A large TPA faced a critical challenge: one of their clients needed to have a working integration with a particular PBM set up and ready to go by 7/1.
Establishing trading relationships with new PBMs is a complicated and labor-intensive process that only the most skilled teams can handle at scale. Offering this kind of service was a core part of this TPA's differentiation in the market-place, and they had clients who relied on them to expand their list of trading partners.
The Challenge: Enable Two Highly Complex Systems to Fluently Speak to Each Other
The major hurdle to making this integration successful was that the PBM was working in files, while the claims system had an API-based system. Historically, the TPA relied on human data engineers to not only map the incoming files to their claims system, but also to hard-code logic within the claims adjudication system to make this transformation happen. Flume would need to do the same work faster, cheaper, and in a more scalable way.
Flume’s Solution: High-Tech Integration and Orchestration Services
Flume’s task was twofold: clarify the highly fragmented mapping of both the PBM’s and the claims system's databases, and standardize the data bi-directionally so that each system received the data in a clean and ingestible format. The data would flow through the claims system with Flume overlaid as the transformation and standardization layer.
To achieve this, Flume followed a clear, structured process that combined advanced technology, thoughtful methodology, and a committed team:
- Flume’s Product Analysts first sat down with the Director of Operations at the TPA to understand how their database was formatted and how they wanted to receive incoming data from the PBM.
- Flume’s Product Analysts then engaged the PBM’s Implementation Team directly to receive their spec and sample files.
- Flume ingested the PBM’s claims files into its Flume Data Model, simplifying the accessibility of that data for any downstream recipient. Flume’s Data Engineers then custom-developed a connection directly into the claims system’s API. This allowed Flume to write claims directly to the database, removing the need for human interaction on daily trades.
- Next, Flume’s Data Engineers mapped and transformed the data received in the spec files to align with the data model of the claims system. Because the platform uses SQL and Python to code data transformation logic, Flume was able to do this much faster than traditional methods, such as updating hard-coded logic that would require extensive input from the client.
- Finally, Flume’s Product Analysts quality tested the trades and ensured the data was flowing smoothly between all parties.
Overall, this job took Flume less than 8 weeks.
Flume's approach to integration didn’t just streamline the process—it also enhanced the fidelity of communication between systems. By leveraging modern languages, Flume was able to build flexible, adaptable transformation logic without the burdensome, rigid coding structures of older systems.
Additionally, Flume's use of a data model provided a level of elasticity that legacy approaches simply cannot match. Traditional claims system logic often required cumbersome, hard-coded solutions that are fragile and difficult to update. In contrast, Flume’s data model offers a more dynamic, future-proof architecture that can evolve with the changing needs of the business. This ensures that clients not only meet their immediate integration requirements but are also positioned to scale and adapt quickly as new trading partners or data sources come online.
Today, Flume is a key component of the client’s data flow architecture. Data runs bidirectionally daily, with Flume working in conjunction with the TPA’s Director of Operations to monitor for data discrepancies, sync errors, etc. The client has now been able to offload all maintenance work to Flume, freeing up their team to focus on product development and maturing their core business functionality.
Key Metrics & Results
- Seamless Go-Live: The TPA had eligibility trades live well before the July 1st deadline set by their client, ensuring all members had full access to their PBM services from day one.
- Client Relationship: The TPA preserved and strengthened their relationship with their client, avoiding any potential disruptions or negative outcomes.
- Future Scalability: Now that Flume has an API into their database, when the TPA wants to integrate any kind of net-new trading partner, they can simply submit a ticket request via Flume’s secure portal, and Flume will take it from there. The TPA can also use Flume to migrate existing partners in the future.
Flume’s ability to handle complex, fragmented data in a modern way - and deliver a seamless integration under tight deadlines - helped this TPA client deliver on their promise to their customer.
To learn how Flume can simplify your healthcare data flow, contact us today!
