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Our Successes

Process Overhaul

Background

A healthcare insurer was responsible for processing over 3 millions claims annually. The majority of claims were adjudicated and a significant number were re-adjudicated due to system configuration issues, manual processing errors, and medical management review. The company was seeing significant expenses due to prompt pay, large staff was required to try to keep up, and team members were shifted frequently to address high queues.

The Needs

The company had to be able to find ways to pay these claims timely, free up claim processor time to focus on initial claims payments, and reduce prompt pay penalties. This required a complete rebuild of the claims re-adjudication process.

The Results

Within 9 months, a custom application was designed, developed, and implemented. Staff was trained and documentation and integrated reporting was developed. The new system had built-in security, auto-assign work, built-in business rules, validation, metrics programming, reporting, internal escalation process, and the generation of claims files.

  • Annual $6 million savings in cost avoidance and administrative savings.
  • Corrected regulatory reporting and files.
  • Enhanced custom application.

Services Rendered

  • Application Development
  • Lean Six Sigma
  • Training
  • Security
  • Quality
  • Metrics
  • Cost Avoidance
  • Regulatory

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