BCBS Policy: Compliance

Insurers deploy tools to conform with HIPAA transaction privacy codes.

Insurance carriers are deploying project management software from Business Engine Inc. and application integration tools from Vitria Technology Inc. to provide broader access to data in compliance with the Health Insurance Portability and Accountability Act, known as HIPAA.

The first component of HIPAA, which will be enforced beginning in April, requires businesses involved in health care to meet a set of code and transaction standards that are designed to reduce the costs and complexities of administering health care policies. In October, additional provisions of HIPAA will kick in and impose privacy requirements for dealing with patient records.

Together, the HIPAA requirements impose a potentially large change in the way some companies do business.

"In some respects, [complying with HIPAA] is not all that different from a Y2K remediation," said John ONeil, CEO of Business Engine.

The San Francisco-based companys BEN (Business Engine Network) is being used by Horizon Blue Cross Blue Shield of New Jersey to help manage its HIPAA compliance. The Newark company processes 25 million claims a year.

BEN provides a framework that integrates projects; resources, such as staff; and budgets to provide real-time visibility into the status of Horizons HIPAA projects. It gives Horizon employees a Web-based portal through which to collaborate and manage projects and documents.

Each of the dozens of HIPAA-related projects that Horizon has under way has its own deliverable. BEN enables Pamela Miller, vice president of enterprise strategy and quality at Horizon, to stage the projects so that contingencies required for future stages are completed in the most efficient order. For instance, some changes in contract language need to be approved, loaded into new software and tested before the step can be completed.

"HIPAA was so huge, and it was iterative, and there were so many parts that we had to translate it into numerous projects," said Miller. "We use BEN to translate [a] law into a project that will allow us to come into compliance."

In addition to the challenge of HIPAA compliance, Horizon is consolidating its IT infrastructure from five legacy systems to two. Miller said BEN is helping manage projects around that conversion.

Business Engine last week released Version 5 of BEN, which comes embedded with Microsoft Corp.s Project software. Also new in this version is integrated planning and budgeting capabilities, which Miller said she is looking forward to using.

"As people plan their project budgets, [these new capabilities will allow us to] have one repository for our financial people," Miller said.

Separately, Blue Cross and Blue Shield of Minnesota, that states largest health plan, recently went live with its Inter Plan BlueExchange Connectivity solution for HIPAA Member Eligibility and Claims Status transactions, which is based on Vitrias integration software.

BlueExchange lets the carrier route provider inquiries and link seamlessly to other insurance providers in its network, as well as to other insurance carriers, to send and receive HIPAA transactions. This allows consistency of information across all points of entry and across all Blue Cross Blue Shield Association member plans.

The BCBSA comprises 42 independent, locally operated Blue Cross Blue Shield plans that provide health care coverage to about 84.7 million Americans, officials said.

BCBSA went with Vitrias BusinessWare platform for modeling, integrating, automating, tracking and optimizing business processes and transactions across the network. The BusinessWare platform is geared toward enterprisewide application integration. Vitrias namesake Collaborative Application for HIPAA sits on top of BusinessWare and provides a vertical orientation to streamline the necessary business processes for compliance, according to officials at Vitria, of Sunnyvale, Calif.

BusinessWare and VCA combined to serve as a business process management foundation as well, Vitria officials said. BCBSA also needed to meet format, transaction management and validation requirements related to the HIPAA mandate.

Once BusinessWare was in place, BCBSA found it could centralize transactions and collaboration. At the same time, it is able to streamline administration and build on the HIPAA standards across member plans.

Initially, BlueExchange focused on communication and claims status requests among Blue Plans, principally for national account and out-of-region business.

The goal for BlueExchange is to provide a unified framework for the central exchange of information among members and automate transactions.

John Ounjian, senior vice president and CIO at BCBS of Minnesota, is implementing Phase 1 of connectivity to BlueExchange.

"We are able to execute HIPAA-related transactions through the plan, to us and others, to not only get a response but to actually turn around and process that response," said Ounjian, in Eagan.

"Right now, BlueExchange is earmarked to facilitate [the eligibility inquiry and claims data request transactions]," Ounjian said. "Down the road, it will become a very strategic platform to extend those transactions. Right now, the focus is to bring compliance to the Blues. The second part is to create batch and real-time [transaction] environments."