SYBASE Healthcare Solutions

A Presentation For TheSybase Users' Group of Texas Tuesday, September 16, 2003

Catherine SchultenHealthcare Business Development Managercatherine.schulten@sybase.comAugust 6, 2003

Lisa Rasor, Acct MgrMax Sanchez, SC

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AgendaAgenda

• Sybase’s Healthcare Vertical• Overview of Healthcare Issues• Overview of Healthcare Solutions• Q & A

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The Sybase Healthcare HeritageThe Sybase Healthcare Heritage

CenturyAnalysis Inc.

EAI for Hospitals

MicroScriptEAI for Hospitals

PaperFreeEAI for Payers

New Era of Networks

19971998

19992000

20012002

Sybase, IncDatabase, Mobile and Wireless for Hospitals

1983

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• Top six U.S. managed-care organizations

• 29 of the 47 Blue Cross Blue Shield plans

• 1,250 payer and provider organizations worldwide

• Sybase teams with more than 95 application partners, offering clinical, financial, administrative and medical management solutions

Sybase Powers Major Healthcare Solutions

Sybase Powers Major Healthcare Solutions

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Healthcare CustomersHealthcare Customers

Partial Listing

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Healthcare CustomersHealthcare Customers

• MVP Health Care• NASCO• Nationwide Health

Plans• OAO Healthcare• Ochsner Health Plans• Ohio Medicaid• Oxford Health Plans• PreferredCare• Quest Diagnostics• Sagamore Health

Network• Trigon BCBS• TriZetto• Union Labor Life• Wausau Benefits• WPS Insurance

• EDS/Connecticut Medicaid

• EDS/EBX• EDS/Indiana Medicaid• EDS/North Carolina

Medicaid• EDS/Rhode Island

Medicaid• EDS/Vermont Medicaid• Fortis Benefits• Fresenius• Health New England• HealthNow NY• Independence BC• L.A. Care• Mayo• Massachusetts

Medicaid

• American Medical Security

• AmeriGroup• BCBS of Arkansas• BCBS of Arizona• BCBS of Illinois &

Texas• BCBS of Minnesota• BCBS of South Carolina• BCBS of Tennessee• CareFirst BCBS (Incl.

FEP)• CDPHP• CIGNA• CSC Healthcare Group

Partial Listing

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Healthcare CustomersHealthcare Customers

• Tenet Healthcare Corp.

• Kaiser Permanente • HealthNow New York• BCBS Minnesota• BCBS Michigan• BCBS Texas and

Illinois• NASCO• John Muir/Mt Diablo• Universal Care• University of

Colorado Hospital• Cole Managed Vision• Quest Diagnostics

• Hospital Sick For Kids• Arkansas Children's

Hospital• Children's Mercy

Hospital• Children's Healthcare

of Atlanta• Nemours Children's

Clinic• Children's Hospital -

San Diego• Lee Moffitt Cancer

Center• Stanford Medical

Center

• Methodist Hospital Memphis

• Baptist Hospital Memphis

• Johns Hopkins Health System

• Carilian Health System

• UCSD Medical Center• Mayo Clinic• Loma Linda University

Medical Center• Group Health• Univ. California – San

Diego

Partial Listing

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Healthcare CustomersHealthcare Customers

• Quest Diagnostics• HealthNow New

York• BCBS Minnesota• BCBS Michigan• BCBS Texas and

Illinois• NASCO• John Muir/Mt Diablo• Universal Care• Commonwealth of

Massachusetts• Oxford Health Plans

• Mayo Foundation• Holy Redeemer• Sutter Health• Catholic Healthcare

West• Union Labor Life• Conseco – Bankers

Life• Health Alliance• Partnership Health

Plan – CA• L.A. Care• LA County

• St. Luke’s Hospital• John Hopkins • Wake Medical

Center• Kaiser Permanente• Carilion Health

System• UCSD Medical

Center• Research Medical

Center• Detroit Medical

Center

Partial Listing

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• Trizetto – Embedded solution for EDI

and Process Management

• HSD/Perot – Embedded EDI solution for

Diamond 725/950

• OAO MC400 – Embedded EDI solution

• CSC PowerMHS – Recommended solution

Channel PartnersChannel Partners

Payer Vendors

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Commitment to the Healthcare IndustryCommitment to the Healthcare Industry

• AFEHCT membership, co-chair ASPIRE workgroup (CMS 1500 and UB92 print image gap analysis/demonstration project)

• HL7 membership, ASIG workgroup (claim attachments)

• WEDI Board of Directors, ’02-’04

• X12N membership, TG3 WG3 (HIPAA Implementation and Modeling)

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• Testified on HIPAA issues to NCVHS

• SNIP Transaction workgroups, Co-chair Translations sub-workgroup

• NCPDP membership• HIMSS NHII Task Group

Commitment to the Healthcare IndustryCommitment to the Healthcare Industry

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• Costs for healthcare will continue to increase.

• Overall efficiency needs to be improved to be in business.

• Better customer satisfaction needed.

• HIPAA mandate.

• Healthcare fraud.

Healthcare Industry IssuesHealthcare Industry Issues

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Sybase Healthcare SolutionsSybase Healthcare Solutions

• Enterprise Application Integration– Revenue Cycle Enhancement Solution– Sybase Secure Server Solution– HIPAA Compliance Solution– Sybase / PeopleSoft Solution

• Business Intelligence– Centralized Data Management Solution– Sybase Fraud Detection Solution

• Enterprise Portals– HIPAA Security / Privacy Solution

• Mobile / Wireless

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Online Claims CorrectionOnline Claims Correction

• Web-based collaborative case management applications for both payers, providers and service bureaus. Allows processing for:

– Fraud investigation– DDE and claims correction– Customer complaints management– Privacy management– Customer service

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Temporary cache vs. Very long term storage requirements

Temporary cache vs. Very long term storage requirements

• Operational Data Store used for temporary cache of data needed in order to complete an operational process

• Long Term Data Storage Requirements for ongoing analytics, research and to comply with data retention regulations

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ProprietaryFile

Structure*EDI Map

Valid X12

ComplianceMap

HIPAA Compliant

HIPAA

REPOSITORY

Maps

HIPAAData

Repository

TRANSLATION

837 Claim

Remit Trans

835 Data

Claim

Adjudication

System(s)

HIPAA RepositoryHIPAA Repository

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Dat

a A

cqu

isit

ion

Lay

er

Sybase IWS

Data Warehouse

Sybase IWS

Data Warehouse

CRM AnalyticsCRM Analytics

• Patient Demographics• Effectiveness of

Treatments and Procedures

• Disease Management• Etc. . . . .

• Patient Demographics• Effectiveness of

Treatments and Procedures

• Disease Management• Etc. . . . .

Business AnalyticsBusiness Analytics

• Fraud Detection• Government Reporting • Claims Analysis• Facilities Mgt• Insurance Risk Mgt• Etc. . . . .

• Fraud Detection• Government Reporting • Claims Analysis• Facilities Mgt• Insurance Risk Mgt• Etc. . . . .

So

urc

es o

f C

ust

om

er D

ata

Patient EncounterPatient Encounter

SybaseHIPAA

Repository

Lab andTesting

Applications

Lab andTesting

Applications

Claims and Billing

Claims and Billing

R&DR&D

InsuranceInsurance

IndustryEvents

IndustryEvents

CustomerCustomer

ProductProduct

AnalyticalViews of

Data

Automated ETL

Industry Warehouse Studiofor Healthcare

Industry Warehouse Studiofor Healthcare

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Fraud DetectionFraud Detection

• Healthcare fraud is approximately one-seventh of the national economy, or $80 billion annually. Healthcare fraud represents about 10 percent of $1 trillion in annual healthcare revenues.• Types of Healthcare fraud:

• Ping-ponging – the use of a single patient ID to generate billings across multiple providers• Unbundling – false inflation of provider billing in which a single patient procedure is represented as a series of separate treatments• Duplicate entrie and the billing of more hours than feasible for patient services• Inappropriate or inapplicable cost center charges• Over-billing, either in man hours or at a higher-than expected rates• Unusual changes in transactions or amounts over short periods of time• Unusual changes in patient activity or care profiles• Unusual provider billing or treatment patterns

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SYBASE and SPSS:Predictive Fraud Detection for HealthcareSYBASE and SPSS:Predictive Fraud Detection for Healthcare

• Consists of• SYBASE Adaptive Server IQ Multiplex D/W engine• SPSS Clementine Data Mining Workbench with fraud-specific Clementine Application Templates (CATs)

• Enables organizations to• Profile and segment claimants, identifyng those most likely to commit fraud• Predict medical practices among provider base most likely to be subject to fraud• Identify service and product combinations most likely to be out of compliance with claim regulations• Prioritize providers and consumers for enhanced scrutiny and auditing• Detect claim fraud between practices and from region to region within an entire market• Identify duplicate claims, unbundling, and ping-ponging• Take proactive steps to prevent fraud in the claims process

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Security ServerBusiness Case

Security ServerBusiness Case

• Maintaining VPN is expensive and communications via dial-up is slow and unreliable

• Remote connection points not technically sophisticated• Large number of connection points• Need to perform data transformation before sending message over the network• Meeting compliance with HIPAA Privacy rules requires that exchanging

protected health information (PHI) during transmission between trading partners be secure

• Adding, deleting, and modifying trading partner profiles and exchanging data quickly in a secure way is challenging and cumbersome

• There is a need to move to a real-time processing environment from batch orientation in order to integrate with the Internet and WWW

• To stay competitive, organizations must improve quality of service to their constituents

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SYBASE Secure Communications Server

SYBASE Secure Communications Server

• Secure bi-directional communications mechanism between you and trading partner• Firewall-supported queuing technology that automatically deploys satellite queues along with

the digital certificates• Integrate a new trading partner into a transaction network economically ( low cost of ownership)• Ability to centrally monitor and manage all satellite queues and hosts• Guaranteed Transactional Messaging

– Designed for the Internet• Portable – small footprint, pure Java• Only pre-requisite software JVM• Complete and self-contained

– Guaranteed Delivery• “Once and Only Once”

– Transactional at both client and server– High performance – real-time messaging

• Data exchanged between sites are encrypted (RSA Encryption & authentication)• PKI• SSL3

– Automated set-up and administration• Own certificate authority or integrate with trusted third-parties

• Integrate a new trading partner into a transaction network economically ( low cost of ownership)– Automated deployment, release management, and un-installation

• iMercury• Adapters/applications deployed to the client

– Automated installation, configuration and scheduling– Remote client monitoring & management– Automated firewall tunneling

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Example Configuration Example Configuration

Deployment, Integrated Distributed Security, Guaranteed DeliveryDeployment, Integrated Distributed Security, Guaranteed Delivery

SYBASEEDI

Server

Hospital

SYBASE SCSClient

INTERNET

INTERNET

EAIEAI

Provider Ad

ap

ters

Ad

ap

ters

Leg

acy

Syst

em

sLe

gacy

Syst

em

s

Doctor’s Office

SYBASE SCSClient

SYBASE SCSClient

SYBASE SCSServer

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SYBASE HIPAA Privacy PortalSYBASE HIPAA Privacy Portal

• Business Need:– Per the HIPAA privacy rules, enhance patient’s control over their own protected health

information (PHI)– Enhance a covered entitie’s obligation to protect this PHI

• SYBASE HIPAA Privacy Portal Value Proposition:– Reduce cost of meeting privacy compliance by automating the implementation of the key

requirements

• Includes:– SYBASE Enterprise Portal– Pre-Built Portlets for management of

• Disclosures• PHI Access• Authorization• Complaints• Notices

– BPI Suite for Healthcare (Optional for integration)

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Provider ChallengesProvider Challenges

• Reduce Accounts Receivables (AR)

• Decrease Days Outstanding in AR

• Reduce Claims Denied

• Reduce Claims Reviewed and Resubmitted

• Resource Reduction/Realignment of FTEs focused on “fixing claims”

• Direct Submit EDI transactions, avoiding ClearingHouse costs

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Objectives of SYBASE HealthcareRevenue Cycle Enhancement

Solution

Objectives of SYBASE HealthcareRevenue Cycle Enhancement

Solution

• Generate “clean” transactions in the first place, avoiding costly delays with time spent correcting and resubmitting down the road

• Cut out the “middle-man” to reduce costs• Speed up the process to get claims paid faster• Study reimbursement trends to avoid pitfalls in the future

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Streamlining the Revenue Cycle ProcessStreamlining the Revenue Cycle Process

• Immediacy and Accuracy of Charge Capture• Eligibility Checking prior to procedure• Point of service charge capture

• Speed of Revenue, getting the $ in faster• Clean Claims (scrubbing, apply business rules, HIPAA

validation)• Transaction Exception Handling and Resubmission• Automatic Claim Status Checking for claims outstanding > x

days

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QUESTIONS?