Case Study

Managing the Entire Lifecycle for a Top 5 US Health Insurer

Industries
Healthcare
Solutions
Automation
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One of the top five healthcare payers in the U.S., this client was looking to improve their customer experience by transforming from providing as-needed, claims-based interactions to more proactive, preventative healthcare assistance. They wanted to focus on delivering better member-centric services and helping customers get to the right answer fast while resolving claims more quickly and reducing paperwork and costs.

 

 

Objective

In 2003, one of the top five healthcare payers in the U.S. was transitioning from a legacy platform to a new system and was experiencing delays in turnaround times through the transition process. Due to the complexity of enrollment and vast number of insurance products offered, they were also having customer information management challenges.

At the time, the client needed help managing handwritten applications, 6600 possible data fields, and multiple interactions to complete new records. They needed to increase accuracy, improve efficiency, and reduce cycle time. And, they needed to address serious customer experience problems.

The client, like many insurers, is transforming from as-needed, claims-based interactions to more proactive, preventative healthcare assistance. They are focused on delivering better member-centric services through integrated care delivery, self-serve tools, and meaningful clinical and customer insights that encourage positive customer behavioral change.

The client is also working to balance cost per member per month with better member experiences. The client needs access to business process management (BPM) experts who understand their vision and deliver value from enrollment, claims management, and coordination of care, to policy renewal.

 

 

Our Solution

Originally, HGS was engaged to deliver voice and non-voice service for two of the client’s processes, including enrollment and platform 1 pre-adjudication and adjudication. This service solution, delivered primarily offshore from Bangalore, India, was launched with 15 agents.

 

Rapid Scale: By 2004, the Bangalore team grew to 65 full-time equivalents (FTEs) and 5 processes. By 2006, the business had grown to 275 FTEs and 11 processes. By 2010, HGS managed 32 processes and 1750 FTEs on behalf of the client and, by 2012, 68 processes and 2400 FTEs. Today, HGS is global service provided and engages close to 6000 claims and calls professionals in the U.S., Jamaica, the Philippines, and India and covers 95+ processes. The program recently expanded to Colombia to provide Spanish language support and to support business continuity. 

 

Our Solution

Originally, HGS was engaged to deliver voice and non-voice service for two of the client’s processes, including enrollment and platform 1 pre-adjudication and adjudication. This service solution, delivered primarily offshore from Bangalore, India, was launched with 15 agents.

Rapid Scale: By 2004, the Bangalore team grew to 65 full-time equivalents (FTEs) and 5 processes. By 2006, the business had grown to 275 FTEs and 11 processes. By 2010, HGS managed 32 processes and 1750 FTEs on behalf of the client and, by 2012, 68 processes and 2400 FTEs. Today, HGS is global service provided and engages close to 6000 claims and calls professionals in the U.S., Jamaica, the Philippines, and India and covers 95+ processes. The program recently expanded to Colombia to provide Spanish language support and to support business continuity.

 

HGS provides support to the client across the entire spectrum of their core business, including:

  • Quoting
  • Billing and enrollment
  • Product/plan development and implementation
  • Customer service, product testing, and policy renewal
  • Initial claims management and adjudication
  • Customer service for Provider calls claim re-evaluation
  • Cost containment clinical services and care management
  • Medical cost management through fraud and special investigation reviews
  • Reconciliation and cash posting

 

Evolving over a decade, the engagement model of managing the end-to-end healthcare claims lifecycle has placed HGS in a unique position to be the center of excellence among the client’s vendors. Today, we are engaged with the customer in re-engineering and re-imaging the processes with tangible financial gain, time to market, and enhanced customer experience.

Skilled Resources: HGS keeps up with the changing nature of healthcare through initiatives such as:

  • Nurse review and triage
  • SIU (special investigation and fraudulence)
  • Wellness coaching
  • Coding reviews
  • Cost containment management

 

HGS ensures healthcare effectiveness and efficiency through on-staff care experts (e.g., nurses, dental hygienists, midwives, coding professionals). Many employees have U.S. licenses. With these highly skilled resources, HGS simplifies the coordination of care and manages information flow between patients, insurers, and physicians.

HGS provides peace of mind through regulatory compliance and end-to-end process ownership. The operational model is integration- and outcome-focused. With the client, HGS has developed a multi-tiered governance model to discuss opportunities, innovations, and solutions. HGS has aligned to the client’s strategy by enhancing self-service and capitalizing on cumulative experience.

Process Optimization: More than 360 employees apply Lean, Six Sigma, and Kaizen techniques. In every line of business, HGS aims to eliminate unnecessary steps, optimize the experience, and innovate based on data and analytics. Our goal is to evolve from transaction to value-based servicing using such means as process automation (e.g., taking a process from 8 hours to 14 minutes) and productivity measurement. At every healthcare touchpoint, the experience is key to retaining members while optimizing channels, streamlining back office processes, and containing the overall cost per member.

Outcomes

By seeking benefits beyond those provided traditionally through BPM, HGS has helped the client achieve its larger business goals. The secret to the long-lasting partnership includes mutual transparency, meeting metrics, and continuous improvements that lead to core business transformation.

With experience spanning the full lifecycle (and the globe), HGS’s scope has provided hundreds of continuous improvement opportunities in the last decade. Since 2011 alone, HGS has executed 300 projects of varying sizes for healthcare clients. Analyses and recommendations have encompassed everything from new technologies to process re-engineering.

  • Saved nearly $700 million, via both overpayment and underpayment efforts
  • Achieved 97 to 99% score on client-defined metrics for all lines of business
  • Reduced the number of contacts by 94%
  • Reduced claims rework by 5% and claims denial by 3%
  • Increased transaction accuracy by 18% and decreased instances of missing information by 18%
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