Stott Creations Health Plan Use Case
Actionable Member Data

Increasingly corporations are becoming more sophisticated in their use of information. The fact that most
companies spend an increasing amount of money each year on Information technology and yet complain
that they don’t have the correct information to manage their enterprises speaks to this need. This coupled
with customer focused or customer driven business strategies have led most progressive companies to
become ‘hungry’ for information/data to mine to better position themselves with customers, distribution
channels, regulators, employees etc.

The Insurance industry has for years been an information intensive arena. With the majority of the
technology resources expended to control transaction / operational costs and provide for scale of
economies, with the Health insurance industry awash in HIPAA based transaction regulations and
resulting data. Unfortunately, the regulators have kept moving the target and the bulk of IT resources
are expensed to keep up with the regulatory churn and little if any progress is being made in the mining of
their own data.

Additionally, merger and acquisition have resulted in many corporations operating several numerous
and disparate IT processing environments, and once again the IT resources are over allocated in efforts
to consolidate /convert / collapse them to something close to a manageable operating platform with
consistent information reported across all operating arms/entities.

While the ‘hunger’ for better information about customers/ distributors etc. continues, little is happening
to address it due to the constrained resources aforementioned. Most HQ or Corporate offices have
Controllers. Actuaries, CMO’s, Compliance officers, and COO’s who can only dream about a world where
all of the operating entities are able to ‘role-up’ detail transaction data to a corporate/HQ data warehouse
where all manner of analysis could be performed. Their requests for such information for the various
operating entities is met with ‘ Which one of the 000’s of operational improvements would you like to
forego in order for use to construct data feeds from each entities operating platform to feed the requester.

Many years ago when the Banking Industry began its march towards automation, It developed/adopted
some guiding principles. One that has become legend is TRUNCATION: This is the whole Point Of Sale
paradigm. Where you capture the information as early as possible in the supply chain, and then reuse the
same information. Don’t confuse or corrupt the processing chain with multiple feeds that attempt to add/
collect addition information downstream.

Our belief is that a Health Plan enterprise, with little or NO effort required from the operating entities’ IT
resources, copies of HIPAA based transaction data can be replicated to a Corporate Data Archive. This is
where the interested parties can have an unobstructed view of the raw data. Obviously this isn’t aimed at
the corporate Financial / General Ledger Income Statement roll-ups that occur, but rather focus attention
towards those who need to mine detailed transaction level information.

In this scenario, BizTalk is the tool which can easily grab copies of the existing transaction information as
it is submitted, then forward this data to a central/regional archive that is Cloud-based and then use the
Enterprise Service Bus toolsets coupled with additional Microsoft technologies to complete the analysis.