Some claims need to be checked manually by independent medical examiners who analyse electronic healthcare records to determine if procedures are medically necessary.
Our client decided to build a custom Claim Processing System to automate his intermediary business between insurance companies and medical examiners.
The client showed us an out-of-the-box system that had been developed for them over three years by an outsourcing company. The code was written in PHP and based on not GDPR compliant architecture. An Independent GDPR Security Consultant recommended that our client redo the architecture and use not PHP, but only Java or .NET.
Using our GDPR checklist, we compiled the Software Architecture Document for a review by the same consultant. They approved our proposal for GDPR-ready system architecture and we started the development process.
Our Senior Java programmers started converting the PHP code to Java. In fact, it was backend development from scratch. We used the Spring Security framework to reduce development time while maintaining a high level of security: this is a powerful and highly customizable tool that provides the significant number of premade solutions for authentication, privileges management and encryption.
Given that the UI of the system was written in Reactjs and that we have Reactjs developers in our team, we did not rewrite Reactjs but modified it to meet new requirements. This allowed our client not to overpay. In addition, we appreciate that React.js supports quick writing of automated tests, which increases the security level.
On the client side, there was a Product Owner (PO), who had a thorough knowledge of system requirements, which allowed us to significantly reduce the development time.
We followed Agile/SCRUM principles.
- Our client took part in activities throughout the development process, including daily meetings, backlog refinement meetings, and planning meetings. If the PO requested certain changes to the product, they were taken into consideration and implementation during the next sprint planning meeting.
- Each sprint ended up in the DEMO meeting where the BelITSoft team presents the results of work to the Client.
- After the sprint is finished BelITSoft provides budget/financial reports to the Client. The reports are based on completed job/ activities performed within the sprint (usually 2 weeks).
We choose the Service-oriented architecture (SOA) as the interoperability approach to architecture design. The application is split into several modules (services) and these modules communicate with each other via REST API. This type of architecture provides great possibilities of scaling, fault isolation and maintenance.
Our client received a full-fledged operating system that meets the requirements on time and on budget and began its active implementation in their business.
- Insurance companies that send claims impersonalized according to the GDPR for review.
- The system administrator is a medical professional. They receive a claim from the insurance company, decide which of the doctors to redirect it to as well as receive opinions from the doctors and check whether the reviewer performed the work properly.
- Doctors who receive claims for review.
A claim is a form for collecting electronic healthcare records (gender, age, diagnosis, list of procedures and tests, appointments). Also, it is a tool to collect feedback from the examiner - whether the procedures and the rationale for them are assigned adequately.
This independent claims adjuster software has a built-in billing module that automatically calculates the cost of the claim review for the insurance company and for doctors based on the case contents and taking into account the price list. The cost difference goes to our client’s company.