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Health insurer Humana Inc. has doubled its membership during the past six years through organic growth, acquisitions and increased Medicare business. During that time, the Louisville, Ky.-based payer also has reduced the number of databases holding information on providers serving its 11.5 million members.

Humana has reduced its primary claims systems from three to two, says Donna Reinhardt, a director of provider I.T. The insurer had "quite a few" databases holding provider information for various markets and now has one. The result is less data being entered or loaded into multiple databases, reducing data inconsistencies-such as misspelled names. "That can affect claims being adjudicated on the first pass," says Bryan Scott, manager of provider informatics. And as duplicative work decreases, so do administrative costs, he adds.

After a year of preparation, Humana in July 2002 deployed data integration and matching software from Initiate Systems Inc., Chicago. The insurer now has what it calls a "single point of entry" database with a Web-based front end for entering provider data. Prior to this effort, Initiate Systems had served provider organizations with its master data management and enterprise master person index applications. Humana became a developmental partner.

Building Out

Over the years, Humana has developed new functionality for its provider data-matching system. Its "provider-at-a-glance" application is a dashboard that gives network contractors, customer service representatives and clinical teams the information they need on a single screen. The clinical teams handle referrals and authorizations, coordinate care, and qualify members for specialized programs.

The "e-bump" feature, designed for the sales side, analyzes the disruption a prospective employer group's membership would have in switching coverage to Humana. The software analyzes claims data to determine the amount of overlap of providers in an employer's existing benefit plan and in Humana's networks that would service the membership.

The feature also is helpful when Humana is considering acquiring a line of business. For example, last year Humana acquired Fort Worth, Texas-based Corphealth Inc., a behavioral health plan serving two million members through 22,000 providers. Humana used the e-bump feature to find out how many of those providers already were in its own behavioral health network. "We actually did it in a matter of hours," says Jim Heffley, director of provider informatics. "In the past, it's safe to say it would have taken a month."

Another newer feature that Initiate Systems added to its technology in early 2007 is "composite view." This enables Humana's staff to find specific data such as a provider's definitive name-Larry instead of Lawrence.

Humana leveraged Initiate's software when it built "smart summary," which Heffley calls "a user-friendly explanation of benefits." The payer is in rolling out the summary to commercial members. The summary provides a quarterly statement in simplified language that shows medical services utilized, out-of-pocket costs, prescription history, appropriate alternative medications that would have cost less, and applicable health savings account balances.

The smart summary also uses provider names that members would recognize.

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