OVERVIEW OF FACETS IN HEALTHCARE
INTRODUCTION TO FACETS
Facets is a comprehensive healthcare payer core administrative processing
solution developed by Cognizant Technology Solutions. It serves as a vital tool
for health insurance companies, enabling them to efficiently manage complex
administrative tasks critical to the healthcare industry. By supporting
functions such as claims processing, member enrollment, provider
management, billing, and utilization management, Facets helps organizations
navigate the intricate landscape of U.S. healthcare.
One of the primary functions of Facets is claims processing. The solution
automates the adjudication of claims, ensuring that providers and members
receive timely payments. This automation streamlines workflows, reduces
administrative burdens, and enhances accuracy by minimizing the risk of
human error. Furthermore, Facets provides robust member enrollment
features, enabling payers to easily track member coverage, eligibility, and
demographic information. This capability is essential for maintaining
compliance with healthcare regulations and ensuring that members receive
the benefits they are entitled to.
In addition to claims and enrollment management, Facets excels in provider
management. It maintains crucial provider information, including contracts,
credentials, and network affiliations. This ensures that payers can effectively
manage their relationships with healthcare providers, which is essential for
delivering quality care. The billing capabilities within Facets allow
organizations to manage premium billing, payment collections, and refunds
efficiently, contributing to overall financial stability.
Utilization management is another critical function provided by Facets. It
allows healthcare payers to monitor and manage the appropriateness of care
provided to members, ensuring that services are delivered effectively and in
accordance with established guidelines. This aspect of Facets plays a
significant role in supporting healthcare quality and cost management.
Overall, Facets is strategically designed to address the complexities of U.S.
healthcare administration, making it an indispensable asset for health
insurance companies striving to enhance operational efficiency and
compliance in an ever-evolving regulatory environment.
IMPORTANCE OF FACETS IN HEALTHCARE
Facets plays a pivotal role in the healthcare payer landscape by providing a
centralized system that streamlines various administrative tasks. This
comprehensive solution allows health insurance companies to manage
essential operations more efficiently, significantly enhancing productivity and
reducing the likelihood of errors associated with manual processes.
One of the standout features of Facets is its commitment to ensuring
regulatory compliance. The system is designed to meet critical U.S. healthcare
standards, such as HIPAA and CMS regulations. By adhering to these
standards, organizations mitigate the risks associated with non-compliance,
safeguarding both their operations and their members' sensitive information.
Scalability is another key benefit of Facets. The platform is versatile enough to
cater to both small health plans and large insurance companies, allowing
organizations to grow and adapt without the need for a complete system
overhaul. This scalability ensures that as a payer’s membership base expands
or as they diversify their service offerings, Facets can support these changes
seamlessly.
Moreover, Facets enables electronic data interchange (EDI), which facilitates
efficient data sharing with providers, members, and clearinghouses. This
capability not only accelerates communication but also enhances the
accuracy of data exchanged, further supporting operational efficiency.
Cost savings are a significant advantage of using Facets. By automating
manual processes such as claims processing and billing, organizations can
reduce administrative costs and minimize errors, which can be costly in a
highly regulated environment.
Additionally, Facets allows for customizable workflows tailored to the unique
needs of each organization. This flexibility ensures that healthcare payers can
design their operations to align with specific operational goals, enhancing
overall effectiveness and responsiveness to changing market conditions.
In summary, Facets serves as a comprehensive solution that not only
addresses complex administrative tasks but also promotes compliance,
scalability, efficiency, and cost-effectiveness in healthcare administration.
APPLICATIONS OF FACETS
Facets supports a wide array of operations essential for healthcare payers,
streamlining processes that are critical for maintaining efficiency and
compliance within the healthcare system. Below are the primary applications
of Facets:
1. Claims Management: One of the cornerstone functionalities of Facets is
its claims management module. The system automates the claims
adjudication process, allowing for swift and accurate processing of
claims submissions. This includes validating claims against member
eligibility and provider data, which minimizes errors and ensures timely
payments to providers.
2. Membership Management: Facets offers robust tools for tracking
member enrollment, coverage, and eligibility. This capability enables
healthcare payers to maintain up-to-date records of member
demographics and plan details, facilitating compliance with regulatory
requirements and ensuring that members receive the benefits they are
entitled to.
3. Provider Management: The platform provides comprehensive
management of provider information, including contracts, credentials,
and network affiliations. By maintaining accurate and current provider
data, health insurance companies can effectively manage relationships
with healthcare providers, ensuring quality care delivery to members.
4. Billing and Financial Operations: Facets includes a detailed billing
module that manages premium billing, payment collections, and
refunds. This financial management capability helps healthcare payers
maintain a stable cash flow and ensures that billing practices comply
with regulatory standards.
5. Utilization Management: Facets plays a significant role in monitoring
authorizations and care management cases. This aspect of the system
helps ensure that members receive appropriate care while also adhering
to established guidelines, thereby supporting both quality of care and
cost management.
6. Reporting and Analytics: The platform includes extensive reporting
capabilities that facilitate compliance with regulatory requirements and
provide valuable business insights. By generating reports on claims
status, membership counts, and financial performance, Facets enables
healthcare payers to make informed decisions that enhance operational
efficiency.
In conclusion, the diverse applications of Facets encompass critical
operational areas within healthcare payers, enabling organizations to
manage their administrative tasks more effectively while ensuring compliance
and improving overall service delivery.
KEY MODULES OF FACETS
The Facets system is composed of several key modules that facilitate the
efficient management of various operational areas within healthcare payers.
Each module serves a specific purpose, ensuring that organizations can
streamline their processes and maintain compliance with regulatory
standards. Below are the primary modules within the Facets system:
1. Membership Module: This module is essential for managing member
enrollment and eligibility. It allows organizations to track demographic
details, coverage information, and historical changes in member data.
The Membership module ensures that all member records are up-to-
date, facilitating accurate eligibility inquiries and compliance with
healthcare regulations.
2. Claims Processing Module: The Claims Processing module automates
the submission, validation, adjudication, and payment of claims. It
includes features that verify member eligibility and provider credentials,
ensuring that claims are processed accurately and efficiently. This
module significantly reduces the time taken for claims adjudication,
leading to timely payments for providers and improved cash flow for
payers.
3. Provider Management Module: This module maintains comprehensive
records of provider details, including contracts, credentials, and network
affiliations. It supports the management of provider relationships,
ensuring that healthcare payers can efficiently verify provider
information and track compliance with contractual obligations. By
maintaining accurate provider data, this module enhances the quality of
care delivered to members.
4. Finance Module: The Finance module encompasses billing and
accounts management functionalities. It manages premium billing,
payment collections, and refunds, ensuring that all financial transactions
are recorded accurately. This module is vital for maintaining financial
stability within organizations, allowing for effective cash flow
management and adherence to regulatory billing requirements.
5. Utilization Management Module: This module monitors authorizations
and manages care coordination cases. It is designed to ensure that
healthcare services provided to members are appropriate and comply
with established guidelines. The Utilization Management module plays a
crucial role in enhancing care quality and controlling costs, supporting
the overall efficiency of healthcare delivery.
6. Workflow Management Module: The Workflow Management module
automates various tasks and monitors process performance. By
streamlining workflows, this module allows healthcare payers to
manage their operations more effectively, reducing manual effort and
minimizing the risk of errors. It provides a structured approach to task
management, enhancing overall productivity within the organization.
In summary, the key modules of Facets work in concert to provide a
comprehensive solution for healthcare payers, enabling them to manage
their administrative tasks efficiently while ensuring compliance with industry
regulations. Each module is designed to address specific operational needs,
contributing to the overall effectiveness of the Facets system.
FACETS DATABASE STRUCTURE
The Facets system operates on a relational database structure that is
meticulously organized into several categories, each comprising numerous
tables that facilitate the management of various operational areas. This
structured approach enhances functionality and ensures that the system can
efficiently handle the complex data needs of healthcare payers. Below are key
database categories and significant tables within each:
1. MEMBERSHIP TABLES
The Membership category is crucial for managing member-related data. Key
tables include:
• MBR_MBR: Stores comprehensive demographic details about each
member, including names, dates of birth, and contact information.
• MBR_COV: Tracks member coverage and health plan details, ensuring
that eligibility is accurately maintained.
• MBR_ADDR: Contains address information for members, allowing for
efficient communication and service delivery.
• MBR_HIST: Logs historical changes in member data to maintain a
complete audit trail and support compliance needs.
2. CLAIMS TABLES
The Claims category is essential for processing and managing claims
submissions. Important tables include:
• CLM_HDR: Contains high-level information about each claim, such as
claim ID and status, facilitating easy tracking and management.
• CLM_LINE: Details individual services or line items included in a claim,
enabling precise claims adjudication.
• CLM_DIAG: Lists diagnosis codes associated with claims, ensuring
proper categorization and processing.
• CLM_PROC: Captures procedure codes for billed services, essential for
accurate billing and claims management.
3. PROVIDER TABLES
The Provider category maintains vital information about healthcare providers.
Key tables include:
• PROV_PROV: Stores demographic and credentialing information about
providers, which is crucial for verifying qualifications.
• PROV_CONT: Manages provider contracts, ensuring compliance and
tracking of contractual obligations.
• PROV_NET: Tracks provider networks and affiliations, supporting the
management of relationships within the healthcare ecosystem.
4. BILLING AND FINANCE TABLES
This category manages financial operations and billing processes. Significant
tables include:
• FIN_PMNT: Tracks payments made by members and payers, ensuring
accurate financial records.
• FIN_INV: Contains details about billing and invoices, facilitating efficient
financial management.
• FIN_PREM: Manages premium details for health plans, ensuring that
billing practices are compliant with regulations.
5. AUTHORIZATION TABLES
Authorization tables are essential for managing service approvals. Important
tables include:
• AUTH_HDR: Stores high-level information about service authorizations,
facilitating tracking and management.
• AUTH_DET: Tracks specific services or items that have been authorized,
ensuring compliance with care standards.
• AUTH_STAT: Logs the status of authorizations, providing real-time
updates on service approvals.
6. WORKFLOW AND AUDIT TABLES
This category ensures effective task management and compliance
monitoring. Key tables include:
• WF_TASK: Captures tasks and their statuses, enhancing workflow
visibility and control.
• AUDIT_LOG: Logs changes made to system data, which is critical for
compliance and audit purposes.
• WF_QUEUE: Manages queued tasks for workflows, ensuring that
operations run smoothly and efficiently.
7. EDI (ELECTRONIC DATA INTERCHANGE) TABLES
EDI tables facilitate efficient data exchange with external stakeholders.
Important tables include:
• EDI_IN: Stores inbound EDI transactions, such as 837 and 834 files,
crucial for claims and enrollment processes.
• EDI_OUT: Manages outbound EDI transactions for communication with
providers and clearinghouses.
• EDI_STAT: Tracks the status of EDI files and transactions, ensuring
accurate and timely data exchanges.
In summary, the relational database structure of Facets is a well-organized
system that categorizes various tables according to their functionality. This
organization not only enhances the operational efficiency of healthcare
payers but also supports compliance and effective data management across
the healthcare landscape.
DAY-TO-DAY OPERATIONS IN FACETS
In the daily operations of the Facets system, several critical processes are
executed to ensure the smooth functioning of healthcare payer activities.
These operations encompass claims processing, member enrollment,
provider management, billing transactions, authorization management, EDI
transaction handling, and generating essential reports for operational
insights and auditing.
CLAIMS PROCESSING
Claims processing is a fundamental daily activity within Facets. Claims are
either submitted electronically or manually by providers and stored in the
CLM_HDR table. The system validates claims against member eligibility
records in MBR_COV and provider data in PROV_PROV. This validation is
crucial for ensuring that claims are adjudicated accurately. The adjudication
process, which can be automated or manual, applies benefit rules and pricing
logic to determine payment amounts. Payment information is subsequently
recorded in the CLM_PMNT table, enabling streamlined financial tracking.
MEMBER ENROLLMENT
Facets also streamlines member enrollment processes. New members are
added to the MBR_MBR table, with their coverage details recorded in
MBR_COV. The system facilitates ongoing eligibility inquiries through EDI
transactions, specifically the 270/271 formats, which are managed within the
EDI_IN and EDI_OUT tables. This ensures that member information is always
current and compliant with healthcare regulations.
PROVIDER MANAGEMENT
In managing provider relationships, daily operations involve updating
provider details and contracts, stored in the PROV_PROV and PROV_CONT
tables, respectively. This module ensures that healthcare payers maintain
accurate records of provider demographics and contractual obligations,
which are essential for effective care delivery.
BILLING TRANSACTIONS
Billing operations are another critical aspect of daily tasks in Facets. The
system manages premium billing, payment collections, and refunds through
tables like FIN_INV and FIN_PMNT. Daily transactions are carefully logged to
ensure accurate financial reporting and compliance with billing regulations.
AUTHORIZATION MANAGEMENT
Authorization management is vital for ensuring that healthcare services meet
established guidelines. Daily operations involve creating and tracking
authorizations in the AUTH_HDR and AUTH_STAT tables. This process
supports care coordination and ensures that members receive appropriate
services.
EDI TRANSACTION HANDLING
Handling EDI transactions is a cornerstone of daily operations within Facets.
EDI files, such as 834 (enrollment) and 837 (claims), flow in and out of the
system, allowing for efficient data exchange with external stakeholders. The
EDI_IN and EDI_OUT tables manage these transactions, providing crucial
support for seamless communication between payers and providers.
REPORTING AND AUDITING
Finally, generating reports for operational insights and auditing is an
essential part of daily activities. Reports on claims status, member counts,
and financial performance are produced using data from various tables,
including CLM_HDR and MBR_MBR. Additionally, audit logs stored in the
AUDIT_LOG table ensure compliance with regulatory standards and enable
traceability of changes made to system data.
In summary, the day-to-day operations in Facets revolve around a series of
interconnected processes that facilitate efficient claims processing, member
management, provider oversight, billing, authorizations, EDI handling, and
comprehensive reporting, all of which are crucial for maintaining operational
effectiveness within healthcare payers.
BENEFITS FOR DAY-TO-DAY JOBS
The utilization of Facets in daily operational tasks offers numerous
advantages that significantly enhance the efficiency and effectiveness of
healthcare payers. One of the most prominent benefits is the automation of
repetitive processes, which leads to improved efficiency in claims processing,
member enrollment, and billing procedures. By automating these tasks,
organizations can minimize the time spent on manual entries and reduce the
likelihood of errors, ultimately resulting in faster turnaround times and
increased productivity.
In addition to automation, Facets provides enhanced accuracy through real-
time validations. The system actively checks claims and member information
against predefined criteria, ensuring that data integrity is maintained. This
capability is particularly crucial in the healthcare sector, where inaccuracies
can lead to compliance issues and financial discrepancies. By confirming
eligibility and provider credentials in real-time, Facets helps organizations
maintain accurate records, which is essential for both operational success and
regulatory adherence.
Compliance with healthcare regulations is another key advantage of using
Facets. The system is designed to meet rigorous standards such as HIPAA and
CMS regulations, thereby mitigating the risks associated with non-
compliance. This built-in compliance functionality not only protects
organizations from potential penalties but also fosters trust and transparency
with members and stakeholders.
Scalability is also a vital benefit that Facets offers, particularly for healthcare
payers experiencing growth. As organizations expand their member bases or
diversify their service offerings, Facets can adapt without necessitating a
complete system overhaul. This flexibility ensures that healthcare payers can
continue to operate efficiently, regardless of their size or complexity.
Interoperability is another significant aspect of Facets that enhances its value
in day-to-day operations. The platform supports seamless data exchange
through electronic data interchange (EDI) and API integrations, allowing for
efficient communication with providers, clearinghouses, and other
stakeholders. This interoperability not only streamlines workflows but also
enhances the overall quality of care provided to members by ensuring that
accurate information is readily available to all parties involved.
In summary, the benefits of using Facets in day-to-day jobs include improved
efficiency through automation, enhanced accuracy via real-time validations,
adherence to regulatory compliance, scalability for growing member bases,
and interoperability for seamless data exchange. These advantages
collectively empower healthcare payers to operate more effectively in a
complex and ever-evolving industry.
JOB ROLES RELATED TO FACETS
Facets supports a diverse range of job roles across technical, functional, and
operational areas within healthcare payers. Each category plays a crucial role
in ensuring the system functions efficiently and meets the needs of the
organization. Below is a breakdown of key job roles associated with Facets,
along with their responsibilities and required skills.
1. TECHNICAL ROLES
These roles are primarily focused on the implementation, customization,
maintenance, and technical support of the Facets system.
a. Facets Developer
Responsibilities:
• Develop custom modules, reports, and APIs for the Facets platform.
• Integrate Facets with external systems and third-party tools.
• Troubleshoot and resolve technical issues within the system.
Skills Required:
• Proficient in Facets database schema, PL/SQL, and ETL tools.
• Experience in Facets extensions and customizations.
b. Facets System Administrator
Responsibilities:
• Manage user access and roles within Facets.
• Monitor system performance to ensure uptime and reliability.
• Implement patches and system upgrades as needed.
Skills Required:
• In-depth knowledge of the Facets platform and system configuration.
• Strong troubleshooting abilities for system issues.
c. Facets Integration Specialist
Responsibilities:
• Handle EDI transactions such as 837, 834, and 270/271.
• Ensure seamless integration with external systems like clearinghouses.
• Manage interoperability with standards like FHIR.
Skills Required:
• Expertise in EDI formats, data mapping, and integration tools (e.g.,
BizTalk).
2. FUNCTIONAL ROLES
These roles involve understanding business processes and ensuring that
Facets aligns with the organization’s operational goals.
a. Business Analyst (Facets)
Responsibilities:
• Gather and document business requirements for Facets.
• Configure the system to address operational needs in claims,
enrollment, and billing.
• Collaborate with technical teams for system enhancements.
Skills Required:
• Strong knowledge of healthcare workflows and Facets modules.
• Familiarity with claims adjudication and provider management.
b. Facets Product Manager
Responsibilities:
• Define product roadmaps for Facets implementations.
• Coordinate with stakeholders to prioritize system features and
enhancements.
• Oversee system testing and delivery of new functionalities.
Skills Required:
• Understanding of Facets modules, agile methodologies, and healthcare
regulations.
c. Facets Tester/Quality Analyst
Responsibilities:
• Conduct functional and regression testing for Facets modules.
• Validate EDI transactions and integrations within the system.
• Create and execute test cases based on requirements.
Skills Required:
• Experience in healthcare domain testing and EDI validation.
3. OPERATIONAL ROLES
These roles focus on daily tasks utilizing the Facets system, including claims
processing and member services.
a. Claims Specialist
Responsibilities:
• Process and adjudicate claims within the Facets system.
• Review and resolve denied claims while ensuring compliance with payer
policies.
Skills Required:
• Knowledge of Facets claims modules, CPT/ICD codes, and adjudication
procedures.
b. Enrollment Specialist
Responsibilities:
• Manage member data, including new enrollments and terminations.
• Ensure accuracy in coverage details and member records.
Skills Required:
• Familiarity with Facets membership modules and enrollment processes.
c. Utilization Management Coordinator
Responsibilities:
• Handle prior authorizations and care coordination cases in Facets.
• Ensure compliance with utilization review standards.
Skills Required:
• Experience in care management workflows and Facets authorization
modules.
In summary, the job roles associated with Facets encompass a wide range of
responsibilities divided into technical, functional, and operational categories,
each crucial for the effective management and functioning of healthcare
payer operations.
COMPETITION AND MARKET ANALYSIS
In the competitive landscape of healthcare payer solutions, Facets faces
several formidable rivals, each offering distinct functionalities tailored to the
needs of health insurance companies. Key competitors include QNXT,
HealthEdge HealthRules Payor, EPIC Tapestry, Amisys, PLEXIS Healthcare
Systems, and Oracle Health Insurance. Analyzing these competitors reveals
both their strengths and market positioning relative to Facets.
QNXT
QNXT, developed by TriZetto, is a versatile solution that caters to payers of all
sizes. It provides comprehensive functionalities, including claims processing,
member management, and billing. QNXT emphasizes flexibility and
scalability, allowing organizations to adapt their operations easily. Its user-
friendly interface and robust reporting capabilities make it a strong contender
in the market.
HEALTHEDGE HEALTHRULES PAYOR
HealthEdge HealthRules Payor distinguishes itself with its modern, rules-
based architecture designed for real-time claims adjudication and value-
based care. It focuses on advanced analytics, enabling payers to gain insights
into their operations and enhance decision-making. HealthRules’ emphasis on
member-centric workflows positions it as a forward-thinking option for
organizations aiming to improve member engagement and care outcomes.
EPIC TAPESTRY
As part of the EPIC ecosystem, Tapestry integrates seamlessly with EPIC's
electronic health records (EHR) systems, providing a comprehensive solution
for health plans. It covers claims, member management, and EDI
transactions, making it an attractive option for health systems already
utilizing EPIC solutions. Tapestry's strong integration capabilities enhance
data flow between providers and payers, supporting coordinated care.
AMISYS
Amisys, developed by Optum/UnitedHealth Group, offers a robust suite of
functionalities, including claims adjudication, billing, and care management.
It’s known for its comprehensive approach to managing healthcare payer
operations, particularly in supporting complex payment models and
regulatory compliance. Amisys leverages its affiliation with UnitedHealth to
provide extensive resources and insights tailored for the healthcare market.
PLEXIS HEALTHCARE SYSTEMS
PLEXIS focuses on providing flexible configurations for claims processing,
benefit management, and provider reimbursement. Its adaptable platform
allows healthcare payers to customize their operations to meet specific
business needs. PLEXIS is particularly appealing to organizations seeking to
differentiate their offerings in a competitive market.
ORACLE HEALTH INSURANCE (OHI)
Oracle Health Insurance offers scalable solutions for claims processing,
premium billing, and policy administration. By leveraging advanced analytics
and integration with other Oracle products, OHI provides a comprehensive
view of operations, empowering payers to make data-driven decisions. Its
strong emphasis on compliance and regulatory adherence further solidifies
its position in the market.
COMPARATIVE ANALYSIS
While Facets excels in its comprehensive suite of applications addressing
various payer operations, its competitors bring unique strengths to the table.
QNXT and HealthEdge are notable for their flexibility and focus on analytics,
while EPIC Tapestry benefits from deep integration with EHR systems. Amisys
and PLEXIS offer robust management capabilities, and Oracle Health
Insurance leverages advanced technology for scalability.
In conclusion, the competitive landscape for healthcare payer solutions is
dynamic, with each player presenting distinct functionalities and market
advantages. Understanding these competitors enables healthcare payers to
make informed decisions about which solutions best meet their operational
needs and strategic goals.
FUTURE OUTLOOK FOR FACETS
As the healthcare industry continues to evolve, the future of Facets appears
promising, marked by several significant trends and prospective
developments. One of the most notable shifts is the transition towards cloud-
based solutions. Organizations are increasingly seeking scalable, flexible, and
cost-effective systems that can adapt to their growing needs. By evolving
Facets into a robust Software-as-a-Service (SaaS) offering, Cognizant can
enhance accessibility and reduce the burden of on-premises infrastructure.
Interoperability is another crucial area for the future of Facets. With the
regulatory emphasis on data sharing, particularly through FHIR (Fast
Healthcare Interoperability Resources), enhancing Facets' interoperability
capabilities will be essential. This integration will facilitate seamless data
exchange among payers, providers, and other stakeholders, ultimately
improving patient care and operational efficiency.
The ongoing shift towards value-based care represents a transformative
opportunity for Facets. As healthcare systems move away from fee-for-service
models, there is a need for advanced analytics and reporting capabilities that
support new payment models. Enhancing these functionalities within Facets
will allow healthcare payers to better manage costs while focusing on quality
outcomes.
Furthermore, integrating artificial intelligence (AI) and automation into Facets
can revolutionize how administrative tasks are performed. By leveraging AI
for claims processing, fraud detection, and predictive analytics, Facets can
significantly streamline operations, reduce manual errors, and improve
decision-making processes. Automation can free up valuable resources,
allowing staff to concentrate on higher-level strategic initiatives.
Facets will also need to navigate increasing competition from modern
solutions that leverage cutting-edge technologies. Competitors like
HealthEdge and Oracle Health Insurance are setting new standards with
microservices and advanced analytics. To remain competitive, Facets must not
only enhance its core offerings but also consider customization options for
smaller payers. Tailoring solutions to meet the specific needs of these
organizations will ensure that Facets maintains its relevance and appeal in a
diverse market landscape.
In summary, the future of Facets is poised for significant advancements,
driven by trends in cloud adoption, interoperability, value-based care support,
AI integration, and the need for competitive differentiation. By addressing
these areas, Facets can continue to be a leading solution for healthcare
payers navigating the complexities of the healthcare system.
