How to digitize processes across multiple organizations and platforms with an orchestration engine

Business case

Medical billing and payment companies acting as intermediaries between hospitals and insurance providers need to digitize and optimize billing process while leveraging the platforms and infrastructures of the different involved parties.

The three separate organizations and multiple participants involved in this kind of process often experience problems with their billing procedures and communications between all of the parties. Requests initiated and processed via emails sent back and forth between hospitals, billing companies and insurance providers can lead to delays of weeks between initial hospital billing requests and eventual reimbursements. This kind of time-sensitive and financially critical situation can easily get out of hand, thus requiring a solution to facilitate and optimize all aspects of the billing and reimbursement procedure, in particular to properly and efficiently route requests while reducing processing time.

In this kind of architecture, the various applications already in place in the three organizations can include:

• Claims management systems (insurance company)
• Custom applications that handle data such as types of claims, medical procedure and facility codes, and claim splitting and routing (billing company)
• Accounts receivable software (hospital)
• End-user portals (patients, hospitals, insurance providers)
• Industry standard frameworks for transmitting claims data

Requirements

The ideal solution would do the following:

• Give any additional specialists required for particular claims the ability to validate, authorize and complete workflow actions
• Feature customized end-user portals, or interface with the companies’ existing applications and platforms
• Allow process actors to easily escalate cases
• Facilitate communication between departments and between companies
• Provide metrics to ensure tasks are being completed and, when relevant, route the request to the next process actor, whether internal or external
• Coordinate the queuing of tasks
• Ensure prompt and accurate payments to hospitals within the required time frame and without hitches

WorkflowGen has earned a solid reputation both as a stand-alone application and as a behind-the-scenes workflow engine that can be seamlessly integrated into existing software infrastructures and drive any kind of process.

WorkflowGen features a whole new way to perform this kind of integration through the GraphQL API, a cutting-edge technology that provides even more flexibility and configurability when it comes to integrations.

Technical Solutions

• WorkflowGen’s deep and transparent integration capabilities ensure that existing software infrastructures and front-ends as developed by the companies can be maintained.
• Web applications can be built to enhance communication between WorkflowGen and the companies’ own internal software.
• WorkflowGen can be implemented as an orchestration engine to streamline and more effectively coordinate the flow of requests and data.
• Process actors who are still accustomed to using email can continue to do so thanks to WorkflowGen’s Remote Approval and email notifications features, and can still leave comments at every stage of the workflow.
• WorkflowGen’s Quick Mass Approval feature lets process actors validate requests with one click or tap, all in one place and on any device.
• The new GraphQL API allows the creation of completely customized end-user portals (instead of the standard WorkflowGen portal) and can greatly simplify configuring the retrieval of process data that can then be displayed in the front-end interface.

Benefits

By implementing WorkflowGen, companies can accelerate value delivery with a shorter time-to-market and improved operational agility, while leveraging existing skills and solutions and providing enhanced customer experience.

• The behind-the-scenes integration of WorkflowGen allows existing applications, platforms and architectures to be maintained, eliminating any learning curve for process actors, with no disruption to day-to-day operations.
• End-users in the separate organizations involved in billing and reimbursement processes can continue using their familiar interfaces within established software infrastructures while WorkflowGen acts as an engine in the background, with no need for major overhauls or migrations to other environments.
• Queuing and automatic assignment of actions dramatically reduce processing time while eliminating back-and-forth emails, which increases team efficiency.
• Workflow actions such as approvals or request modifications can be performed remotely on any device, reducing delays in claims due to process actors being out of the office.
• Communication and coordination between departments is greatly enhanced.
• Errors in medical billing codes can be quickly flagged and corrected without disruption to the processing that could otherwise delay reimbursements or incorrectly deny claims.
• The GraphQL API and other integration features such as webhooks enable operational agility going forward, allowing the rapid implementation of higher levels of customization and more intricate data manipulation.
• Prompt and accurate reimbursements performed via a rigorous and battle-tested workflow engine, as well as an audit trail, reinforce the financial integrity of the parties involved.
• Improved customer and user experience.
• Greater satisfaction and confidence of hospitals and their patients, the two end-points of the entire request.