Case Study

HGS and Major Payer Drive Volume-to-Value Transformation




In 2013, a major U.S. health insurer was in search of a partner to support achievement of seemingly conflicting objectives: better member engagement, improved patient outcomes, and a cost-efficient, agile operational model. After a diligent selection process, the client chose HGS for our value-driven approach—a distinctive combination of deep domain knowledge, agile workflow innovation, and call center expertise. Over the course of our partnership, we have worked with this client to drive breakthrough success, including:

  • Significant increases in Net Promoter Scores (NPS) and enhanced health outcomes for members
  • Optimized experience for both members and providers, employing cocreated solutions like nurse triage and proprietary solution like provider database management innovation, to drive significant cost savings and improved patient experience.


Our Solution

From the outset of the partnership, HGS initiated a process study to bridge the client’s key business units—service operations and clinical operations. Team HGS defined employee profiles, metrics, and work scope, pioneering a one-transaction approach to increase NPS. HGS provided significant savings with a Philippines location to handle inbound and outbound calls and faxes. HGS also integrated benefits and eligibility inquiries with precertification calls, employing a highly skilled team, including nurses registered in the U.S. and Philippines. HGS leveraged front line employees’ clinical expertise and more than 10,000 healthcare support professionals for other top health insurers, to deliver marked results, fast. Within two years, HGS’s 100 FTE starting base grew to 620 FTEs. Five years later, 2,000 HGS team members work as strong brand ambassadors for this client, every day embracing the client’s brand promise of value-based care.

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.

To improve relationships between the payer and their provider network, HGS makes outbound promotional calls related to the client’s self-serve portal for providers. HGS drives real outcomes like reduced call volume, reduced cost, and increased efficiency by enabling providers to track payments, prior authorizations, and account status, independently. HGS also recently launched an innovative provider quality operations solution to ensure accurate provider demographic and directory information.

Undoubtedly, HGS has played a key role helping this client adopt a more value-driven approach. To achieve key client objectives in support of this shift, we have delivered on all fronts, bringing cocreation, consultation, medical cost management, and new HGS-designed tools customized to the client’s unique needs. As a result, the client has increasingly turned to HGS for a widening scope of solutions and services. Here is a highlight of five key areas of partnership success.

1. 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. These 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.

Business Result

We have slowly increased the engagement scores of members over the past three years. We started in 2015 at around 7% customer referrals to case management. That number has increased to around 45% members being enrolled into case management. This significantly reduces the medical cost of those members.


2. NPS and CSAT Improvement  

How We Do It

In 2015, the client was transitioned to more stringent CMS requirements, with accounts monitored according to additional audits. HGS was a partner of trust and preferred vendor to lead a member satisfaction turnaround, supporting remediation work with voice support for the client’s Medicare base. HGS responded from our El Paso, Texas site, employing an HGS proprietary training methodology for agents. This new, interactive training approach, focused on the senior citizen market and their needs, incorporates sensitivity, empathy, coaching, patience, and accountability. The real-world modules are designed so that agents experience firsthand the specific conditions of the client’s Medicare members—creating environments for the agents where they are sensory or physically challenged. These activities create knowledge and understanding for agents to employ to understand Medicare members and their health profiles—from arthritis to effects of hearing, vision, or other sensory loss.

In this key area of opportunity, HGS has proposed to add value to the new CX measurement approach with defect analysis and action planning. HGS can deploy resources to deep dive into calls using raw survey response data and applying mutually agreed rules, classifying defect reasons into HGS errors and client controllable issues related to process, technology, or customer limitations. Data mining will help develop action plans to reduce HGS controllable defects and further improve member experience. HGS can also provide advanced text/speech mining capabilities on survey responses to elicit additional insights and market experience areas.

Business Result

HGS has driven a dramatic NPS improvement, with a jump from 8.2 to 8.6 in 2017 alone. However, a three-year analysis shows that HGS’s three-month average from May to July 2017 is a 33% increase from HGS’s 6.47 score (a passing score is 5.8) in 2014. With these showcase scores, HGS demonstrates a real outcome of member engagement and satisfaction turnaround for the client, with members increasingly recommending this payer client to friends and family members. Additionally, HGS’s CSAT score has spiked at 3.8 out of a possible 4. The CSAT success is directly attributed to members’ positive feedback in areas of agent courtesy, knowledge, and reduced customer effort. Finally, from an operational perspective, the same HGS training approach that has driven NPS and CSAT success has resulted in a call quality score of 97% (from 95.33%), helping the client comply with the stringency of requirements and significantly reduce CMS complaints—in fact, by up to 51%. This area of achievement has been a direct result of the client’s trust in and transparency with HGS. The client brought HGS to the table to help troubleshoot key operational and member satisfaction weaknesses, and HGS responded with a confident, highly collaborative solution to close loops for a quality-focused, greatly enhanced member experience.

3. Provider Engagement Innovation (PI)

How We Do It

Provider engagement has been another opportunity for change and innovation. In 2016, HGS designed an operational model for the client, for a pilot launch at our nearshore Jamaica location. The provider data quality and compliance initiative has effort of this type by the client, with HGS chosen as a preferred partner to assist with finding and filling gaps in provider demographic data. The client’s business need was threefold:

  • Ensure accurate provider and directory information to support compliance initiatives.
  • Enable differentiated client and customer network selection and new reimbursement capabilities.
  • Validate and maintain accurate provider demographic data in a relational data model, with consideration of contract and network provider structures to maintain criteria-driven and qualified data relationships.


HGS built the provider database management system (PDMS) to capture relational elements of provider demographic data to ensure each data element is accurately captured and reported back, as per compliance and regulatory requirements. This data accuracy enables the client to efficiently seek an appropriate level of care for physicians, for enhanced patient care outcomes and without any errors or delays. This achieves optimized turnaround time (TAT) and quality metrics. HGS customized the DFSS solution for a spring 2016 launch, benchmarking the attributes required in PDM advocates, coordinating with client subject matter experts and using the unique GPI and cognitive index. With the launch set for HGS’s nearshore Jamaica location, the profile of an empathetic and naturally friendly and curious agent was well suited to provider engagement. Intense classroom training was provided to the core batch of five HGS team members. Training was structured for mentoring and optimal agent outcomes. Rigorous project management ensured benchmarking and monitoring of all training, tool customization, and next wave hiring. HGS has employed a recruiting and training process to ensure agent skill set aligns with optimal performance of tasks. HGS uses GPI and cognitive tools to capture key talent attributes, and employs tests to identify team members with attributes that are critical success factors.

HGS agents employ an approach to ensure the most current provider details are captured with calls, including this example of data captured:

  • Validate new office details and update database.
  • Analyze and obtain office closure data.
  • Review dates to align with use of term office/facility (based on business rules).
  • Post validation, order to Term Office.
  • Search and consolidate provider list within groups linked as same office address as termed location, term locations for all    additional office/facilities with same address as previously termed location.
  • Ensure research takes into account where each additional provider within group has moved to, outreach as needed for accurate and updated data.
  • Update provider details within client systems, including but not limited to new addresses for all locations/facilities.

With this innovation, HGS will drive provider experience benefits, including:

  • Reduced Average Handle Time (Speed)
  • Right First Time (Quality)
  • Automated process resulting in better agent productivity
  • Decreased training timeline
  • Increased process compliance
  • Enhanced efficiency and customer experience
  • Higher CSAT scores through faster resolution of the cases


Business Result

This showcase DFSS project has been highly successful, with the first core team now supporting this provider data outcome initiative, having cleared client assessment of calling and classroom training. HGS PDMS customization tollgates have all been achieved, with customization exceeding both client and customer expectations. With this new approach, HGS has been a pioneer of provider quality outcomes.

4. RPA Innovation


How We Do It

HGS began providing an international claims service, to process healthcare claims filed abroad by client members, from our Bangalore site in 2016. 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 employs 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. We use this application for all the following functional attributes toward claims adjudication:

  • Authorization – Preauthorizations of medical services
  • Claims – Claims adjudication
  • EDI Claims – Electronic claims adjudications system
  • Letters – Correspondence system to send letters for members and providers
  • Benefits – Plan benefits coding and updates
  • Members – Subscriber master data base
  • Premium – Premium records and data base
  • Pricing – Pricing logic and contracts
  • Providers - Providers master data base
  • Reports – Inbuilt reporting system
  • Security – Security systems for personal health identification (PHI) / national provider identifier (NPI)
  • Support – Customer support
  • Systems – Systems records and updates


HGS’s India team continued to build on the expanding portfolio of solutions built for the client, with Robotic Process Automation (RPA) and analytics solutions identified for the client’s Premium Collections, Member Enrollment, and Eligibility groups.


  • For Premium Collection, HGS developed a solution with process re-engineering to maximize outcomes for 70% process automation, for a potential savings of $650,000.
  • For Member Enrollment, HGS is currently testing for this 50% automated process solution, with a potential savings of $500,000.
  • For Eligibility, HGS is currently designing a solution targeting an automation outcome 50% or higher, for potential savings of $500,000.

Additionally, HGS has been supporting the 5050 tax form process, automating claims with the client’s proprietary platform and relaying the information, in alignment with 5050 tax form processing, to the client.


Business Result

With all three processes in various states of launch, HGS estimates up to 50% cost reduction in EDI Member Enrollment and Member Eligibility and up to 50% cost reduction in Premium Collections. Additional benefits will be increased turnaround time and decreased manual error. We have already delivered labor savings of approximately 60%, reducing staff from 25 to 10 team members. Additionally, we have dramatically improved TAT, from 3.5 days to only three hours, for a 96% reduction in TAT.


5. Consultative, Proactive Approach to Support Client Scale


How We Do It

Over the course of our partnership, HGS has prioritized the client’s investment, by providing consultative value (and results) above and beyond our success achieving contractual metrics. We have scaled our solutions, resources, and innovation to deliver client benefits in these key areas:

  • Process Innovation: In the first phase of this partnership, HGS brought two of the client’s previously siloed businesses—Services Operations and Clinical Operations—together to drive more holistic value and reduce transfer rates for customers.
  • Design Thinking: Next, HGS employed a design thinking approach to bring PDMS innovation. We continue to cocreate strategy around this innovation for significant client ROI.
  • Rightshoring: As the partnership has matured, HGS has increasingly leveraged four different geos— Philippines, El Paso, Jamaica, and India, as onshore, nearshore, and farshore resources that bring client cost and talent optimization advantages.
  • Industry Pioneer: In recent years, HGS has led value with forward-thinking solutions, like real-time process optimization (RTPO) and agent gamification, to drive cost-containment and bolster the client’s reputation as an industry leader.
  • Cultural Alignment: A consistent, underlying HGS promise to this client has been our complete support of and adherence to a corporate social responsibility (CSR) focus. This is a commitment to people and community that is at the very core of healthcare delivery. HGS and this partner are of like minds in every aspect of this partnership—starting with the everyday focus on people. As real-world evidence of this commitment, these partners have volunteered together in their communities—for example, working to support patients at a Texas provider affiliated with the client.


Business Result

HGS’s scale of support from 1 to 36 processes speaks volumes as a testament to the fact that this client is today the fastest-growing account in the company, a winner across the board, including in year-over-year revenue increase support. But there is much more to this partnership than exceeding benchmarks. While performance excellence is a very real partnership outcome, at the core of the HGS-client synergy is transparency, trust, and values alignment to achieve better outcomes for member customers—the ultimate proof point for this client partner.