Blue Shield of California
 Design and Development of Customized Outpatient Pricing Engine.

The Client
 Blue Shield of California.

Challenge
 Blue Shield was experiencing rising outpatient hospital costs in recent years and the main contributing factors were outdated fee schedule methodologies and existing claims systems limitations. The existing systems were unable to support new or updated reimbursement methods and more than 70% of facility claims were manually priced, resulting in a huge loss of productivity and dollars.
Blue Shield decided to address the problem and build an application that would price claims accurately and quickly. XYKA had successfully implemented a number of projects at Blue Shield and was known for its very good technical expertise, healthcare domain knowledge and excellent customer service. Blue Shield chose XYKA to design a system that would solve their complex problems.

Solution
 XYKA had extensive sessions with the users to understand the existing business processes. After a thorough discussion on Blue Shield's existing and near-term requirements, XYKA designed a system that was modular and easy to use. The system comprised of a user-friendly interface that wrapped a very advanced pricing engine and database in the backend. A flexible data transformation engine helped in maintaining the data transfers completely transparent to the user. The pricing engine was designed to handle complex facility contracts and priced both APG and APC claims. Other key features included customizable price rules and fee schedules that could be associated to contracts. The pricing engine was built to price by fee schedule, percent of charge, case rates, APC and APG. It also supported carve-outs, special cases, and maximum payment limits. The implemented solution was tested extensively and rolled out to more than 800 users across different geographical locations. The solution has reaped significant savings to Blue Shield both in terms of accurate claim amounts and employee productivity.

Technology
 Microsoft Visual Basic 6.0, XML, Oracle 9i, PL/SQL Stored Procedures, Crystal Reports, ASP.