Case Study

Deploying Smart Automation to Re-engineer Leading Payer’s Collections, Enrollment, and Eligibility



As one of the world’s largest healthcare payers, this HGS client works closely with service providers to develop innovative programs; help individuals and families improve their health, well-being, and sense of security; and lower medical costs. 

As part of our unlimited partnership role for this client, HGS assessed several claims and member lifecycle touchpoints to identify key areas of process improvement opportunity. 

How We Do It 

HGS provides a broad array of claims management and member lifecycle services for this client, including international claims service to process healthcare claims filed abroad by client members. This site processes claims from 90 countries. Since January 2017, HGS has supported a key client objective of a turnaround time service level expectation of processing 98% of claims in 10 days. To ensure this success, HGS deploys expertise at every stage of the lifecycle. HGS works with the client’s premium collection and eligibility platform. This claims adjudication system and client/server application is used for the client’s end-to-end operations. 

HGS’s team continues to build on the expanding portfolio of solutions built for the client, with intelligent automation and analytics solutions identified for the client’s Premium Collections, Member Enrollment, and Eligibility groups.

Premium Collections: HGS developed a solution with process re-engineering to maximize outcomes for 70% process automation, for a potential savings of $650,000. The bot conducts premium cash posting of appropriate remittances received, as well as posting of fallouts, 5500 tax processing, and premium reconciliation.

Member Enrollment: HGS is currently testing for this 50% automated process solution, with a potential savings of $500,000. The HGS bot automates enrollment for new members with bulk form submission.

Eligibility: HGS is currently designing a solution targeting an automation outcome 50% or higher, for potential savings of $500,000. This automation increases efficiency for the automated eligibility and benefits administration process, including focus areas of enrollment, termination, reinstatement, additions, and changes.

Additionally, HGS’s bot creates a reporting dashboard to track incoming cash, postings, and fallouts on eligibilities, with extensive enrollments tracking. This is a value-added consultative service, as the client uses these insights today to ensure operational efficiencies and refocus their financial forecast.

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