Challenge

The timeliness of this information exchange was critical. Failure to properly synchronize the data could result in inaccurate claims payment for the member. APWU Health Plan administrators needed to ensure that several actions took place in order to properly support the MOOP requirement, which included:

  • Daily receipt of the claim information from external third party partner
  • Processing and adding this information to the total OOP accumulator
  • Returning the updated accumulator information to the partner nightly

The APWU Health Plan reached out to RAM Technologies in hope of resolving this issue. As an existing RAM client, the health plan has experience working with the team at RAM and the company’s enterprise product suite, HEALTHsuite Mercato. APWU benefited from RAM’s flexibility and willingness to adapt the solution to meet their specific needs.

Solution

Once the team at RAM and APWU evaluated the business issue, it was determined that RAM’s HEALTHsuite Mercato solution could best address and resolve the health plan’s needs. HEALTHsuite Mercato is a rules-based and plan-configurable enterprise application with fully integrated functionality to reduce expenses in the administration of government sponsored healthcare programs.

RAM’s solution, HEALTHsuite Mercato, creates an inbound process for updating the OOP accumulators based on incoming information from the client’s third-party processing partner. This enhancement created an outbound process for extracting the accumulator information to an exportable file format. Accumulator adjustment information also was displayed on the appropriate HEALTHsuite screens.

The implementation was not without its challenges. One particular issue involved a change in the defined business requirements. Following a detailed business and functional analysis that took place between RAM and the APWU Health Plan, additional requirements surfaced during interactions with the third-party vendor partner (the recipient of the accumulator data). This ultimately resulted in a better solution for all parties involved.

“We had to map the incoming and outgoing data and create new fields in our database. RAM handled that entire process for us,” said Ingrid Bricker, manager of application development at APWU.

Results

RAM Technologies is dedicated to providing the personal attention necessary to understanding its clients’ business requirements and to proactively address their current and future needs. “RAM brought us from discussion to project completion in less than six months, which is amazing,” Bricker said. “We tested the solution for three weeks before go live and RAM helped us resolve any issues that we had to correct.”

RAM’s close working relationship with APWU through all phases of the implementation helped to effectively identify the problem, outline the overall business requirements, and facilitate the development of functional specifications to accurately address the needs.

Within six months – from identification of the problem to delivery of the solution – the APWU Health Plan’s ACA compliance issue was successfully resolved. Automating the process eliminated manual intervention and provided a tangible reduction in administrative expenses. In addition, the solution eliminated the potential for downstream penalties and fees due to non-compliance. The solution was configured to not only accommodate the client’s immediate needs, but also its future accumulator data exchange needs as well.

“RAM went the extra mile in working with us. They patiently walked us through the entire process,” said Brigitte Aulakh, EDI team lead, applications, for APWU Health Plan. “RAM was always available via phone or email to handle our needs.”