The healthcare payers segment is today facing a unique challenge that needs the payers to improve the quality of the healthcare delivery while also maintain the double digit rise in healthcare spending through appropriate medical management initiatives. To be competitive, the payer organizations also have to take into account the consumerism and regulatory needs in addition to balancing the conflicting needs. This has become a business necessity rather than an option and the payer industry is looking at ways and means that can help improve their internal process and maximize their existing investments.

As a result, payers segment have started adopting Service Oriented Architecture (SOA) in enterprises so that they can:

• Leverage existing investments
• Seamlessly interact with business partners and customers
• Employ new services that can easily be plugged into the existing setup
• Reduce the operating and maintenance cost

With its domain and technology expertise, Wipro’s best of breed alliances and certified pool of domain consultants has been supporting number of leading payer organizations in business transformation using SOA-based systems.

Our SOA services for healthcare payer segment include:

• Technology consulting
• Enterprise system transformation
• Integration with Commercial off the Shelf (COTS) and custom build products
• Business process and rules management

Wipro has built a SOA enterprise platform framework for payers that can be easily customized for the individual organization needs in order to enable quick implementation of the solution.

Wipro SOA-Based Enterprise Platform
Wipro SOA-based enterprise platform enables organizations to streamline and reengineer the business processes, as need be, and offer services under following domain models with features as:

• Member management - End-to-end enrollment and eligibility verification
• Provider management - Enrollment of providers, trading partners and determination of provider eligibility
• Claims management - Auto claims adjudication for institutional, professional, dental pharmacy claims with customized business object models
• Benefit management - Easy and flexible benefit plan design structures for rates and network design
• Pharmacy management - Scalable extensions to Medicare Part D and e-Prescriptions
• Care management - Plug and play care management support for disease management and pay for performance accelerators

Key Highlights of the Platform

• Seamless web-based real time claims adjudication for all claim types along with enrollment, authorizations, referrals, payments, etc.
• Secure, configurable and scalable system based on the SOA and enterprise service bus design concepts with loose coupling among different layers of the application
• Provides member, provider and customer with self-service functions
• Business configurability with respect to business processes and rules
• Application adaptability - Ease of technology change, flexible deployment, and single sign on field level security
• Streamlined workflow automation
• Interoperability with other major components
• Common event logging, notification, messaging, audit logging, change data capture
• Reusable integration approach in integration of various COTS / home grown systems based on end client / state needs
• Reporting and analytical components
• Adherence to regulatory compliance standards