Case Study

Increasing Efficiency While Personalizing Care


In 2013, a global health insurer (based in the U.S.) issued a Request for Proposals (RFP) for a new business process management (BPM) partner to help reduce call transfer rates, increase Net Promoter Scores (NPS), and develop a more positive experience for healthcare providers (HCPs) and members.

HGS began with a mix of standard clinical intake, benefits, and eligibility calls and expanded to include processes that require even greater sensitivity, clinical knowledge, and judgement — case management, medical necessity review, and level of care assessments related to oncology, maternity, and neonatal ICU cases.

HGS initiated a process study to bring together two of the client’s business units — service operations and clinical operations. Team HGS defined employee profiles, metrics, and the scope of work, pioneering a one-transaction approach to increase NPS. HGS offered an innovative perspective — a single, cost-effective location in the Philippines for handling faxes and inbound and outbound calls. HGS also integrated benefits and eligibility inquiries with precertification calls

HGS nurses answer incoming member calls on the client’s health information line related to symptoms, conduct a level of care assessment, and advise when/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 by coaching them on how to improve their health, where to go for medical services, and how to ensure each visit is productive.

  • As a result of HGS’ consistent performance, the program began with 100 FTEs and grew to 620 FTEs within two years.
  • Reduced transfer rates to 7%
  • Increased members’ sense of security
  • Increased value and efficiency by helping members and HCPs
  • Exceeded client satisfaction expectations of 5.8 by scoring between 6.24 and 6.47