For more than a decade, global insurers have struggled to adapt to an increasingly consumerdriven marketplace. More than five years ago, one payer’s immediate need was back-office workers’ compensation medical bill review support. They turned to HGS to provide these services from our Bangalore location. From day one, HGS worked diligently to problem solve and turn critical workflow gaps into opportunity. Over the course of our partnership, HGS has evolved our role—from a transaction partner to a co-creative, trusted resource. What started as 10 FTEs handling one of the TPA client’s bills has now expanded to a portfolio of 8 unique services delivered by our 415-member team, with the clinical expertise of 17 RNs and 75 coders. Today our payer-provider ecosystem expertise, payment accuracy vigilance, and tactical process reengineering drives results including $20 million in annual savings.
How We Do It
Our breakthrough success with this client started with only 10 FTEs handling one of their Service Center clients. Based on our in depth workers’ compensation experience with a sizable client portfolio, HGS immediately identified approximately 12.5% of the total bills were inaccurately coded which resulted in higher payout. We took on the challenge to understand coding patterns across various specialties and potential overpayments/opportunities for improved payment accuracy. We deployed a payment accuracy tool, tailored to the client, to filter and extract sample bills. HGS reengineered strategy to show the client the value we could bring with our RNs and CPC-certified coders reviewing medical records, patient history, and severity to determine appropriate coding. Our strategy is a structured approach to determine factors of value, apply change management feasibility, and work through a technology feasibility lens.
The client has since counted on HGS for a widening scope of services, including Re-evaluations; Complex Nurse Review for medical necessity, compensability, relatedness/appropriateness; and Code Review by Certified Professional Coders. Today HGS is successfully handling more than 30 independent clients on the client’s platform supporting end to end medical bill review services.
Throughout our partnership, HGS has demonstrated value that transcends our initial role as a transaction partner. We have provided crucial support to this client’s savings objectives while also co-creating solutions and innovation to support larger business goals.
In addition to reengineering payment integrity processes to drive breakthrough $70 million (over 4 years) in savings for this client, HGS has brought proprietary tools such as our Inventory Management Tool to proactively manage inventory within state stipulated timeframes to avoid interest and penalty due to delays. Today HGS’s consultative, proactive strategy works across siloes to also enhance profitability, provider relations and enable billing and coding, which are all key to transformation for this client partner.
The client has been so confident in HGS’s consultative approach that they have trusted us with another casualty line of business on the auto side. We have started providing the people, process, and technology to pave the way for even more value creation. Additionally, we have taken on provider calls and provider negotiations, as another area of significant opportunity for CSAT and TAT enhancement.