A business case study:A business case study:

This study highlights how the managementmanagement, within a span of 12 months helped a US Health Insurance consortium; improve its business processes.

It also details how the management the management delivered a significant qualitative change and operational cost savings; in less than a year of operations.

THE CLIENT ORGANIZATION: THE CLIENT ORGANIZATION: A Health Insurance consortium based out of Florida operating multiple companies in Healthcare & Insurance domain in 10 states inclusive of CA, FL, GA, NY, NC, SC and TX. ‘Comprehensive Care’ domain since 1996.

The company partners with both Medicare and Medicaid programs Associated with Humana, Kaiser Permanente, Aetna, HealthNet, United Healthcare and Anthem Blue Cross of California. It operates 7 health plans.

It health plans includes:•HMO•POS•PPO•PFFS•Traditional Indemnity PlansIt is registered with both NCQA & URAC.

The Client Organization’s core services include:The Client Organization’s core services include:

• Utilization Review

• Member Services

• Claims and Billing

• Care Management

• Quality Management

• Network Management

• Intensive Case Management (ICM)

BUSINESS SITUATION BUSINESS SITUATION • The client had been outsourcing to multiple vendors and the results were far from

satisfactory. Despite the client management’s considerable effort to support their vendor for the desired outcome; the results were far from satisfactory.

• The reporting was infrequent & not to the level (detailed) required.

• The accuracy was floundering and as the employee attrition was high - the output (Quality) was suffering.

• Provider and Member Support Services response was often inadequate- leading to frequent contacts on the part of Service Providers and Members.

• These inefficiencies could have resulted in the company missing claims timelines goals, which had a negative customer impact. The Provider Payment cycle was prolonged, leading to dissatisfaction.

THE SOLUTION THE SOLUTION

•Management Management was made aware of the situation.

•Management Management based a Sr. Management professional (Six Sigma – Black Belt)in the client operations for 30 days.

•The senior professional studied work done by other vendors; identified the gaps and proposed a work around. He mapped the lowest vertical of the claim processing – data entry. A detailed Step By Step document SOP (Standard Operating Procedure) and a phased transition plan were submitted.

THE SOLUTION THE SOLUTION

•Post sign off and SLA (Service Level Agreement) the Recruitment and Training activity was completed within 45 days. SLA mandates near 6 Sigma Accuracy.

•The client Training Department with support of Management In-House experts trained the processors using WebEx sessions. The Client Audit & Training Departments certified the processors and the process went live in production environment flawlessly.

Note: The detailed SOP was submitted and Audited by CMS subsequently, successfully. The document was adopted by the Client Claim Processing Department as an Internal Document.

THE MANAGEMENT SOLUTION THE MANAGEMENT SOLUTION

•The client organization ensured that the training was on different LOBs (Lines Of Businesses). The Management teams was exposed to multiples of claim scenarios and this ensured deeper understanding.

This on the hind sight proved a visionary step as it lead to later process migration time being significantly reduced, to under 15 days.

THE MANAGEMENT SOLUTION THE MANAGEMENT SOLUTION

•Mentoring sessions

•Creation of Quality Awareness culture – embedded in the process

•Stratified random sampling technique – 15-10 % Process & Individual Processor

•Frequent knowledge calibration sessions - training programs, quiz and evaluation test

•A staggered training approach - to address the need for a speedy productivity ramp-up.

THE MANAGEMENT SOLUTION THE MANAGEMENT SOLUTION

•Elimination of investment from the client organization - towards training its processors on healthcare basics and claims processing – data entry. As a result claim processing was transitioned under 45 days with all due diligence.

•Institution of a knowledge management team -to create detailed process documentation and check lists. To ensured rapid training and applications of the concepts, into ‘live production environment’.

•An Internal and External (Independent) Quality Audit Metric Team - which leveraged the Management Process Quality tools to consistently exceeded accuracy of 99%

KEY KEY

BENEFITSBENEFITS

Minimal training & business process migration cost

The client Training Dept. and the In-House training resulted in saving of over 200 hours of training and approximately $185,000.00 of savings in transition costs

Significant improvement in productivity in a span of 180 days; thereby allowing Management to maintain timely handling of claims

Due to claim processing – data entry efficiency; Management was able to lower the client organizations unit cost by 32%

THE MANAGEMENT EDGE THE MANAGEMENT EDGE

Process Complexity GraphProcess Complexity Graph

12

Rising up the value chainRising up the value chainRising up the value chainRising up the value chain

MANAGEMENT SERVICESMANAGEMENT SERVICES• Healthcare Claims Processing

•OTC (Members Order) Sales & Support Services

•Member and Provider Support Services – Voice Non-Voice Support: Chat and Mail Support

•Configures Services Providers and Members in the Business Application

•AR/AP Services

•Claim Adjudication Services

•Provider Credentialing Services

THE MANAGEMENT - IT SECURITY SOLUTIONS & PARAMETERS THE MANAGEMENT - IT SECURITY SOLUTIONS & PARAMETERS SECURITY & ACCESS CONTROL SYSTEMS - SECURITY & ACCESS CONTROL SYSTEMS - Access Reader (RFI card)

• 100% Controlled & Monitored & 24 * 7 Physical Security

• The Server room has Advanced BIO Matrix Access Control with dual security (Thumb and PIN)

CCTV CAMERAS & DVR RECORDINGCCTV CAMERAS & DVR RECORDING

• 100% Controlled Monitored & 365 * 24 Recording (10 Year Data Storage)

DISASTER RECOVERY PLANNING (REMOTE LOCATION) & RISK MITIGATIONDISASTER RECOVERY PLANNING (REMOTE LOCATION) & RISK MITIGATION

• Multiple location based Data warehouse Multiple location based Data warehouse

IT REDUNDANCY & RISK MITIGATIONIT REDUNDANCY & RISK MITIGATION

• Fiber Optics – Multiple Leased lines

• Radio Frequency – Backup link