To help healthcare payers embrace new market opportunities while meeting U.S. healthcare reform requirements, provide more flexible and responsive customer service and reduce costs to improve competitive advantage, Oracle today announced Oracle Health Insurance Components. Together, the integrated components provide an end-to-end solution to support the complete health insurance claims lifecycle, including pricing and benefits adjudication, as well as the payment of providers through alternative, non-fee for service reimbursement methods.
Healthcare payers can deploy Oracle Health Insurance Components individually in in their service-oriented architecture (SOA) environments or pre-integrated as a complete, end-to-end processing backbone for payment processes. Built on a common architecture, Oracle Health Insurance Components enable a phased implementation, allowing customers to avoid a "big bang" system replacement and substantially reducing project risk.
Oracle Health Insurance Components include:
• Oracle Health Insurance Claims Adjudication provides automated claims benefit adjudication to help payers accelerate processing, reduce costs and focus resources on more complex claims. This application, which supports first-pass processing, enables payers to quickly configure rules to manage flexible benefits, pre-authorization matching, duplicate claim (line) recognition, filing limit detection and call outs that retrieve information from other SOA components.
• Oracle Health Insurance Claims Pricing helps payers to reduce operational costs by bundling claims into an episode of care and making a single payment to a provider, who then reimburses the other providers. Payers can recognize a new episode of care, in real time, from the submitted claims or can receive it from a care management application. The solution enables payers to support U.S. healthcare reform requirements and the shift from a fee-for-service model toward pay for performance.
• Oracle Health Insurance Product Definition enables payers to rapidly configure plans to meet unique client requirements. As a benefit plan configuration platform that feeds into a benefits engine, it provides healthcare payers with the best of both worlds: ease of configuration and outstanding performance. The solution enables payers to use a set of core components as the foundation for a plan and then strategically focus resources on required customization, speeding time to market and optimizing operational efficiency.
• Oracle Health Insurance Benefit Accumulator Management enables payers to avoid overpaying deductibles or benefit limits by providing a central source of truth for all member and family-level accumulators shared across multiple claims engines, and automatically tracks annual deductibles, out-of-pocket maximums and other limits. The solution gives payers the flexibility to configure these limits for varying time periods based on calendar year or contract start date and to accommodate carry-over periods.
• Oracle Health Insurance Alternative Reimbursement helps payers to reduce operational overhead by providing automated payment generation. The solution enables payers to automatically identify members, periods, rates and calculations to create payment records, saving time and administrative costs. With a highly user-friendly approach to configuration and rules creation, payers can configure the Oracle solution to calculate nearly any scenario. Payers can change these configurations whenever a policy or regulation changes or when they want to support a new product or benefit to meet changing market demands.
• Oracle Health Insurance Claims Analytics provides payers with prebuilt dashboards, reports and metrics that enable them to monitor performance analyze key performance indicators and compare them to benchmarks. With the flexibility to customize the dashboards for each role within the organization, payers can detect issues and diagnose them, thus enabling them to quickly and cost-effectively implement corrective actions and/or cost containment measures.
"Today, healthcare payers face common challenges, including rising treatment costs, ever-changing government regulations, new payment models, uncertainty around the impact of U.S. healthcare reform and a highly competitive marketplace. All of this is putting pressure on payers to change to keep pace with the market and reduce administrative and treatment costs in an effort to stay competitive. Oracle Health Insurance Components’ rules-driven, SOA architecture enables payers to adapt quickly to regulatory changes, respond to competitive threats, plan for the future and meet any opportunity or challenge the market delivers,” said Srini Venkatasanthanam, vice president, Insurance and Healthcare, Oracle Insurance.
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