MediLink Network: Delivering Simplified and Standardized Health Insurance

Esther Go, MediLink NetworkEsther Go
Given the skyrocketing costs of best-in-class care and medicine, it’s a no brainer that healthcare insurance has become a monumental boon for patients worldwide. However, year after year, as the healthcare insurance garners more popularity, the complexities in its benefits and claims have also grown tremendously. Each year, millions of healthcare transactions are processed, withthousands of simultaneous transactions during peak periods. These peak periods might coincide with the most critical and inconvenient times, such as a disease outbreak, flood, or earthquake. Frequently, during peak demand periods, it has been observed that authorizations could be delayed due to the shortage of trained personnel at the healthcare operation centers.

The shortage of healthcare personnel is one of the major drivers of complications in the healthcarelandscape today. While modern healthcare has traversed new heights with groundbreaking technology and rapid innovation within the field, it still functions very much like a complex administrative wagon. The health ecosystem involvesa consortium that requires consistent coordination among various stakeholders such as insurers, hospitals, clinics, doctors and practitioners, pharma companies, and patients, each representing a vital linkwithin an intricatesystem.

"We believe that an efficient machine learning model must encapsulate the ideas and expertise of different stakeholders that are involved within the workflow and that is what we are offering to our healthcare customers"

If left unchecked, this intricate system runs a serious risk of intense stress,especially under adverse natural factors that are beyond the control of a single stakeholder, such as an increase in the patient population, longevity, and the earlier incidence of disease. Gaps between the supply and demand of healthcare services is partially due to structural reasons such as the long gestation period that is required to train and equip health workers.

Driven by thezeal to standardize these irregularities in modern healthcare services, MediLink—a reliable health ecosystem platform provider, has turned toward machine learning models to pioneer the use of artificial intelligence for fraud monitoring and claims processing. Through its unique technology, MediLink enables its healthcare clients to channel more resources toward patient care while the company takes care of their back-office services related to health benefits and administration. “We believe that an efficient machine learning model must encapsulate the ideas and expertise of different stakeholders that are involved within the workflow, and that is what we are offering to our healthcare customers,” says Esther Go, President and CEO of MediLink.

Beating 16 other entries in the race for 2017’s ‘Best Innovation for Services and Solutions’, MediLink’s machine learning solution proved its mettle by presenting an integral solution for healthcare that was builtonfeedback and continuous improvement at the core of its innovation. The solution takes the synthesis of human judgment and machine learning to enable the entire healthcare community to elevate its services to the next level by simultaneously improving speed and reducing fraud.

Serving as aplatform that bridges the demand and supply of health services, MediLink specializes in providing reliable technology solutions that significantly minimize insurance and reimbursement related administrative paperwork and ensures that healthcare payments are prompt and accurate. The company provides a range of technology solutions for eligibility verification, authorization, claims processing, electronic payments and fraud monitoring.

Today, MediLink prides itself as a healthtech/ insurtech company that enables payors, providers, and members to implement ict solutions that promote efficiency, transparency, as well as sustainable and profitable growth

MediLink authorizes and then pays for member transactions at hospitals and doctors’ clinics on behalf of insurers through electronic means.“Today, MediLink prides itself as a healthtech/insurtech company that enables payers, providers, and members to implement information, communication and technology (ICT) solutions that promote efficiency, transparency, as well as sustainable and profitable growth,” states Esther.

Furthermore, MediLink is helping tosimplify and standardizevoice operationswith its machine learning engines that eliminate the requirement of service agents to have a medical background to adjudicate pre-authorizations. With this new development, the service agents may simply express transaction parameters in regular English. Non-voice operations such as email or chat are pre-screened by bots, with frequently asked questions resolved instantaneously without further human intervention. At each insurer’s discretion, service options may be configured as either human decision support which allows a human to make the final decision after pre-evaluating the transaction, or perform fully automated stand-in processing in place of a human being.

The Story of Health Insurance

The advent of automation and digital processes within the global healthcare insurance landscape was soon followed by the inevitable rise of blind spots within insurance pipelines. As a result, today, high volumes of simultaneous transactions originating from diverse locations have become the very source of fraudulent misconduct, creating new realms of challengesfor insurers in processing healthcare insurance claims.

The executives of one of the leading health insurers found themselves stuck with a similar complication when they noticed that the increase in member utilization was disproportionate to the growth of their member base. More alarmingly, auditors were identifying more fraudulent cases arising from internal control issues or provider fraud. Adding further concerns was a severe lack of trained medical, allied personnel who could review the transactions. Also, the manual screening of each transaction resulted in long wait times for members, making it difficult for their customer service department as well. Amidst this chaos stepped in MediLink, with advanced expertise in big data analytics and IT services, to help increase the throughput and accuracy of claim adjudicators using a combination of its machine learning and rule-based models. The models not only reduced customer wait time, it also drastically reduced the number of transactions that needed to be reviewed by the clients’ highly trained personnel.

MediLink was able to prevent fraud effectively through intelligent verification and exception-based human intervention while also minimizing processing cost along the way. The healthcare organization estimated saving 12 percent of utilization expenses from avoidance of fraudulent claims. They even managed to improve their customer satisfaction arising from the instant response to authorization requests. “Our fraud analytics enabled the client to lower the cost of healthcare and make healthcare coverage more affordable,” affirms Esther.

MediLink’s expertise enables health facilities to instantly access insurance eligibility of patients, without having to call the insurer or subject the patient to a long waiting period or the need for paperwork. Facilitating unparalleled accessibility, MediLink employs machine learning techniques to monitor potential abuse and fraud. Timely interception of anomalous transactions helps the company ensure that the pooled healthcare funds are directed to the patients that are in need while helping the insurance organization to keep premiums down and therefore making healthcaremore affordable.

Timeline of Success

MediLink brings its clients 20 years of experience in offering both IT solutions and managing healthcare payment gateway operations. The company’s road to success is attributed to several service upgrades undertaken over the years. MediLink introduced its first service offering— electronic health benefits eligibility verification and authorization in 1999, which was enabled by re-purposed retail POS terminals. Four years later, the company launched the next logical service—payments. Esther explains, “We began to pay doctors and hospitals on behalf of insurers and Health Maintenance Organizations (HMOs) based on the authorized transaction, which originated from the terminals. This prompted the need for a healthcare payor enterprise system.” With this development, MediLink launched an enterprise solution in 2007 that allowed insurers to design a policy, underwrite risk, enroll members, provide customer service, process claims, and bill. Extending further into the customer service arena in 2014, MediLink created self-service portals available for providers such as members, doctors, hospitals, and clinics. In addition to POS terminals, the company’s services were made available through web and mobile applications as well. When the clients experienced high growth in transaction volume, MediLink helped them understand their revenue and utilization drivers through business intelligence services such as analytics, visualization, and forecasting.

“We also perform escrow services for payments from insurers to health facilities and practitioners, enabling us to guarantee payments for authorized transactions,” adds Esther.

As MediLink excels in offering software-as-a-service to various insurers and health maintenance companies, the company also utilizes its own offerings through a business process outsourcing (BPO) service. MediLink functions as a stand-in processor offering business continuity during peak periods and holidays. As a user of its own solution, the company ensures that features are secure, scalable, and reliable.

Aligned with the best practices in the market, MediLink subjects its operations to external reviews and audits. In 2007, the company secured its ISO9001 quality management certification and has used it as a benchmark to continuously improve its systems and processesevery year since then. Given MediLink’s dependence on the automated systems and its compliance with data privacy laws, the company was also certified for ISO27001 last year. With prospects of securing certification of Business Continuity Management (ISO 22301), Service Management (ISO 20000), Occupational Health and Safety (45001)in 2019, MediLink is well on track to achieve the additional certifications.

Beyond the Horizon

Currently, as MediLink continues to automate high-volume transactional processes such as pre-authorization, claim processing, and payment settlement, the company wants to free its user base including payers, hospitals, clinics, and doctors from routine, repetitive tasks. The company will launch its mobile app for members in Q4 that will incorporate features to allow patients to consult with health practitioners via voice, chat and video. MediLink plans to continue adding features to the app and engage members through gamifying their health-seeking behavior, and connecting the health circle that includes patients, family, friends, and health partners.

After establishing a strong presence in Singapore, the company is actively seeking to expand their portfolio in the ASEAN region in the coming months. “As we step into other geographies, our core technology and business principles will continue to empower healthcare communities with essential tools and expertise to deliver efficient, accessible, and affordable healthcare,” concludes Esther.

- Annie Johnson
    March 23, 2021
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Top 10 Insurance Tech Solution Companies - 2019

MediLink Network

Makati City, Philippines

Esther Go

MediLink is a healthtech company committed to enabling efficient, accessible, and affordable healthcare. The company is a joint venture between Equicom and F.E. Zuellig that was established in 1999. The health community is a complex ecosystem that requires interactions among several key stakeholders — patients, doctors, hospitals, clinics, companies and insurers. MediLink’s integrated IT platform connects insurers, healthcare providers and insured members through an electronic network covering 2 million+ lives. Our services include underwriting validation, card production, eligibility check, transaction authorization, claim processing, and payment settlement, analytics, and AI-enabled decision support

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