Program Management and Support for an APR DRG Reimbursement Model Implementation

Client Description

The client, a leading New England health insurer, is a local carrier with a national reputation for quality and care management.  The client offers a variety of commercial products in addition to Medicare and Medicaid products and covers one million members across three states.

Challenge

The client was looking to build an HSA-HRA integrated solution with a specified vendor due to rapid growth in the HSA market and in order to remain competitive within the local market.  In addition, the integrated solution would include a single sign-on from the client customer web portal to the specified vendor. In addition, this project included implementing two new pharmacy benefit managers for groups that have chosen to carve out their pharmacy services to a third party. The client brought on Ninestone to lead the effort for the technical implementation.

Ninestone’s Approach

The client engaged Ninestone to manage all of the software development lifecycle, from business requirements to the final implementation for the new integrated HSA vendor and the two new pharmacy benefit managers. Ninestone was selected because of its long-standing relationship with the client, our ability to lead projects using their rigorous project management approach, the implementation of multiple projects on different platforms, and Ninestone’s ability to understand the Software Development Life Cycle. Ninestone was able to implement the first phase within an aggressive four-month period and Phase 2 within a six-month period. Phase 1 included sending and receiving member accumulator, claims and eligibility files, and the single sign on from the client to the specified vendor. Phase 2 included the ability to support multiple HSA vendors, additional PBM vendors, additional types of files, single-sign on to different vendors, making the set-up for new or existing groups that carve out Rx configurable by the business with no IT intervention, and the ability to load pharmacy accumulators more often.  

Technology

The work streams crossed multiple business areas such as Sales, Underwriting, Actuarial, Claims, Marketing, Member Services, Employer Services, Premium Billing, Benefits and Information Services. The strategy employed by Ninestone called for a rigorous requirement documentation methodology and tracking of requirements metrics that allowed for the iterative process from designs through testing in the software development lifecycle.

Ninestone worked with the Business and IT departments to analyze and document the new features and create an Operations Manual to be used post deployment.   

Results

Phase 1 of project met the January 1, 2016 production deployment date and the remaining code was deployed in June, 2016 to meet the HSA-HRA Integration project goals.  There were gaps identified in the design and development phases of the project and those were addressed within a formal Project Change Request and Review process that allowed all approved requests to be implemented.

Ninestone provided project management support for the project and business strategy support throughout the project’s lifecycle.