Healthcare Solutions
Hexplora specializes in providing enterprise solutions for Healthcare and Pharmaceutical verticals. Since 2000, Hexplora has a proven history of implementing IT solutions for large payers and health management services companies in the US and abroad. Our experience spans the full range of business processes and systems that are critical for the operations of all health plans.
Historically, health plans used to place more emphasis on healthcare utilization and cost containment to improve profitability. Therefore, most of the focus was on improving operational effectiveness by managing claims processing and utilization. However, emerging trends in the healthcare industry have significantly altered the priorities for health plans. Employers and governments are increasingly holding payers accountable for overall health and well-being of the member instead of being exclusively focused on paid claims.
Consumerism and Health Advocacy are rapidly driving the use of richer sources of clinical data relegating the use of claims data to a strictly financial role. Enormous amounts of new data are now available for payers including HRA, biometrics, risk scores, diseases, conditions, outcomes, ETG, ERG etc. Integrating all these data subject areas and providing a 360 degree longitudinal view of the member across time is a key information requirement for payers.
With HIPAA, industry is moving towards standards based Information management model for data acquisition and data exchange. However, there are no standards for organizing data within an organization to support advanced Informatics capabilities including real-time reporting, dashboards, scorecards, analytics, and data mining.
In this new paradigm, payers are now forced to seek competitive advantage through innovative solutions driven by Informatics and intelligent use of data. Hexplora has been in the forefront of delivering projects for large payers encompassing strategy, architecture, design and implementation of very large Enterprise Data Warehouses that can support their full range of Informatics and data requirements.
Hexplora's team of highly knowledgeable professionals possesses outstanding expertise and experience in implementing industry leading solutions that enable payers to leverage Informatics as a strategic asset that can deliver market differentiating capabilities.
Our comprehensive healthcare domain expertise covers the following areas:
  • Health Plans
  • Commercial, Medicare, Medicaid
  • Business lines
  • Medical, Pharmacy, Behavioral, Dental, Group Life
  • Detailed understanding of Payer operations and business processes
  • Member Eligibility and Enrollment
  • Providers and Networks
  • Claims Adjudication and Payment
  • Premium tracking and Reconciliation
  • Pharmacy Claims
  • Lab Results
  • Disease Management
  • Case Management
  • Utilization Management
  • Healthcare Transaction Portals
  • Health Risk Assessment (HRA)
  • Healthcare Informatics
  • Financial Analytics
  • Clinical Analytics
  • Clinical Rules Engines
  • Predictive Modeling and Risk Scores
  • Disease Conditions and Outcomes Analysis
  • Disease Identification and Stratification
  • HIPAA Standards and Compliance
  • X12 EDI transactions - 820, 834, 835, 837 I/P/D, 270/271
  • 5010 Compliance
  • 4010 to 5010 migration
  • ICD-10 migration
  • Regulatory Reporting
  • Medicare Part C & D Reporting
  • Medicare RAPS
  • Medicaid Encounters Reporting
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