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LiveHealthCare – A revolutionary big data healthcare adjudication system

Unique healthcare design has evolved from early concepts such as “do the sick no harm” from Florence Nightingale, Hospitals and healthcare facilities are continually changing to meet new regulatory requirements, introduce new technologies and continue providing a healing environment for patient care. LiveHealthCare provides a fully Web based application that adapts to continuous changes through its unique design and technologies by reducing the investment in system changes and shortening the Return On Investment (ROI) time frame and ensure efficient, economical management with effective health care outcome. LiveHealthCare is designed to provide a cohesive management for providers to enroll in the program, update enrollment information, verifying patient eligibility, submit a claim online and know instantly if it is approved for payment. Additionally, providers can request service authorization. Beneficiary can inquire for their own coverage, eligibility status and service authorizations. At the core LiveHealthCare provides claim, member and provider management.

LiveHealthCare architecture illustrates the layered Service Oriented Architecture (SOA) synchronized with Enterprise Service Bus (ESB). Developing a SOA brings about separating out common activities, tasks and business events into common reusable components. The ESB is the core service mediator for a successful MITA architecture implementation. ESB is flexible in integrating the system with external sources or COTS product coupled with security management. Each component interacts through ESB and all the interfaces follow the standards (X12). Application is engineered to interact to legacy or public administrative sources to facilitate data migration and with other necessary data sources.

LiveHealthCare extensively supports Big Data (NoSQL - MongoDB), which allows the database to scale horizontally (Scale Out) and high availability with a radical increase in performance on the processes.

LiveHealthcare is aligned with business rules by integrating with LiveRules business rules engine, which extensively provides out of the box integration for web service, messaging interface and the ability to handle complex business rule decisions. LiveRules provides the ability to adapt to ever-changing healthcare policy and mandates, hence focusing on the functional versus the technical.

The critical SOA architectural components used are:
  • SOA based Web Services for complete MITA alignment
  • Enterprise Service Bus (Camel, ServiceMix)
  • Big Data (NoSQL - MongoDB)
  • Rules Engine (LiveRules) based Claims Processing for High customization and quicker turn around time

"Cost Optimization"

In Claims Processing:
  • Duplicate Claims
  • Claims Paid Over Billed Charges
  • Claims Overpayment
  • Limits and Conflicts Edits
  • NCCI (National Correct Coding Initiative) Edits
  • Bilateral, Endoscopy, Multiple Surgery Pricing
  • Modifier Global Payment
  • E&M (Evaluation and Management) Codes Edits and pricing.
  • Auto Lab Pricing
  • and more...
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Summary of key features:
  • Support for multi-source claims (via EDI, mail, fax, web, web services), provider enrollment, prior authorization entry via multi-channel, and flat file
  • A proven technology platform with extensive throughput of claims processing based on our big data implementation
  • Efficient, accurate, and timely claim processing for providers and beneficiaries
  • Highly automated on healthcare policies by reducing the claim resolution process
  • Integrated machine learning techniques to guide and help automate across systems
  • Post-payment and pre-payment detection capabilities to analyze past incidents and automate claim payment
  • Customer controlled and configurable business rules engine
  • Reduce claims costs and risk through proactive detection, recovery of claims payments
  • Developed on NoSQL MongoDB for any big data systems. The system SCALES OUT rather than the traditional RDBMS way of SCALE UP
  • Built for Cloud Deployment - As needed, it can scale out on the performance without any code changes
  • One half reduction on operational cost
  • Improve customer satisfaction and retention by making it easy to provide detailed and sophisticated analytic assessments of the claims
  • Ability to move into new markets in months, not years
  • A complete modern web based healthcare claims processing architecture