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Application of Web services technology in Health Insurance

Web services technology, which has been actively promoted by Microsoft, proves itself as an excellent tool for solving complex business tasks. The fundamental idea of this technology is in extracting some logical core from the system and working with that core exclusively through Simple Object Activation Protocol (SOAP). Thus the system can be easily divided into layers, what makes the system highly flexible. This is especially convenient, when a to-be-developed system is supposed to be used as a data processing module together with other third-party systems.

Many software solutions used for business automation only allow information input, storage and output, but not information processing. Implementation of powerful data processing modules often turns out to be too expensive for small and average systems.

Data processing modules could be developed by large-scale enterprises. However, some critical issues arise at this point:

  • How to make analysis modules applicable for the wider scope of users working in this field?
  • How to implement these modules?

While the first question should be directed to analysts at the developing company, the Web services technology-based applications should help to solve the second issue. In order to implement data processing module it is not necessary for a customer to buy a more powerful end-to-end solution and replace the previously used one. That way could be too costly for the customer. It is enough to provide a simple interface to your module, describe that interface and show end users how to develop an easy gateway for data transmission and reception.

We can see a similar situation in the market of software solutions for the Health Insurance industry. Today insurants use hundreds of different software products, which have been created for decreasing routine work of insurance clerks. The majority of these products have been developed in haste by one or two programmers. Those products simply allow keeping records of invoices for payment, while the processing of incoming invoices has still to be carried out manually.

On the one hand, the rules for processing of medical invoices are well known and already formalized. On the other hand, there are too many rules and the insurance regulations vary by region. Even more importantly, a considerable quantity of these rules (by the way, the most laborious for testing!) is specified by nonlinear predicates. Due to the great amount of possible logic errors in working with nonlinear predicates, it is difficult for small insurance companies to conduct mechanical verification of such rules.

That situation could be successfully resolved by means of Web services technology, and in particular by means of the scheme described above.

The most interesting task, arising while solving this problem, is specification of data processing rules on the server for the user. Of course, several skilled programmers could adjust the system when necessary, at the user's request. But there is a smarter solution.

In terminology of program systems, each rule of medical invoice processing is a certain database query. The prime task is to correctly write these queries and connect them to the system. Insurance experts do not have to know how to write database queries in, for example, SQL language. However, what they could do is to formalize their daily activities on invoice verification.

One of the possible solutions could be developing a language in which any activity regarding medical invoices verification is described. For the users' convenience - users are insurance specialists, but not programmers - there could be created a flexible macro system that allows to specify rules in the system in common language of insurance clerks.

Novosoft Inc. has extensive experience in developing systems of that kind. In our opinion, the most appropriate working technology for implementing such systems is .NET technology (C# language) together with SQL 2000 database management system. According to our estimation, the application of .NET (especially for processing complex XML queries and creating complex XML answers) reduces the development time by 30 %. The system itself saves on average up to 8 % of insurance companies payments. The systems we have developed are successfully integrated with different existing applications implemented on platforms such as Active Service Pages (ASP), Microsoft Access, Fox Pro and Power Builder.

Ivan V Basov
PhD (Mathematics)
Project Manager
Novosoft Inc.