The BlueCross BlueShield plans are an association of health-care plans that operate independently, with their own negotiated rates with local health-care providers. On average, however, about 10% of the claims coming to a local plan involve subscribers covered by another plan, so they need a national agency to process them. The National Account Service Co. was set up to do this processing. The systems of local BlueCross BlueShield plans recognize when a claim is associated with another plan and automatically forward those claims to the national account center, typically via IBM's WebSphere MQ.
In addition to processing financial claims, the center is likely to receive follow-up inquiries from health-care providers and patients on claim status or eligibility for additional services. Patients frequently wish to change their physicians, check on their benefits, or receive new identification cards, and these inquiries also come to the national account center when the patient has moved outside the ring of health-care providers associated with a regional plan.
A California doctor who has treated a patient from Maryland will submit a claim, then "eight days later he wonders what the status of it is," says Doug Simpson, director of production support at the center. "That inquiry is processed ultimately" by the center. The center's systems receive and respond to inquiries, which are monitored by Bristol's TransactionVision. The monitoring application watches the message traffic through IBM's WebSphere MQ and identifies the sequence of steps that completes the message transaction.
Sometimes a health-care provider's inquiry doesn't use the correct terminology for a treatment and the message stalls. "We do 300 edits and checks on a message," Simpson says. TransactionVision uses sensors placed in WebSphere MQ to track inquiries and can drill down to follow an individual message, helping pinpoint the step where it failed. Such identification saves the time of system and network managers and database administrators, who in the past would pore over system logs looking for the step that failed. It also improves customer relationships by reducing response time to health-care providers and patients.
|The BlueCross BlueShield Association's national claims-processing agency implemented Bristol Technology's TransactionVision, which does the following:|
|Identifies and maps messaging transactions across mainframe, Windows, and Unix systems|
|Monitors transaction volume and response time in near real time|
|Pinpoints transaction failures|
|Provides capacity planning for handling future transaction loads|
Simpson also uses a feature in the tracker, the TransactionVision dashboard, to get real-time indications on performance, letting his staff know how well BlueCross BlueShield customers are being served. The center's system administrators can readily see whether response times for submitted inquiries are in line with expected norms or unaccountably slow. "A regional plan may say, 'I sent you a bunch of messages and your response time is terrible,'" Simpson says.
Or the monitoring system can provide proof that the problem isn't with the center's message processing but in another area, such as a health-care provider's firewall. That proof can put to rest arguments over where responsibility lies for bad performance or lost transactions. Says Simpson: "We humans expect instantaneous answers."
The Bristol application also tracks incoming messages that take a particularly heavy toll on the IT infrastructure's CPU cycles, which helps with capacity planning.