:

Change with the market demands

Meet or exceed customer expectations

Decrease impact of legal requirements related to provider directories

While many questions have been answered many more have been created. For example:

What is an electronic mold for publishing?

How is a benchmark user interface developed for Web access?

How is a benchmark navigational design developed for information access?

Media independent publishing offers the enterprise an opportunity to automate three work processes previously thought to be unique. The MIP process illustrates how the three process can be combined and their synergies exploited. Development teams for the project should be across all work groups to ensure inclusion of all user requirements.

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