POINT OF VIEW

Health insurance is a complex industry to navigate with myriads of hurdles in the form of processes tangled with regulations and age-old legacy systems. While automation has become the new normal in a world of digital business, health insurance has lagged behind. Even the technologically advanced payers are crippled with greater operational cost, poor customer experience, higher cycle time, and a tangled back office. It’s now time to run at the speed of new and evolving opportunities and fully embrace the power of intelligent automation.

Intelligent Automation for Health Insurance

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With the above thought in mind, Coforge has built its healthcare intelligent automation capabilities leveraging our partnerships with Pega, UiPath, Automation Anywhere and Appian to automate processes in healthcare core areas of sales, quote to card, enrolment, consumer engagement, claims processing, referrals and authorisation, payment integrity, and case management – ultimately delivering a superior customer experience.

Our services allow us to deliver a comprehensive mix of capabilities integrating class-leading partner products and our in-house capabilities. We bring best-in-class technologies, IPs, frameworks and solution accelerators to set the client on an incremental automation path towards delivering business outcomes and adding value. We also help existing and new clients develop an automation strategy focused on all key functional areas. Our proprietary ProcessGymTM framework allows us to take a very holistic and strategic approach towards delivering clear outcomes in any consulting and automation engagement.

Our expertise in developing, deploying and operationalizing bots is icing on the cake in this automation paradigm- be it a first level engagement in customer service or the more complex claims processing and adjudication, our bots can make it a breeze. We maintain an industry-leading certification standard which reinforces our partnerships with OEMs- having the highest percent of certified resources across any Pega practice or being consistently ranked first in Appian’s A-Score program are testimonies to our partnership commitment.

Our in-house capabilities and partnerships let us bring in top notch capabilities around BPM, case management, RPA, and CRM, allowing payers to deliver unmatched customer experience with ease. Our healthcare industry knowledge aligns in concert with the technical expertise to tailor a solution package that works in harmony with client’s existing systems.

Intelligent Automation for Healthcare Transformation

Our automation capabilities have transformed enterprises spanning across industries, turning them into smart organisation of the future. We firmly believe that intelligent automation technologies will continue to enable payers to deliver business agility, self-service enablement, and superior experiences. Automation has been a major enabler impacting Healthcare leading to cost take-outs and reinvestments in strategic areas, however automation approach is quite fragmented and silo-ed. We believe that there is a greater need to move away from these siloes to systematic automation of processes for handling scale without compromising on the quality and consistency of service.

For healthcare payers, Automation can be leveraged in areas such as Product and Rating, Marketing and Sales, Member Enrolment, Billing, managing provider network, claims processing, and customer services. The following process heat map depicts a comprehensive list of areas where we can assist payers leveraging automation:

RDA (Assisted Automation)

RPA (Unassisted Automation)

IPA (Intelligent Automation)

AI (Cognitive Automation)

Data Type Structured Structured and Semi Structured

Structured and Semi Structured

Structured, Semi and Un-Structured

Processing Deterministic Deterministic Probabilistic Probabilistic

Ability to Learn No No No Yes

Context

AwarenessNo No Yes, but limited to

environmentYes, similar to Human

Brain

Approach Human Triggers Orchestrated Process Automation

Distributed Computing

Machine Learning, Deep Learning, NLP

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Intelligent Automation Use Cases for Healthcare Payers

We address specific automation needs of customers while removing dependency on a single proprietary platform/approach, which allows us to pick and choose from the best and tailor a bespoke solution and approach for your organisation. Coforge has invested

Key Cognitive Robotic Automation Areas

MediumLow Very highHigh

Corporate Functions

Customer Service

Medical ManagementClaimsProvider

NetworkBillingEnrollmentSalesMarketingProduct & Rating

Finance

HR

Training

Actuary Analysis

Pricing

Risk Assessment

Product Strategy

GTM

Benefits Design

Campaign Management

Content Management

Segmentation & Training

Sales Portal

Broker Management

Marketing Strategy

Lead Management

Quote Management

Contract Management

Account Management

Channel Management

Pre-filing Enrollment

Enrollment Application

ID Card Issue

Subsidy Calculation

Benefit Setup

Case Installation

Renewal Termination

Payment Collection

Payment Processing

EOB

Delinquency Management

Subsidy Processing

Network Design

Providing Credentialing

Performance Management

Provider Contracting

Provider Data Management

Provider Payment

Claims Intake

Claims Processing

Claims Adjustment

Claims Payment

Fraud Management

Coordination of Benefits

Policies

Case Management

Utilization Management

Disease Management

Health & Wellness

Service Request

Member Portal

Correspond

Appeal & Grievances

Contact Center

in a dedicated intelligent automation practice with its product experts and automation practitioners working in tandem with healthcare domain experts drive enterprise automation roadmap and enable automation institutionalization. The practice also manages partnerships and alliances with OEM vendors and explores innovative automation technologies to serve our clients better.

Few of the payer use cases around which we have explored and built capabilities are-

Provider Credentialing

Provider credentialing is a process of obtaining, verifying and accessing the qualifications of a practitioner. Provider data, e.g. education, license, experience, certifications, affiliations, malpractice etc., needs to be accurately verified in order to enrol them to provide care or service to a health care organization. Manual credentialing process not only increases the chance for inaccurate validation but also effects payer’s credibility. Inaccurate credentialing also impacts revenues and patient experience.

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Clinical Claim Review for Utilization Management

Our multiple solutions across the automation continuum can help a registered nurse (USRN) expedite the clinical claims review for Utilization management.

Provider enrollment frorm

Provider data entry to credentialing

system

Approval letter creation

Provider data creation/update

Information validation & verification from different sources

• Board certification - verify current certificate level

• Criminal background - verify state and/or federal criminal history

• Department of health and human services

• Education - verify medical education and post-graduate education

• Work history - extract work history from the curriculum vitae

• Sanctions - query state license and medicaid/medicare

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Member Enrolment

Current enrolment process is time consuming and error prone as all the enrolment requests need to be validated & verified manually for all required information and data entry. The challenges faced in the process are:

• Applicants missing precise information on the name, address, income and other demographic and basic health information

• High turnaround time between submission and approval of an application

• Lack of a robust tracking mechanism for monitoring

We bring together multiple input channels such as email, shared folders, web portals managed by the bots for enrolment request data intake. Data can then be extracted from these sources and be validated as per the predefined business rules. Automation in member enrolment saves cost, increases process efficiency, can reduce administrative efforts by 75% and AHT (Average Handling Time) by 35-45%.

For more information, contact information@coforgetech.com

© 2021 Coforge. All rights reserved.

Coforge is a leading global IT solutions and services organization which believes that real transformation cannot be driven by thinking in technology terms alone. With a mission to “Transform at the Intersect” it aims to bring both deep domain and deep emerging technologies expertise to achieve real-world business impact. A focus on very select industries, a detailed understanding of the underlying processes of those industries and partnerships with leading platforms provides us a distinct vantage. We leverage AI, Cloud and Insight driven technologies, allied with our industry expertise, to transform client businesses into intelligent, high growth enterprises.

Learn more about Coforge at: www.coforgetech.com

Stay connected:

For more information, contact information@coforgetech.com

© 2021 Coforge. All rights reserved.

Coforge is a leading global IT solutions and services organization which believes that real transformation cannot be driven by thinking in technology terms alone. With a mission to “Transform at the Intersect” it aims to bring both deep domain and deep emerging technologies expertise to achieve real-world business impact. A focus on very select industries, a detailed understanding of the underlying processes of those industries and partnerships with leading platforms provides us a distinct vantage. We leverage AI, Cloud and Insight driven technologies, allied with our industry expertise, to transform client businesses into intelligent, high growth enterprises.

Learn more about Coforge at: www.coforgetech.com