Case Study

Employing Clinical Process Outsourcing to Drive Down Medical Costs for Major Payer

Industries
Healthcare
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CLIENT CHALLENGE

As one of the world’s largest healthcare payers, this HGS client works closely with brokers and consultants to develop innovative programs; help individuals and families improve their health, well-being, and sense of security; and lower their medical costs. Drawing on more than five years of partnership with HGS, the client recently approached HGS about controlling member medical costs.
What started as a mix of standard clinical intake and benefits and eligibility calls has expanded to include processes that require even greater sensitivity, clinical knowledge and judgement—a scope that today includes case management, medical necessity review, and level of care assessments related to oncology, maternity, and neonatal ICU cases.
For members, HGS nurses answer symptoms-related calls on the client’s health information line. These nurses conduct a level of care assessment and advise when or under what circumstances to seek medical attention. Care associates work with members who have had high dollar claims in the past, to minimize future claims, with preventive coaching on how to improve and monitor health, where to go for medical services, and how to ensure productive visits.

Medical Cost Reduction, Better Outcomes through Clinical Process Outsourcing

How We Do It

Our Case Management Program engages customers who are incurring significant medical cost based on either a chronic condition or a condition that requires long-term medical care. HGS supports this client engaging with customers for the following conditions:

  • Neonatal ICU patients
  • Chemotherapy/radiation therapy patient
  • Cardiac rehab
  • Expecting mothers/maternity patients

HGS’s Case Management solution aims to drive toward two key client and member outcomes: improving population health and reducing costs. Our 500 (140 U.S.-certified) nurses engage with member/patients to educate them about case management. These nurses educate members as to how nurse case managers can assist the member/patients on providing alternate medium of treatment/ secondary opinion. Our team members keep track of treatment plans for customers, so that additional costs are not incurred. Education is provided on cost-effective providers and alternate treatment options.

Increased Case Management Referrals from  7% to 48%

Business Result

Over the past three years, we have steadily increased the engagement scores of members. In 2015, we started at around 7% customer referrals to case management. That number has increased to around 48% members being enrolled into case management. This significantly reduces the medical cost of those members.

“HGS has an impeccable staff from leadership down. There is a level of caring and pride at HGS that you cannot articulate in words. You ‘feel’ it. They do several things well, but what I really appreciate about HGS is their ability to push back. It sounds small, but in a service operation, this is huge when it comes to satisfaction and consistent delivery. HGS will not give us a flat out no; they come back with a possible solution and a confident timeline. This prevents us from making promises to our customer base, then missing the target date or propping up a model that is fraught with issues.” 
– From recent CSAT Survey