Background

Chorus Community Health Plans (CCHP), formerly known as Children’s Community Health Plan, is a nonprofit Health Maintenance Organization (HMO), affiliated with Children’s Wisconsin. CCHP coordinates health care services for over 140,000 adults and children across 28 counties through the state of Wisconsin’s Department of Health Services Medicaid and commercial plans. CCHP also administers Wisconsin’s Foster Care Medical Home Program (Care4Kids), which is also a Medicaid program.

Use Case

CCHP receives claim and enrollment data from its Third-Party Administrators (TPAs). The state requires HMOs to provide healthcare services utilization and claims reports to determine their Healthcare Effectiveness Data and Information Set (HEDIS) score. This score is used to evaluate an HMO’s performance and plays a critical role in retaining a Medicaid certified status with the State of Wisconsin.

Providers submit claims directly to TPAs and their records are sent to CCHP in an EDI format, called Encounters, on a bi-weekly basis.  The data reporting and solutions team thoroughly reviews Encounters and performs various data quality checks to ensure accurate information is sent to the state department. The state requires HMOs to have a minimum 95 % State Medicaid EDI data submission acceptance and approval rate to avoid financial penalties.

“I would literally need to go in, copy the data file into Excel, and use a number of Excel functions to find and manually correct errors in each file.”

– Amanda Moede, Health Plan Data Analyst

For many years, CCHP struggled to meet the 95 % Encounter data submission and approval rate for State Medicaid reimbursements because of errors and inconsistencies in the Encounters from vendors and TPAs. CCHP initially used a third-party vendor to prepare their EDI transactions. However, the process proved ineffective as the data reporting team had to intervene by requesting correction files for all Encounters that were denied by the state. CCHP would have to manually go through each file, line-by-line, to perform EDI corrections to ensure the reported transactions were accepted and recorded by the state.

Enter Astera EDIConnect

CCHP decided to search for a robust EDI solution that could automate the process completely. After evaluating several products in the market, CCHP chose Astera EDIConnect for the job because of its superior functionality, quick learning curve, intuitive, easy-to-use development environment, and process automation capabilities.

Astera EDIConnect is an enterprise-grade EDI solution that allows businesses to perform frictionless B2B information exchange through its robust EDI parser, validator, and transaction builder functionalities.

CCHP has built an end-to-end EDI correction system. Data analysts only have to copy-paste EDI files into the EDIConnect server folder, and the tool will do the rest. It runs dataflows to clean and prepare the data, verify the corrections, and sends the files to the state department.

Since the process now involves little to no intervention from the data reporting team, it saves about five weeks’ worth of manual coding and reviewing efforts, which translates into roughly $26,000/year.

Previously, due to recurring errors in the Encounters, CCHP had barely met the 95 percent criteria of Encounter data submission and approval rate for State Medicaid reimbursements. With EDIConnect automatically maintaining data quality, the non-profit HMO has been continually reaching 97 to 98 % EDI approval rates. CCHP has solidified their Medicaid-certified vendor status, which ultimately brings in more revenue from the state.

For CCHP, the real value of adding EDIConnect to its technology stack comes from the huge increase in the yearly retention of funds from accepted Encounters, which is directly attributed to the improved EDI data accuracy. Now the state is paying back dollar-for-dollar for claims related to the Care4Kids program, allowing CCHP to retain over $100,000 in reimbursements.

Overall, CCHP has found the product to be comprehensive as it checks all the boxes, from providing stellar data accuracy and validation capabilities to automating the process end-to-end, taking away the headaches of manual data quality completely out of the process. In the future, CCHP hopes to use the Astera tool for more EDI files like the 834 and 278.

“On top of the hours and weeks it has saved the data reporting team, it has actually increased our revenue by over $100,000 because of the higher accuracy of data sent to the state.”

– Amanda Moede, Health Plan Data Analyst