Eugene Sayan, CEOTraditionally, the term “healthcare” has not been paired with the practice of Business Process Management (BPM), however the industry is evolving with new healthcare regulations that have resulted in the creation of a more competitive healthcare environment. From the Patient’s Bill of Rights and electronic health records, to health insurance and Medicaid, Affordable Care Act (ACA) reforms are making healthcare more complex. With numerous new regulations, plus additional data to gather, analyze, and share, healthcare organizations can face tremendous challenges in not only integrating new processes, but also continuing their mission of delivering quality patient care. Failure to meet these demands can result in serious financial losses, as well as patient dissatisfaction. With BPM at the core of healthcare, organizations can overcome these challenges and avoid the pitfalls of change in the industry. BPM can help healthcare organizations manage new requirements, regulations, and processes required by the ACA, which allows them to focus on improving the quality of care that their customers receive. New York-based Softheon is an eminent technology company that offers BPM solutions to healthcare payers, providers, and government organizations to thwart complexities arising from the volatile state of the healthcare market. The firm is set towards enabling the healthcare payers and government agencies to be more operationally efficient and meet ACA mandates.
Suitable BPM for Healthcare
BPM has become a key focus for many healthcare payer organizations, whether aimed at streamlining and automating critical processes, reducing cost, or improving process effectiveness.“Our BPM layer orchestrates complex business processes that may span across multiple systems,” states Eugene Sayan, Softheon founder and CEO. The firm offers a cloud-based BPM platform to deliver Health Insurance Exchange (HIX) integration, Direct Enrollment (in conjunction with healthcare.gov website), and compliance with Edge Server submissions, which is a necessary filing for subsidized insurance products.
The firm’s BPM repository hosts composite service “Agents” which are highly automated and configurable modules that handle known business processes. Softheon BPM manages, orchestrates, and runs agents that can perform an array of different functions including importing data from various formats, rule based distribution, notifications, security, and many others. “This is all done by interacting with the data in the Softheon Data Repository,” explains Sayan.
Softheon’s BPM adaptability stems from the wide variety of automated workflow processes and exception handling that exists within the application. “We take an agile approach in designing a solution that accounts not only for routine business processes, but also for exceptions that may appear in day to day processing,” says Sayan. With the use of Softheon Agents, customers can design automated workflows and procedures for a wide range of business issues. Agent configurations can be created or modified with Softheon Rule Composer to allow for the creation of complex rule-based workflows.
Expanding Healthcare Payers Reach
Alternatively, Softheon offers Marketplace Connector Cloud (MC2) which is a SaaS platform for remediation of the interactions between insurance marketplaces and health plan partners' existing IT assets. Softheon MC2 serves as an abstraction layer, isolating insurer systems from technical and integration requirements of the Federally Facilitated, State based, or private marketplaces. “Through a single unified platform, Softheon MC2 supports interfacing with diverse sales channels such as public and private exchanges, while minimizing disruptions to health plans’ existing information systems and processes,” says Sayan.
The firm’s platform provides health insurance services to consumers in real time. In regards to the functionality of Softheon’s BPM based cloud platform, “We provide critical services like real time underwriting, premium billing, invoicing, and integrated payment platforms,” affirms Sayan.
We see ourselves as industry disruptors because we often challenge current processes in an effort to make them more efficient
In addition to the MC2 solution, Softheon provides a variety of services that help organizations have an effective business process. The firm has worked with both private and public agencies to devise a solution for Asset Verification (AVS), which allows users to consolidate a variety of information from disparate sources and calculate a risk score based on the findings. These risk scores allow caseworkers to review questionable applicants for Fraud or Abuse of government programs. “We have also served as the EDI gateway, not only for internal carriers, but also for state agencies,” says Sayan.
Keeping up with Customer Demand
Softheon BPM provides the tools to effectively and rapidly improve an organization's processes as their goals and objectives evolve. Utilizing an agile methodology, the firm continues to add to its pipeline of innovation, based on industry trends and new compliance requirements. In general, Softheon has been successful in laying the groundwork for organizations to achieve operational efficiency. For instance, one client, a mid-size regional health plan, faced some operational challenges in their first year participating in the public exchange space. The client first participated in the health insurance exchange market in the 2014- 2015 open enrollment period, but did not have a clear strategy because they were too concerned with the operations and integrations associated with the new sales channel. Due to these distractions, this health plan did not meet their expected sales volumes. After allowing Softheon to handle the operations and integration efforts involved, the client began to focus on plan benefit design and the strategic marketing of their products. Their second year was a huge success, where they increased their enrollment count by 300 percent. Overall, Softheon provided the client with the resources they needed to successfully participate in this new outreach channel.
Staying Ahead and Relevant
The technology of today can be prevalent only for a short period. However, “Disrupting technologies in the BPM arena are the ideas or processes that attempt to change the status quo of operations,” asserts Sayan. “We see ourselves as industry disruptors because we often challenge current processes in an effort to make them more efficient.” Furthermore, Softheon produces its best solutions by working together with industry experts, taking their business knowledge, combining it with technological knowledge, and producing something that can be truly amazing.
Anticipating a future with greater opportunities, Softheon will continue to enhance its MC2 platform by adding new components such as Credit Card Merchant Processing, and ACA Data Analytics & Risk Management. Softheon provides Cost Share Reduction Reconciliation services, and enables the establishment of additional channels of business as well. In addition, Softheon has created an online health insurance brokerage, Welltheos, and works to assist Hospitals and ACOs with design, implementation, and the operation of their insurance business unit.
“We have ventured into the Payvider space, where we plan to show healthcare providers how to create their own insurance products by leveraging our extensive expertise in the Healthcare Payer space,” says Sayan. Furthermore, as the value proposition of private exchanges gain more and more traction, “We anticipate to setup a competitive position for ourselves in the market,” concludes Sayan.