Astera > Case Studies > CCHP Saves $65,000 Every Year by Reducing the Need for Additional Staffing and C4K Retains over $100,000+ Every Year in Healthcare Claims Reimbursements from the Wisconsin Department of Health Services

CCHP Saves $65,000 Every Year by Reducing the Need for Additional Staffing and C4K Retains over $100,000+ Every Year in Healthcare Claims Reimbursements from the Wisconsin Department of Health Services

Customer Company Size

Large Corporate

Region

America

Country

United States

Product

Astera Centerprise
Astera EDIConnect

Tech Stack

Implementation Scale

Enterprise-wide Deployment

Impact Metrics

Cost Savings
Productivity Improvements
Customer Satisfaction

Technology Category

Application Infrastructure & Middleware - Data Exchange & Integration

Applicable Industries

Healthcare & Hospitals

Applicable Functions

Business Operation

Use Cases

Regulatory Compliance Monitoring

Services

System Integration

About The Customer

Children’s Community Health Plan (CCHP) is a non-profit 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 BadgerCare Plus (Medicaid) program and Together with CCHP (commercial) plans. It also administers Wisconsin’s Foster Care Medical Home Program (Care4Kids), a Medicaid program that coordinates the health care for youth in Out of Home Care in 6 southeastern Wisconsin counties. Like other HMOs, CCHP is required to maintain a high encounter data submission and approval rate to maximize the resulting capitation rates calculated using this encounter data and the quality outcomes calculated by the Wisconsin Department of Health Services. With Astera EDIConnect, CCHP has been able to meet and exceed state department’s encounter data quality standards, while enabling the encounter data reporting team to automate the EDI correction process.

The Challenge

Children’s Community Health Plan (CCHP) is a non-profit 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 BadgerCare Plus (Medicaid) program and Together with CCHP (commercial) plans. It also administers Wisconsin’s Foster Care Medical Home Program (Care4Kids), a Medicaid program that coordinates the health care for youth in Out of Home Care in 6 southeastern Wisconsin counties. The state requires HMOs to have a minimum 95% State Medicaid EDI data submission acceptance and approval rate to avoid financial penalties. For this, CCHP has to send accurate EDI 837 files regarding members’ healthcare utilization comprising of records from TPAs and vendors. By ensuring a high EDI approval rate, CCHP remains Medicaid-certified vendor and enjoys better claim reimbursement and capitation rates. 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. Some common errors included missing the National Provider Identifier (NPI) on referring providers, invalid state code, and missing NPIs to the service location segment.

The Solution

After carefully analyzing the situation to improve the EDI approval rates, it boiled down to hiring a full-time data analyst to manually make corrections or opting for a robust EDI solution that could automate the process completely. CCHP did the cost and benefit analysis and went out to search for an EDI tool. After evaluating several products in the market, CCHP chose Astera EDIConnect for the job mainly due to its superior functionality, short 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 that only takes a few clicks to remove errors from the encounters with the product. The process only requires data analysts to copy-paste EDI files into the EDIConnect server folder, wait for the tool to run dataflows to clean and prepare the data, verify the corrections, and send the files to the state department.

Operational Impact

Since the process now involves little to no intervention from the data reporting team, it saves about 5 weeks’ worth of manual coding and reviewing efforts to resolve errors, which roughly translates into $26,000/year. In addition, CCHP has also saved $65,000/year in hiring an additional full-time employee for managing these EDI files.
Due to recurring errors in the encounters, CCHP barely met the 95% criteria of encounter data submission and approval rate for State Medicaid reimbursements. With EDIConnect in the driver’s seat to maintain data quality, the non-profit HMO has been continually reaching 97 to 98% EDI approval rates. This has led to a higher number of accepted claims that solidifies its Medicaid-certified vendor status and brings in more revenue from the state.
For CCHP and C4K, 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.

Quantitative Benefit