Delivering Outcomes with a Quality, Cost-Containment Lifecycle Focus

Medical cost management has always been a core focus area for health insurers because 80% of premiums are allocated to managing the health of the members.

HGS Medical Cost Management services comprise a combination of concierge, health education, and outcome management services. We currently employ 1,100 clinical staff members, many of whom carry US RN licenses offering Utilization Management, Case Management, and Care Coordination. We also assist providers in evaluating their patients' health outcomes at every encounter in the most cost-effective way. HGS leverages rightshoring to ensure optimal cost-containment for our health plan partners.

How We Do It

HGS medical cost management services include:

  • Nurse Triage HIL & Triage, Care Coordination: Our health information line is a resource to members for 24x7 servicing. This clinical expertise directly answers to the outcomes focus and also provides care deflection and call triage. Our U.S.-certified RNs provide these services from the Philippines.
  • Utilization Management: Our RNs provide skills and expertise to effectively manage healthcare costs for the payer by helping to guide patient decision making and payment processes with case-by-case assessments of medical appropriateness.
  • Case Management: We work to assess, plan, and facilitate care coordination for chronic or complex medical conditions. Nurses evaluate a patient's eligibility to join the case management program in which dedicated case managers support the patient through treatment options for that medical condition.
  • Medical Necessity Review, Provider Engagement: HGS checks the medical appropriateness and necessity for the level of care rendered. HGS educates intermediaries, and has established operations centers to work all Medicare and Medicaid accounts in the USA.
  • HEDIS Reporting: We provide medical records review and abstraction of star rating indices to enable healthcare organizations to track, monitor, and improve HEDIS compliance, develop and measure proprietary quality metrics, facilitate NCQA submission and implement year-round clinical compliance reporting that increases health plan ranking.

Our Value

Our solution presents this measurable value:

  • Impact to health outcome metrics
  • Cost containment, via offshoring, accuracy of payouts
  • Proactive payment management eliminates need for reconciliation
  • Impact to member behaviors in managing their health
  • Improved member experience
  • Impact to operational efficiencies

"We are extremely excited by your proactive approach. It is great to know that HGS is looking out for us and working to find ways to improve our process and save us money. This is a great example of perfect service, which is a principle that [our company] strives for. We very much appreciate all that the whole team does for us on a daily basis."

Production Manager,
Top Ten Health Insurer

25% Reduction in Cycle Time

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of Top Healthcare Payers Supported
Healthcare Professionals
Serving Members on behalf of Payers and Providers
Industry-Leading Compliance
100% Client Retention