At a Glance

Background and Challenge  

When Geisinger Health Plan (GHP), a regional payer in Pennsylvania, needed to update time-consuming manual claims payment methods, its leaders engaged Tegria to help them select and smoothly transition to a new platform. The solution needed to save time and resources by automating claims payment while integrating with Medicare, Medicaid, and commercial lines of business.  

Solution 

Tegria began with a detailed analysis of GHP’s existing claims payable process, Amysis fee schedules with manual pricing. The team also evaluated several competing claims processing platforms. GHP used Tegria’s analysis and recommendations to select Cognizant’s Facets with the NetworX Pricer platform for their new platform. Transitioning to Facets would allow GHP to manage multiple fee schedules for a single provider and share pricing methodologies for multiple providers at one time. 

To ensure an accurate and timely transition from Amysis to Facets, Tegria’s experts converted the existing Oracle database to Microsoft SQL through the data governance council. They also documented the existing Amisys and vendor data to be readable across multiple platforms. The Operational Data Storage (ODS) was created and configured to convert Amisys Data into a cross-platform, central source of truth that would allow GHP to communicate with third-party vendors such as pharmacy, radiology, and credentialing. 

Tegria successfully installed and configured Facets and NetworX Pricer to automate more of the claims payment process. The ODS was ultimately migrated to the Hadoop Distributed File System platform for expanded storage, scalability, and speed. 

Results

The engagement achieved:  

• On-time and on-budget implementation of Cognizant’s TriZetto Facets and NetworX Pricer configured with RBRVS and Optum Pricer
• Significant improvement of claims accuracy for hospital and professional claims processing
• Elimination of manual fee schedule loads and pricing methods   
• Increased auto-adjudication rates 
• Improved integrations with third-party vendors (pharmacy, radiology, and credentialing)