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PBT GroupPrivate health insurance embarked on a system replacement program of work

The Company

One of Australia’s leading health insurance funds with over 3.7 million members and paying more than $5.3 billion in benefits per annum, this private health insurer has been delivering better health to Australians for over 40 years.

The Business Challenge

The initial program, known as the BSR (Business System Renewal) program, was estimated to be 2 years in length and consisted of an overall team of approximately 180 people from different vendors. This initial program focused on the processing of hospital and in-hospital treatment claims. Legacy data was sourced from different data sources like DB2, VSAM, CRM, Lotus notes, Access and Spreadsheets, and consolidated into three applications: iMed, CRM and SAP. Each system is responsible for a certain business area, with iMed forming the core of the whole new health insurance system.

The company wanted to address these issues:

  • Information distributed across multiple applications
  • Business rules distributed across multiple applications and inconsistently applied
  • Benefit and premium leakage
  • Outdated and multiple technology platforms
  • Applications that could not “grow” with the business, as they were dated, inflexible, costly and difficult to modify

The Solution

As part of the initial phase PBT was responsible for developing a migration methodology and platform allowing legacy data to be sourced from different data sources like DB2, VSAM, CRM, Lotus notes, Access and Spreadsheets, to facilitate the initial phase in automating hospital claims, and allowing the new platforms to operate seamlessly with the remainder of the legacy applications.

Medical Claims Project

The second phase of the program focussed on Medical and in-hospital treatment claims with real time integration to MediCare, this again allowed Medibank to decommission a set of legacy applications, and further improvement in the real time claims processing ability.

Non-Resident Claims Project

The third phase added non-resident medical claims and concentrated on clinical validation and eligibility as private health insurance in Australia is heavily regulated and medical treatments for resident policies are mainly governed by Medicare this is not the case for non-resident.

Ancillary Claims Project

The fourth phase added ancillary claims and high availability of the claims processing platform enabling 24X7 claims processing capability. This was the last phase on the claims journey and enable the decommissioning of all the legacy claims systems. This push the straight through real time processing outcome to above 90% of all claims processed by MPL.

Policy and CRM Project

The fifth phase introduced SAP as policy and CRM application platform, as part of this phase PBT and the capability established in the previous phases by PBT assisted Medibank in a business transformation where their portfolio of legacy products where transformed from in excess of 3000 products to less than 250 allowing additional efficiencies in the business and complexity in the policy and CRM platforms.

Throughout all these phases PBT was responsible for the operations and stabilisation of the previous phases and successfully implement a system development methodology allowing multiple streams of development and maintaining traceability within these streams from business requirement through to final test case execution and we currently establishing development operations driving further efficiencies in the lifecycles of delivering improvements across the platforms.

The Value Proposition

PBT was the systems development partner within the consortium, responsible for all iMed application software development, including the data conversion and migration of all legacy data into the new system.

PBT Group delivered and is still involved in the new claims application that formed part of the overall health insurance platforms. It enabled a simplified claims process, predictable, real-time, reliable and consistent claiming, 360-degree view of claim, quicker adaption to market, regulatory, legislative and technology drivers as well as continuous improvement of claims experience and lifecycle.

The iMed solution today assesses nearly 20 million claims each year with over 90% processed through electronic “no-human-touch” channels.

PBT proudly remains with Medibank as an ongoing core solutions partner, providing continuous functional developments and data management services to enhance and support the iMed Claims Solution across the enterprise.



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