e-busIness

for
hanaged Care DrganIzatIons
A WhItepaper on CognIzant's Approach and CapabIIItIes














TALE DF CDNTENTS
1. e-business in HealthCare ......................................................................................... 3
2. Managed Care Organization & e-business ............................................................. 4
2.1 Background.....................................................................................................................4
2.2 Business Requirements ..................................................................................................4
2.3 e-business Trends in Managed Care.............................................................................5
3. Cognizant's Approach to building e-business solutions ......................................... 6
3.2 Encompassing Technical components:.........................................................................6
3.3 Methodology: ..................................................................................................................7
3.4 e-business Technologies & Enterprise Application Integration.................................8
3.5 e-business Applications & Enterprise architecture for Facets clients....................11
4. Sampler Applications (Prototypes)......................................................................... 12
5. Benefits of a Cognizant Solution ........................................................................... 13



LIst of FIgures

FIgure 11: ebusIness prospects ___________________________________________3
FIgure 21: ebusIness 0rIvers E FequIrements _________________________________5
FIgure J1: |ethodology _________________________________________________7
FIgure J2: |etrIcs CockpIt _______________________________________________8
FIgure JJ: 8usIness Process |anagement ____________________________________9
FIgure J4: Process |anagement |atrIx ______________________________________9
FIgure J5: ServIce vIsIon for |CD's EnterprIse ntegratIon PractIce ________________10
FIgure J6: Dverall Process vIew the key framework components _________________10
FIgure 41: easyH|D Prototype ___________________________________________12
FIgure 42: Sampler ApplIcatIons __________________________________________13





ebusIness for |anaged Care DrganIzatIons WhIte Paper 7ersIon 1.0 3

1. e-busIness In HeaIthCare

ebusIness In HealthCare may be defIned as the combInatIon of two components

CollaboratIve Commerce HealthCare collaboratIve commerce Is defIned as electronIcally
enabled healthcare InteractIons among a healthcare payer organIzatIon's (payer's) Internal
personnel, supplIers, busIness partners and customers.

ecommerce electronIc admInIstratIve and fInancIal transactIons (referral and
authorIzatIons are consIdered admInIstratIve transactIons In thIs defInItIon). HealthCare e
commerce buIlds on the transactIon data collected from ecommerce InItIatIves and then
engages the healthcare consumer, wIth other stakeholders, to Interact through a shared
InformatIon envIronment. TheoretIcally, thIs promotes better customer servIce, enablIng
healthcare benefIts and treatment customIzatIon, and ImprovIng overall health outcomes.
CreatIng the technology envIronment and fosterIng stakeholder technology adoptIon to
achIeve a collaboratIve commerce envIronment wIll be a multIyear strategIc effort,
because of T evolutIon and user adoptIon rates.

























FIgure 1-1: e-busIness prospects

The Impact of the ebusIness on |anaged Care DrganIzatIons (|CD) wIll be nothIng short of
revolutIonary. DfferIng affordable unIversal access, the nternet promIses to slash
admInIstratIve and medIcal expenses, Improve customer servIce, and enhance customer
loyalty.

Employer
Member
Provider
Broker
mprove member suLIsIucLIon
Reduce udmInIsLruLIve expenses
Reduce medIcuI expenses
Reduce seIIIng expenses
Reduce udmInIsLruLIve expenses
Reduce udmInIsLruLIve expenses
mprove provIder suLIsIucLIon
Reduce cycIe LIme
MCO


ebusIness for |anaged Care DrganIzatIons WhIte Paper 7ersIon 1.0 4


2. hanaged Care DrganIzatIon e-busIness
2.1 ackground

|ost of the HealthCare DrganIzatIon's are beIng affected by theIr current Inventory of
dIverse and dIsparate set of healthcare applIcatIons, whIch does not support theIr busIness
objectIves fully. As a result, a hIgh percentage of healthcare organIzatIons often have
several dIfferent applIcatIons that rarely communIcate outsIde of theIr departmental
functIon. Further, the enterprIse fInds that Its T systems are no longer homogenous.
|oreover, applIcatIons and InformatIon systems that have been In place and operatIonal for
several years represent a sIgnIfIcant Investment that cannot be easIly replaced.

lndustry trends ndccte thct the heclthccre ndustry hcs ncrecsnyly opted to mplement
cn lntrcnet Soluton to lnk these dverse cnd dspcrcte cpplcctons. 6lobcl heclthccre
stcndcrds such cs HlPAA, Heclth Level Z (HLZ) cnd 0ytcl lmcyny Communccton n
Medcne (0lCDM), coupled wth recent developments n technoloyes, lke XML, ActveX
cnd 1cvc, hcve crected cn opportunty to nteyrcte mcny o] these n]ormcton systems
nto c browser bcsed lnternet/lntrcnet soluton.

UtIlIzIng a common browserbased ntranet solutIon to unIversally access, retrIeve, and
dIsplay data from the many InformatIon systems across enterprIse allows departments to
keep runnIng wIthout sIgnIfIcant dIsruptIon to theIr routIne. AddItIonally, the aggregated
productIvIty gaIns of provIdIng InformatIon access to personnel who dId not have It before
can be rapIdly and cost effectIvely realIzed by ImplementIng an ntranet solutIon.

Another area, whIch Is hIgh on prIorIty, Is complete web enablIng of servIces and forgIng a
better relatIonshIp between members, provIders, agents and HealthCare DrganIzatIon's
usIng nternet. The Idea beIng to brIng about complete supplIes chaIn IntegratIon by wIrIng
In the servIce provIders, the customers and the HealthCare DrganIzatIon's. ThIs approach
not only brIngs about a better cohesIon of the busIness process but also makes the entIre
cycle effectIve E effIcIent.

A research by |erIll Lynch has estImated, that nearly S J0 bIllIon wIll be Invested by
HealthCare DrganIzatIon's In webenablIng of theIr servIces In the next fIve years
2.2 usIness PequIrements
As the wave of nternet technology sweeps towards healthcare, the challenge to executIves
In these IndustrIes Is clear. They can understand the potentIal of the nternet In the health
IndustrIes and can control and dIrect Its power to the benefIt of theIr customers, health
plan members and patIents. Dr they can allow the new technology to roll uncontrolled
through and around theIr organIzatIons. f they choose the latter, they wIll effectIvely hand
over theIr markets to fastermovIng, betterfocused competItors some of who do not even
exIst yet.

EnablIng patIents/members and staff to do more wIth less support

StreamlInIng managed care contract admInIstratIon, E0 and claIms processIng



ebusIness for |anaged Care DrganIzatIons WhIte Paper 7ersIon 1.0 5

8uIldIng relatIonshIps and brand equIty wIth patIents, physIcIans and affIlIated
provIders

mprovIng access to vItal patIent InformatIon at the poInt of care to reduce cost and
Improve care delIvery

TransformIng the organIzatIon, buIldIng market Image and posItIon, ImprovIng
employee productIvIty and morale

FacIlItatIng pharmaceutIcal research, clInIcal trIals and regulatory submIssIon,
promotIng dIrect contact wIth consumers
2.3 e-busIness Trends In hanaged Care
|anaged care organIzatIons have been slow to take advantage of the nternet. nsuffIcIent
InformatIon technology budgets, preoccupatIon wIth Y2K problems, and securIty and
regulatory Issues have been major obstacles delayIng the ebusIness explosIon In health
care. However, enough busIness drIvers wIll force the Industry to embrace ebusIness:

The Health nsurance PortabIlIty and AccountabIlIty Act wIll catalyze explosIve growth of
nternetbased busInesstobusIness eCommerce. Currently, most non-|edIcare/ |edIcaId
electronIc claIms are processed by clearInghouses, whIch transform claIms from provIder,
formats Into a myrIad of proprIetary payer formats. However, government standards for
health care admInIstratIve and fInancIal transactIons wIll elImInate the need for thIs
functIon.

AddItIonally, the nternet Is the Ideal platform for aggregatIng and delIverIng transactIons
from many sources to many destInatIons.

Health plans wIll soon reach prIce parIty, leavIng servIce as the maIn dIfferentIatIon.
Unable to maIntaIn artIfIcIally low premIums, managed care organIzatIons wIll turn to
technology to Improve admInIstratIve effIcIency and enhance connectIvIty wIth provIders,
employers, brokers, and members. Health plans that are able to demonstrate qualIty
servIce through fast, effectIve, and effIcIent responses to customer calls and resolutIon of
Issues wIll have a competItIve advantage In the market.















FIgure 2-1: e-busIness 0rIvers PequIrements
ncreased nternet usage
CompetItors onlIne InItIatIves
Customer expectatIons
Customer servIce costs
LImItatIons to tradItIonal
connectIvIty methods
nquIry, update, and
submIssIon transactIons
ProvIder, group, broker, and
member functIons
ntegratIon wIth exIstIng
systems
HPAA complIance
PequIrements 0rIvers


ebusIness for |anaged Care DrganIzatIons WhIte Paper 7ersIon 1.0 6

3. CognIzant's Approach to buIIdIng e-busIness
soIutIons
8ased on extensIve experIence In buIldIng complex busIness crItIcal ebusIness solutIons,
CognIzant belIeves that an evolutIonary approach of harnessIng legacy Investments Is the
best approach. ThIs approach allows |CDs quIckly gaIn the benefIts of ebusIness wIthout
dIscardIng the substantIal Investments that they have made In buIldIng legacy systems.
ntegratIng web systems wIth legacy systems wIth sophIstIcated mIddleware tools wIll allow
the |CD to offer support for ebusIness transactIons, whIle maxImIzIng the value of legacy
data and busIness logIc.

CognIzant's works wIth numerous busIness partners such as dIgItal consultants, ASPs
(ApplIcatIon ServIce ProvIders) and ebusIness servIce provIders to provIde a best of breed
solutIon. ThIs approach allows CognIzant to delIver an endtoend solutIon, wIth a short
turnaround tIme.

WorkIng joIntly wIth CognIzant, the |CD maps out Its ebusIness busIness strategy and
ImplementatIon plan. CognIzant's extensIve Healthcare experIence provIdes It the domaIn
knowledge to understand the |CD's busIness prIorItIes. CognIzant wIll then deploy Its
superIor ebusIness expertIse to create the technIcal Infrastructure to support the strategy.
n thIs way, CognIzant helps the |CD move up from the Access stage of ebusIness maturIty
to the Enablement stage, thus fulfIllIng the complete potentIal of ebusIness.

3.1 PractIce offers:
Business Assessments
Strategy, Planning and Implementation
Internet Application Development
Project Management
3.2 EncompassIng TechnIcaI components:
ecommerce
Portal 0evelopment
ntranet 0evelopment
Web 0esIgn and 0evelopment
Web ArchItecture
Web ntegratIon
Workflow AutomatIon
0ata WarehousIng
Content |anagement

The nternet based applIcatIons encompasses of Inbound and outbound transactIons from
Payer TransactIon system along wIth 0ata Warehouse and other busIness systems. The
applIcatIons are accessIble through nternet. Each applIcatIon Is desIgned to cater the
needs of a partIcular servIce group of Payer. Each component of the applIcatIon Is desIgned
In accordance to HPPA regularItIes. The solutIons should NDT be based on 7endor specIfIc
transactIon system, but It should be flexIble enough to be Integrated wIth other systems.


ebusIness for |anaged Care DrganIzatIons WhIte Paper 7ersIon 1.0 7

3.3 hethodoIogy:











FIgure 3-1: hethodoIogy

CognIzant has evolved a hIghly cost effectIve onsIte/offshore model for executIon of e
busIness solutIons at web speed. ThIs model enables a 24x7 development wIndow exploItIng
the tIme dIfference between the |CDs US offIces and CognIzant's development centers In
ndIa. A judIcIous mIx of onsIte and offshore resources can cut project schedules by half
whIle sImultaneously offerIng substantIal cost savIngs.
hethodoIogy for e-busIness soIutIons
P0

E Ex xp pe er rI Im me en nt t
P Pr ro ot to ot ty yp pe e
T Tr ra an ns sf fe er r
C Co on ns su uI It t


S Su up pp po or rt t p pr ro oj je ec ct t
g gr ro ou up ps s, , I Id de en nt tI If fy y
r re es so ou ur rc cI In ng g, , b bu uI II Id d
c co om mp pe et te en nc cy y t to oo oI Is s
a an nd d p pr ro od du uc ct tI Iz ze e
TechnoIogy
ExpertIse
W We eb b- -e en na ab bI II In ng g
W We eb b- -
a ap pp pI II Ic ca at tI Io on n
d de ev ve eI Io op pm me en nt t
T Tr ra an ns sa ac ct tI Iv ve e
c co on nt te en nt t
. .N NE ET T T Te ec ch hn no ol lo og gI Ie es s
J Ja av va a T Te ec ch hn no ol lo og gI Ie es s
S Se ec cu ur rI It ty y T Te ec ch hn no ol lo og gI Ie es s
n nt tr ra an ne et ts s a an nd d
E Ex xt tr ra an ne et ts s, , 0 0a at ta ab ba as se e
I In nt te eg gr ra at tI Io on n, , T TP P
ArchItecture
ExpertIse
0 0e es sI Ig gn n a an nd d
0 0e ev ve eI Io op pm me en nt t
C Co on ns st tr ru uc ct tI Io on n
S Se er rv vI Ic ce es s
h he et th ho od do oI Io og gI Ie es s
F Fr ra am me ew wo or rk ks s
U U| |L L, , A Ap pp pl lI Ic ca at tI Io on n
s se er rv ve er rs s, , C Co om mp po on ne en nt t
m mo od de el ls s, , F F| | , ,
C CD DF F8 8A A
C CD D| |, , 0 0N NA A, , 0 0 C CD D| |
0omaIn
AppIIcatIon
KnowIedge
I In nd du us st tr ry y
A Ap pp pI II Ic ca at tI Io on n
b bu us sI In ne es ss s
p pr ro oc ce es ss s
k kn no ow wI Ie ed dg ge e
C Cl la aI Im ms s P Pr ro oc ce es ss sI In ng g
E En nr ro ol ll lm me en nt t
8 8I Il ll lI In ng g
F Fe ep po or rt tI In ng g
8 8r ro ok ke er r C Co om mm mI Is ss sI Io on n
P Pr ro ov vI Id de er r | |a aI In nt te en na an nc ce e
H H P PA AA A



ebusIness for |anaged Care DrganIzatIons WhIte Paper 7ersIon 1.0 8


ThIs methodology Is supported by a proprIetary webbased tool called |etrIcs CockpIt,
whIch Is a powerful decIsIon support and project management tool. ThIs tool represents
data In an easy to grasp graphIcal form of gauges and
graphs. t provIdes clIents wIth InformatIon on the
status and progress of a project, the abIlIty to IdentIfy
strengths and potentIal areas for Improvement, the
capabIlIty to compare performance agaInst
benchmarks and the abIlIty to determIne future
targets based on the benchmarks. t also gIves team
members and clIents the abIlIty to examIne the
metrIcs of the project. ClIents can then analyze thIs
InformatIon to determIne If the project meets theIr
requIrements.


FIgure 3-2: hetrIcs CockpIt
3.4 e-busIness TechnoIogIes EnterprIse AppIIcatIon
IntegratIon
The ebusIness solutIons and the exIstIng enterprIse applIcatIons should be Integrated to
effIcIently and effectIvely Implement the busIness requIrements. Dur solutIons can help
you by provIdIng the best possIble applIcatIon IntegratIon servIces whIle maIntaInIng a
return on your Investment.

The standard ebusIness applIcatIons possIble or avaIlable In the market are subjected to
customIzatIon. The transactIons may be InquIry type or Update type. The ebusIness
applIcatIons are desIgned to Integrate wIth one or more healthcare legacy applIcatIons
and/or workflow systems and/or 0ata warehouse. 0ue to regulatory Issues the HPAA fIlter
applIcatIon may be the part of IntegratIon, whIch needs to be consIdered for the
transmIssIon of complIant data.

AchIevIng seamless IntegratIon Is not all that easy as It appears, as It Involves IntegratIon of
Internal, home grown applIcatIons, legacy systems wIth the external busIness processes and
systems. ThIs Involves
User Interface Integration
0ata ntegratIon
8usIness Process ntegratIon
|ethod or FunctIon ntegratIon






ebusIness for |anaged Care DrganIzatIons WhIte Paper 7ersIon 1.0 9












FIgure 3-3: usIness Process hanagement

























FIgure 3-4: Process hanagement hatrIx
EnterprIse e-busIness
hgmt.
usIness Process
TransformatIon
TechnIcaI ServIces
Customer ServIce
|anagement
ProvIder IntegratIon
|ember access, health
record and self servIce
Croup 8enefIt
AdmInIstratIon
Interchange
|arketIng/sales and
enrollment IntegratIon
ClInIcal ServIces
Content |anagement

- 8usIness Process Change
and AdmInIstratIve
SImplIfIcatIon
-ClaIms operatIons
-Enrollment
-|embershIp E 8IllIng
-ProvIder FelatIons
-Customer ServIces
-UnderwrItIng
- LD8 AnalysIs
- Work 0IstrIbutIon and
|anagement
Systems ntegratIon
0ata WarehousIng
ApplIcatIon |anagement
ApplIcatIon Fe
engIneerIng
HPAA TransactIon
Cateways
Strategy and ArchItecture

EnterprIse Performance
hgmt.
Interface and PortaI
hanagement


ebusIness for |anaged Care DrganIzatIons WhIte Paper 7ersIon 1.0 10













FIgure 3-5: ServIce vIsIon for hCD's EnterprIse IntegratIon PractIce
























FIgure 3-6: DveraII Process vIew - the key framework components

HIPAA Exchange

HeaIth PIan AppIIcatIon and System IntegratIon Infrastructure
hembershIp CIaIms
enefIt 0esIgn
Customer
ServIce
ProvIder
hanagement
us|ness Process Transformat|on
Web ServIces - Interface and PortaI hanagement
CIearInghouse ProvIders HeaIth PIans
Croups
IndIvIduaIs
FInancIaI
InstItutIons
EnterprIse e-busIness
EnterprIse Performance Hanagement


ebusIness for |anaged Care DrganIzatIons WhIte Paper 7ersIon 1.0 11

3.5 e-busIness AppIIcatIons EnterprIse archItecture for
Facets cIIents
ArchItectural vIew and technIcal aspects for the |CD usIng Facets as processIng system:
Technology perspectIve Java.














FIgure 3-7: EnterprIse archItecture for Facets cIIents




















FIgure 3-8: TechnoIogy components


PersIstence
User Interface
Use-case UI workfIow, syntactIc
vaIIdatIon, InteractIon wIth
servIets
JSPlHThLlJavaScrIpt
ServIets
EJ SessIon eans
ControIIIng transactIons,
busInesslworkfIow IogIc
PersIstent storage of object
state
Java cIasses ImpIementIng data
access operatIons
Layer Name

PesponsIbIIItIes TechnoIogy Used
ServIces
AppIIcatIon
PresentatIon


ebusIness for |anaged Care DrganIzatIons WhIte Paper 7ersIon 1.0 12

4. SampIer AppIIcatIons (Prototypes)

Cognizant has developed few prototypes to demonstrate the Internet use of business
transactions. The easyHM0 constItutes a set of applIcatIons, whIch demonstrates how
|CD's can Improve theIr busIness and delIver superIor servIces to Its customers wIth the
power of ebusIness.

Few samples are:

easyHM0 Enrollments (8J4). ElectronIc enrollment of employees, helpIng you streamlIne
admInIstratIon.

easyHM0 Premums (820 and ACH debIts). Collect both monthly premIum payments
(dollars) and payment data electronIcally. FeassocIatIon of payments to data.

easyHM0 0sbursements (DrIgInatIon of 8J5 ElectronIc FemIttance AdvIces and ACH
CredIts). ElectronIc payment and remIttance advIce dIsbursements.

easyHM0 Quote - DnlIne quotatIon for potentIal customers.

easyHM0 Provder 0rectory Search and locate provIders for the members.

easyHM0 Clams (DrIgInatIon of 8J7 ElectronIc ClaIms submIssIon). ElectronIc submIssIon
of claIms.

FIgure 4-1: easyHhD Prototype


ebusIness for |anaged Care DrganIzatIons WhIte Paper 7ersIon 1.0 13



















FIgure 4-2: SampIer AppIIcatIons
5. enefIts of a CognIzant SoIutIon

Strong focus on HeaIthcare
WIth more than 700 person years expertIse In developIng Healthcare applIcatIons,
CognIzant possesses extensIve domaIn knowledge of Industry busIness processes.

TechnIcaI expertIse
CognIzant has several competency centers for FE0 on the latest technologIes ensurIng that
clIents remaIn at the cuttIng edge of technology.

24x7 onsIteloffshore operatIonaI modeI
ThIs operatIonal model allows CognIzant to reduce turnaround tIme of solutIons whIle
offerIng substantIal cost savIngs.


PremIum
Payment/
8IllIng
Internet
EnterprIse AppIIcatIon
Framework












ElIgIbIlIty
Check
ClaIm
SubmIssIon
/
Status

ProvIder
Search


Enrollment

DnlIne
Quote
0ata warehouse
ProcessIng System
HIPAA Cateway
WorkfIow System
Feferral
SubmIssIon
AuthorIzatIo
n


ebusIness for |anaged Care DrganIzatIons WhIte Paper 7ersIon 1.0 14


Component-based deveIopment
CognIzant has a welldeveloped component culture that facIlItates the development of e
busIness solutIons usIng prebuIlt components. The component reposItory contaIns a
number of Healthcare busIness components that substantIally reduces the tIme and effort
to develop ebusIness solutIons.

HIPAA expertIse
CognIzant has setup a HPAA competency center to assess the Impact of HPAA on |CD
systems. t has also developed powerful tools to aId In the process of makIng T systems
HPAA complIant. 8ased on thIs research, CognIzant has developed a comprehensIve
solutIon set to achIeve HPAA complIance.

est-of-breed soIutIon
CognIzant has forged strategIc partnershIps wIth leadIng ebusIness Infrastructure provIders
and servIce provIders ensurIng that clIents get solutIons IncorporatIng the best technology,
developed at web speed.

EmphasIs on quaIIty
CognIzant's software engIneerIng processes are certIfIed at optImIzIng level of the SEC||
model, whIch few companIes worldwIde have been able to emulate. The optImIzIng level
means that CognIzant collects metrIcs for all projects executes and uses these to make
Improvements to the processes.





















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