Case Study

Objective
In 2011, a top three California health plan, serving a member base of approximately 3.4 million, was aiming to streamline relations with members and providers with a system-wide claims administration and platform upgrade. For this technology modernization effort, the client was looking for a BPO partner to provide efficient acquisition of claims administration skills along with a carefully coordinated ramp-down of claims and administrative activities on the legacy systems. After a competitive selection process, HGS was chosen as a preferred partner, because of our superior rankings in all of the following areas:

  • Health insurance administration and claims processing experience
  • Agile staffing for seamless service and no interruptions
  • Operational efficiency, benchmarking, and strategy
  • Client relationships built on transparency, trust, and growth
  • Flexibility to meet clients’ evolving needs
  • Willingness to invest and lead the partnership

With this decision in place, the client agreed to deploy HGS’s core knowledge transfer team at their training site, while technology teams from both sides worked to develop a speedy transition plan, which maintained the rigid network standards required for a secure, HIPAA-compliant process. From our Bangalore site, HGS assisted with migration of Commercial, Medicare Advantage, ITS, Medicaid, and ASO claims.

Our Solution
HGS collaborated with the client to support a claims migration plan that increased quality of claims
management, for optimal data integrity with error-free, agile migration with absolutely no service
interruption. Our flexible, skilled staffing provided simultaneous data entry during transition from
legacy to FacetsTM
Within the five-year migration period, all claims were transitioned to Facets, including a complete
migration and claims history. HGS initially provided data entry and also edit resolution, with a day
one focus on the legacy system. After exceeding client expectations, our partner expanded our
agreement to also provide Facets system support, as well. Our detailed, procedures, and practices
have enabled the client to monitor and manage even the most complex claims. Comprehensive
conversion methodologies were applied to ensure data integrity and concurrency with an errorfree,
hassle-free migration. A total of 80,632 work hours were invested to support migration, with
500,018 ad hoc claims supported.
HGS has met 98% or better for all TAT and SLA requirements and for the more stringent IPP
requirement, 95% or better. The conversion was managed and successfully completed within the
five-year time frame.

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