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Business Intelligence and Enhanced Claim Processing Goes to Puerto Rico With TriZetto for Medical Claim Processing and Algorithm

Posted Feb 19 2010 7:48am

As you can see here the tech side of healthcare continues to beef up their resources so when you are fighting a claim denial, there’s the potential of 3rd parties in many areas now who are also involved and usually provide the algorithms that electronically determine claim status.  These are SQL statements that qualify and score imageclaim submittals. It certainly appears our government is still in the sword and dagger business trying to deal with health insurance companies who have machine guns in the data and information departments, and again why simple figure heads don’t cut it today, need some individuals in office who “get” this without having to start a blog and look for answers all the time, those are getting to be numerous and people don’t have time for them. 

Unfortunately it’s they still focus on creating agreements and contracts with old methodologies and that is why the financial worlds and health insurance today flourishes, technology and the algorithms use to create profits. 

Expect more anger and frustration as this process continues as most citizens of the US see it, but don’t know how it happens as tech denial lives on.  I understand that business intelligence companies are part of the the way business is done, but we are missing balance here and are cutting healthcare from the wrong side sometimes as these are investors who want a return and could care less about your individuals claims and care when it comes right down to it. As written before United or their subsidiaries seem to be involved in one way or another so they are getting paid for electronic services and thus why they are making big profits, they have many embedded sources of revenue outside of just selling policies. 

Certainly with the complexity of healthcare and who gets paid for what today, companies who provide this transactional related service are making big dollars.  As you can read from the links below Trizetto works with many of the algorithmic formulas created by Ingenix (a wholly owned subsidiary of United Healthcare) for their reporting, “scoring” and algorithmic formulas to verify enrollment, pay claims and so on.   As you can see United Healthcare is in here for a cut of the profits with their subsidiary and with share holder liabilities taking the front run and we heard about the record profits made. 

TriZetto Announces New Feature for Personal Health Records – Auto Populated for the Consumer But Payer Access for Eligibility Questions from Providers

You can read more about what the 2 companies say about their collaboration here.  TriZetto was purchased by Apax Partners, a London based private equity firm for 1.4 billion so somebody wants a return on their investment somewhere along this line.  They also have a large agreement in the Netherlands for processing claims and other financial interests.   This is all about “power to the employer” so again we see more efforts directed in the way of employer controlled health insurance with continued dwindling efforts for the individual.  BD 

NEWPORT BEACH, Calif.--(EON: Enhanced Online News)--The TriZetto Group, Inc., today announced that Aveta Inc., one of the nation’s largest providers of managed healthcare services, has purchased the QNXTTM enterprise administration system for its MMM Healthcare operations in Puerto Rico and has selected TriZetto to implement, manage and host the application.

Utilizing TriZetto’s QNXT application is another step in Aveta’s ongoing commitment to develop innovative, cost-effective models of care management. The application will automate claims adjudication, premium billing, enrollment, customer service and other functions central to the administration of MMM’s Medicare HMO for more than 180,000 members across 78 counties. The system, which will reside in and be managed from one of TriZetto’s data centers, is expected to be implemented by the summer of 2010 and will replace two production versions of MMM’s legacy platform.

TriZetto’s QNXT application has 48 health plan customers, covering more than 15 million licensed members. TriZetto Services manages applications for more than 35 healthcare payers representing more than 35 million lives in the United States and internationally.

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