Processing Healthcare Claims with Radley Hosted EDI

Brightree is the fastest growing provider of business management solutions in the Home Medical Equipment (HME) and Durable Medical Equipment (DME) market. As Brightree’s client base grew the need for an automated EDI solution became evident. Brightree is the only software solution of its type endorsed by the 2,200+ member VGM service organization.(www.brightree.com)

Productivity Challenge

Manually processing healthcare claims was time consuming.

Brightree’s EDI claims process was a manually intensive process. An operator was required to login to each of the four Medicare Durable Medical Equipment Regional Carriers (DMERC’s) or an EDI clearinghouse to send or receive files for the insurance provider. Because the DMERCs use asynch dial-up technology, the process was time consuming and frequently required reconnects to handle dropped connections. As their customer base increased, the time required increased as well.

In addition, the challenge of “payor specific” edits was continuing to grow as more and more payors became supported. Each of these edits required a new release of the software to generate the claim in the format required by the payor. Because of these challenges, Brightree decided to find an automated solution that could accommodate the submission requirements of the DMERCs and provide a more timely solution to payor specific edits.

The Radley Solution

Hosted Healthcare EDI

Brightree made the decision to replace their manual system with a hosted version of Radley Corporation’s B2B EDI solution, iR*EDI. Brightree now has the ability to produce and verify EDI and the capacity to automate all of the processes related to EDI. With iR*EDI Mapper they also have the flexibility to produce a standard document and allow iR*EDI to verify it.

In addition they can optionally add or change information that is required for a specific carrier, without the need to hard code the solution. Claims are now started from the Brightree software application through a web service, and generated claims are placed in the iR*EDI Scheduler for immediate transmission. Upon completion, a process status is returned to Brightree along with any applicable reports for that transmission. Receiving of data is scheduled for every customer and automatically moves the data and makes reports available to the Brightree customer.

Productivity Improvements

Brightree now has the ability to be flexible and connect to different software platforms easily.

One of the most beneficial features of iR*EDI was the ability to handle specific insurance carriers specifications in a mapping situation rather than hard coding. They are also benefiting from the automation of the DMERC’s dial-up async access. Now the iR*EDI Scheduler automates the dialing and redialing capabilities to the DMERCs. The added benefit of Radley’s Service Oriented Architecture (SOA) will help Brightree respond more quickly and cost-effectively to the changing market conditions. With the SOA environment Brightree now has the ability to connect to many different information systems, whichever platform or technology it might have been developed on.

“Brightree is a progressive medical claims processing software company. We are known in the industry for aggressively leveraging technology to speed and automate business processes” notes Brightrees IT Manager, Mike Durnwald, “The Radley partnership has helped us meet our EDI goals by removing all of the manual processes from our eCommerce processing. It has allowed us to standardize our processes and produce faster claims, and in turn, helped us better meet the needs of our clients.”