Artistic Background

Preferred Health Professionals Cures File Transfer and Encryption Woes with AutoMate

Preferred Health Professionals Preferred Health Professionals
Rick Gould, Senior Applications Systems Programmer/Analyst


With over one million medical claims to handle every year, Preferred Health Professionals (PHP) has a standard remedy for repetitive IT processes. The Kansas City-based PPO network provider has relied on the AutoMate business process automation platform since 2003 to carry out its philosophy that "Anything that can be automated should be automated." Today, the firm uses AutoMate to trigger and execute more than 175 tasks ranging from retrieving and decrypting claims to sending those claims to the firm's EDI translator, encrypting and forwarding EDI files to the appropriate parties, and generating and emailing SQL reports. Building each new automation routine typically requires only a few hours of dragging and dropping pre-programmed commands into the proper sequence, eliminating hours of expensive programming and code maintenance while also saving at least 10 hours of IT busywork daily.

The Challenge

As a rental PPO network that provides substantial savings on healthcare costs for employer groups, PHP receives medical claims submitted by hospitals and physicians in its various provider networks, applies pre-negotiated discounts, and then forwards the claims to employers or third-party administrators for payment. The need for a business process automation strategy became clear in 2003 when several healthcare providers began sending claim files electronically rather than on paper.

Until that time, PHP's only daily file download job had involved retrieving EDI files from an FTP site operated by a vendor that scanned and OCR-converted paper claims into EDI format. With electronic claims now entering the picture, PHP employees would have to fetch other files from additional third-party FTP locations as well as PHP's own FTP server. Senior applications systems programmer/analyst Rick Gould recognized that continuing to transfer files and perform other routine technical chores manually would quickly give PHP's five-person IT team a headache.

"I knew the work was going to expand, and that would mean more time, more room for error and more stress on the staff," Gould said. "We had to automate and do it quickly."

The Solution

Gould's supervisor alerted him to the existence of business process automation software designed to streamline the automation process by minimizing the need for coding. After evaluating the available products, Gould zeroed in on AutoMate for its rapid task-building methodology and ability to support hundreds of business processes. "The other tools I looked at required programming and were extremely limited in their functionality," Gould recalled. "No other product had AutoMate's drag-and-drop interface or breadth of functionality."

The first task that PHP automated was transferring claim files from an EDI clearinghouse used by a large healthcare provider. In just a few hours of compiling a list of commands like "Open FTP Server" from the AutoMate menu, Gould created a script instructing AutoMate to go to the appropriate FTP site at 2:00 a.m. every business day, log on, navigate to the appropriate page, click on the links containing the needed files, insert the download destination, transfer the first file, wait for the download to finish, and then repeat the procedure until all files had been imported and placed in a folder for loading into the company's database.

With that first automation alone, PHP freed staff of several hours of work every morning.
In the years since, Gould and his team have turned to AutoMate as an Rx for scores of other chores, and in the process added a second copy of AutoMate Professional as well as the AutoMate BPA Server client/server edition when it was released in 2008 to spread the workload. The AutoMate platform now launches and runs tasks such as:

• Downloading and decrypting medical claim files via FTP to a directory for automatic pickup by the in-house Sterling Gentran Integration Services system. Sterling GIS then loads the files to PHP's homegrown SQL-based claims processing system and converts the processed files to the industry-standard ANSI X12 837 electronic medical claims format for submission to payors.

• Encrypting processed claims files for HIPAA-compliant transmission, utilizing the GnuPG open source version of the PGP encryption standard and each payor's unique PGP key.

• Transmitting outbound claims to 28 payors via EDI five nights a week, beginning at 9:00 p.m. and running on a staggered basis until 5:00 a.m., with separate file sets and destinations required for each party.

• Zipping and transferring updated PPO provider directories to payors every month via FTP, as well as emailing payors to inform them that the new provider directories have been posted on PHP's FTP site.

• Generating and emailing daily internal and external reports from SQL Server Integration Services (SSIS), as well as producing customized SQL-based reports requested by payors.

And the list keeps growing. "I've been using AutoMate for six years, and I am continually thinking of new automations that I can build with it," Gould noted.

The Benefits

AutoMate has saved PHP 50 hours per week.

With so many critical responsibilities, all three of PHP's AutoMate installations run 24/7 ("AutoMate is the hardest-working employee in the building," Gould quipped). In the process, the platform relieves the company's 7.5-member IT team of at least 50 hours of necessary but menial work per week. It also helps ensure that PHP can administer medical claims in a timely manner for its more than 150,000 members.

In addition, the use of AutoMate has saved PHP tens of thousands of dollars in programming, eliminated manual errors, kept IT headcount in check, and enabled IT staff to maintain an 8-to-5 work shift despite the volume of work that must be done in the early morning and late night hours to meet business demands. For PHP, all of these benefits translate into strong medicine for controlling the disease of IT overload.