Replacing a Core Administrative Processing Solution (CAPS)
With a license agreement set to expire, a regional nonprofit health plan with Medicaid, Medicare, and commercial lines of business needed to replace its existing core administrative processing solution (CAPS). The health plan turned to Change Healthcare Consulting to help with its vendor selection and implementation projects. The goal was to implement a new enterprise architecture that reduced complexity, tightened integration, increased automation, and improved end-user experience and productivity.
After a consulting-facilitated procurement process to ensure a thorough evaluation of products on the market, the health plan chose to implement an enterprise architecture based on the TriZetto® Facets® platform. As the plan had been using its legacy CAPS for more than a decade, it had built thousands of reports, interfaces, and other wraparound applications to augment the system’s capabilities; evaluating and redesigning these processes would require a massive undertaking. The client recognized the need to move forward with a new enterprise data warehouse (EDW) to begin data normalization across its old and new platform solutions.
The health plan understood that this transition was much more than a technical initiative. Its leadership realized that the implementation presented an opportunity for a digital transformation that would enable the business to reduce costs, improve customer and provider experiences, and accelerate market expansion. The system replacement was business-driven, with executive leadership in full support.
The overall program was broken into eight tracks, with six focused on business process and requirements, one focused on QA Testing, and one focused on IT. The IT track was further segmented, with project managers responsible for key deliverables related to infrastructure, data warehousing, reporting, and integration. The consulting team led the overall program as well as many of the individual business and technical tracks, including enrollment and billing, customer service, referral management, claim processing, interface and report development, and system and integration testing.
Given the size and complexity of the project, completing it on budget and on time would require careful planning. One of the largest challenges was related to the integration effort. While the new enterprise architecture was less complex, there were still a number of wraparound applications and third-party vendors to consider. The team needed to address several integration upgrades and purchases, including Cactus for provider credentialing, HSS Easy Grouper, and an upgrade to FIS Global’s Macess Entrendex and MACESS.exp solutions as well as an acquisition of McKesson’s ClaimCheck® solution for claims editing.
Another challenge was the implementation of an EDW, which was designed to be a parallel but integrated project that would incorporate data sources from legacy applications as well as the new enterprise architecture. Extensive coordination was required to ensure the EDW project milestones aligned with the plan’s digital transformation initiative. The client wanted both projects to converge for integration testing, and both were scheduled to go live at the same time.
The need to sunset the legacy application almost immediately after go-live created additional complexity. The legacy platform was not going to be available for transaction processing after a fixed date, due to licensing restrictions. This deadline meant that hitting the scheduled go-live date was a critical milestone, and it also made the data conversion process much more complicated. Every aspect of the existing data needed to be mapped to align to the new system, including code sets, group and plan structures, members, rates, premium data, broker data, and provider data. All claims history, provider contracts, and member enrollment data for the past three years would be brought over to the new system so the client could process any new claims and/or claim adjustments for this period of time.
The Change Healthcare Consulting team collaborated with the client to develop a robust and resilient program-governance structure that enabled speed, agility, and focus. Consistent production updates helped ensure the team was assessing and incorporating changes throughout the implementation. The client’s executive leadership team was actively involved in the project, and their disciplined approach to scope and risk management contributed greatly to the program’s overall success.
The client recognized early on that its requirement and solution documentation needed upgrading. Utilizing a file system with documents stored in folders was not an efficient or effective way to manage its requirements. This realization prompted a move to a database-driven, relationship-based, objectoriented software solution that would allow the client to better reflect the three-dimensional, objectbased nature of its data while supporting seamless concurrent updates and data security.
This solution provided the teams with new project-management capabilities, enabling project tasks and dependencies to be tracked and reported. This tool provided greater transparency and traceability from design through development, culminating in testing. While implementing the new solution temporarily diverted resources for setup and training, it was worth the investment, as it streamlined processes and accelerated the pace of the configuration. The client’s QA and testing teams also acquired a solution to enable them to trace testing requirements to test cases and outcomes.
Change Healthcare’s consultants worked hand-in-hand with the client to facilitate its business transformation. This included redesigning workflows, configuring business rules, converting data, developing system interfaces, building an EDW, producing reports, and performing integrated testing that validated all the business processes and their enabling technologies.
The consulting team helped the client transform their business by implementing a modern architecture that better aligned with the company’s strategic objectives. The new platform enabled innovative reimbursement models, interoperability, and predictive analytics. These new capabilities led to improved customer satisfaction and reduced provider burden while accelerating the plan’s launch of innovative new products. The client is now better positioned to serve its clients and expand its reach to improve the lives of more individuals and families. The lessoned learned from the consulting team’s leadership have had a long-term impact on how the health plan looks at other enterprise project within the organization.