Case Study

Combining Rightshoring and Design Thinking to Reduce Costs and Improve Value-Based Care


In 2000, a top 10 healthcare payer wanted to test the idea of handling claims management offshore to drive cost-containment and higher-quality outcomes. Based on HGS’s history of successful right shore program management and process re-engineering, this payer asked us to launch a small proof of concept (PoC) program to show the viability and potential cost savings of taking this critical function offshore. From day one, the PoC was highly successful in driving process efficiency, cost-savings, and geographic diversification for our client. This initial success became the foundation for a growing multi-process collaboration, as HGS has played an increasingly consultative role in growing and transforming our client’s business. In the 18 years since launching that PoC with only 23 FTEs, our relationship with the client has grown to encompass 4,000 HGS employees handling more than 150 different processes across seven different business units including back-office and clinical applications. Over these past two decades, HGS has delivered consistently strong performance for this payer client, driving real business transformation outcomes and efficiencies, including consistent year-over-year savings, by a combination of right-shoring and process re-engineering.

This partnership success has driven the creation of a dedicated process re-engineering and improvement team, called Bright Ideas, staffed with business excellence and innovation personnel of both the payer and HGS. These teams work in close collaboration to develop, review and implement new and innovative ways to improve all operational processes for the client.


Across the operational landscape—from claims management to clinical support—this has been a partnership based on transparency and the trust earned by consistently exceeding our client’s goals/targets. In fact, this client recently chose HGS as the single partner among all service providers, for pioneering and deploying a revolutionary approach to member engagement and a new, client-branded member engagement platform. HGS’s success in proving and launching this new framework has resulted in the client solidifying plans to roll it out across all internal and external delivery centers next year.

HGS provides strong proof points and ROI at both ends of the lifecycle—member engagement and also the back-office process improvements that can cut turnaround times and improve provider engagement. “Service providers with both front- and back-office expertise are in a unique position to help clients achieve and exceed their objectives,” says Russ Uhlmann, HGS Vice President of Client Services. “HGS’s co-creation model and willingness to partner with our clients in proof-of-concept efforts, create both upstream and downstream insights and innovation to truly transform our client’s operations.” 

Our Solution

1. Improved Member Engagement

In 2014, the client was looking to meet the evolving market demands of value-based care, with a complete commercial segment revamp of their member engagement processes, starting on the front lines of voice service delivery. At that point, the client was well familiar with HGS’s 14-plus years of operational intelligence and innovation, and had a firm understanding of the breakthrough solutions we provide. As a result, HGS was selected as the preferred partner for this service excellence pilot.

HGS was with the client at the table during the early stages of the development of this businessexcellence model. With four decades of extensive expertise and experience, we were able to bring to this 

program development our healthcare knowledge expertise across commercial and government healthcare segments, as well as our overall extensive experience working across geographies to build and establish standardized processes, uniformity of tools and methodologies, and continual improvement.

For two years, HGS and our partner worked closely to co-create a business excellence framework centered on the mission of globalized service excellence, with a Unified Customer Engagement® across channels and along the lifecycle. Employing HGS’s design thinking innovation and consultative approach,we provided the cross-training and skillset focus to drive for higher SLAs and a premier, precedent-
setting service excellence. We designed a complete revamp of all operational processes—working
with the client to analyze those service elements that critically affect service delivery. What were the strengths, weaknesses, and opportunities in hiring? What is the ideal profile for agent fit? What training improvements were needed to optimize CSAT, member retention, and—at the core of it all, agent performance and engagement? HGS worked closely with our client, sharing our own business excellence expertise, to assess voice of the customer feedback, ask the right questions, and then provide the solution consulting for a program designed to specifically meet excellence objectives. The final program mission was to better advocate for members’ optimal health by helping them get the most from their benefits,building trust, and always providing a clear path to care.

This HGS service excellence team officially took calls on December 27, 2016. The Pilot Voice Services Team was evenly divided between two locations in Manila, Philippines and comprises one Operations Manager, two Shift Managers, two Team Leads, two Training Managers, two Line Trainers, and 20 CSRs. At the heart of our business excellence model are key solution features, to support an agent that advocates striving to help members optimize their benefits:

• A more empowered agent with member engagement mindset that incorporates the common purpose in all of their phone calls. This includes better engagement with service improvements such as:

  • Answering the unasked questions that members or provider offices don’t know to ask;

  • Educating members on the special health programs that they have available;

  • Building trust with active listening and accurate info provision;

  • Providing clear and complete explanations on service asks like procedure steps or assistance finding a doctor;

  • Offering a lifeline that can be called for the right answer, faster—for example, cost parameters or pharmacy representative-specific help. This information is just a phone call away for agents providing service within this business excellence framework;

When needed, educating providers on the steps they need to take to obtain a precertification for the member’s procedure.

Ultimately, with these premier service excellence features, HGS has provided customer-centric focused excellence that is transforming this client’s member engagement, for a more B2C market leading approach.

Client ROI for this program has been immediate. The Business Excellence Model Team’s performance has been outstanding from day one, with improvements in AHT, FCR, and CSAT. For example, year-to-date quality reached 99.45% in only five months, while HGS drove CSAT to 96.9%, for a 50% reduction in dissatisfiers. Another critical outcome that showcases the source of the positive outcomes for the client? At the five-month mark, agent attrition is 0%.

2. Process De-coupling

In mid-2015, the client, impressed with our grasp of operational efficiencies, sought our help in another area of their business: a proof of concept on Medicare Part D. They already trusted our claims management expertise, and they understood firsthand that, with our deep domain knowledge of both commercial and Medicare market segments, we were well versed in the stringent regulations and compliance of government healthcare programs. Ultimately, this client was looking for a more effective process and better use of costly clinical resources as part of their drug labeling and authorization

  • process. Their existing process was burdened with turnaround time (TAT) issues, inconsistent accuracy, anda cumbersome need to source, recruit and train highly paid clinical resources for a short period during open enrolment each year.

    For our PoC, HGS leveraged our Bangalore and El Paso locations to employ trained (but unlicensed) resources with pharmacy claims knowledge to follow a 24x7 process that decouples initial call triage and fax labelling from the actual clinical authorization process. With our proprietary workflow solution, HGS handles each provider/member interaction with the appropriate level of trained resource (clinical and non-clinical), thereby making the most cost-effective use of both high-cost clinical and lower-cost non- clinical resources. HGS has also re-engineered the working hours and locations on a “follow-the-sun” model to ensure adherence to strict regulatory requirements for TAT on all transactions. In addition to TAT and cost improvements, HGS’s decoupled approach solves for the critical—and often overlooked—issue of 

    incorrect drug form labelling, which can result in non-compliance with CMS audit, lowered CAHPS rating, and possible federal sanctions.

    HGS’s key role in the Med D drug review and authorization process has included:

  • Offshore—Validation of the drugs listed in provider faxes and ensuring appropriate drug labeling before transferring to clinical personnel (licensed pharm tech) to approve or deny claims

  • Onshore—Triaging member calls and handling or routing calls to the appropriate resource based on member need, including referral to clinical resources for authorizations/denials needing immediate clinical decisions

With a flexible, decoupled process that provides for optimal process timing and effective resource allocation/utilization, the ROI was immediate for our client and included better turnaround time (25% improvement), significantly improved accuracy and consistency, substantial cost-savings (greater than $1 million per year), and reduced need for expensive clinical personnel. HGS was also able to drive a 60% improvement in call average handle time (AHT) from initial estimates and trigger a mutually successful gain-sharing program. This program was designed to incent the client and HGS teams to work hand-in-glove toward improving the Med D drug approval/denial process.

As a result of the level of success HGS demonstrated in this PoC, the client chose to transfer all this work from multiple vendors and in-house sites to HGS, prior to the upcoming open enrollment season. The client has been so impressed with HGS’s performance that a bid has been extended to adapt this process to the client’s commercial business.

3. Overpayment Recovery

HGS launched a Six Sigma project, supported by certified Black Belt professionals, to address a challenging payment integrity audit methodology. The team narrowed the focus to critical lines of business (LOBs) and designed a “Hire Selectively & Train Continuously” program to ensure the workforce delivers consistent efficiency and quality. Training roadmap was revamped to meet the changing process dynamics and calibration sessions were organized to address the analyst and auditor gaps. Boosting KPI’s of low performers through routine feedback & coaching sessions, regular refresher courses

and close monitoring via pre- and post-assessment scores had the most visible impact on quality scores. Analysts were tiered and dedicated to performance-guaranteed accounts. Efforts invested in developing a tool to verify overpayment recovery reasons, benchmarking against inaccurate entry or coding errors yielded results.

The client’s goal was to achieve 95% accuracy score and HGS has shown a drastic improvement in moving the scores from 85% to 95% within a period of 7 to 8 months. HGS has been consistently meeting the targets and is the scores are currently hovering over 97%.


Looking ahead, the client is seeking to build on HGS’s toolset and unlimited partner approach. There is potential for HGS to assume more utilization management, clinical intake, and medical necessity responsibilities, in line with the client’s growing population health management focus.