HEALTHCARE ADJUDICATION CASE STUDY
Client: The client is a leading, national
Third Party Administrator in the US that focuses on improving
the administration process for self-funded employers and
insurance companies. The client has over 74 employer groups
constituting over 150,000 members
Challenge:
The TPA needed a partner who could:
• Consolidate different data management processes
• Enhance their legacy systems with new technology tools
• Build reporting and performance metric tools which were
non-existent
• Improve service levels in terms of claims payouts
• Reduce the cost of claims inaccuracies
The time frame that the TPA was looking for to observe
these results was within a few months
EMR solution:
EMR used its outsourcing experience, technological strengths
and domain led process capabilities to implement its solutions.
These included:
• Modifying the systems to improve efficiency, reliability
and increase automation
• Build web based application layer over the legacy
systems to improve functionality
• Build additional dashboards and performance metric
tools to provide base for continuous process improvement
• Implement robust and proven offshore delivery
model for delivery of services from India.
Processes:
• Data capture of claims received from the TPA, including
typical medical forms and those received from hospitals
such as HCFA, UB92, Dental, Vision and FSA forms
• Validation of claims in client’s software in accordance
with the policies and rules pre-specified by the client
• Claims adjudicated upon by the adjudicators who are
well trained on taking decisions on health claims
• Final payment decision (approve / deny)
• Auditing of claims adjudicated
Benefits:
• Augmented competence and accuracy of the claims adjudication
process
• Homogenized manpower requirement for the process by
benchmarking competency parameters
• Increase in auto adjudication of claims upto 40%
• Improvement in process productivity by 30%
• Reduction in turnaround time by 70% using “follow-the-sun”
approach and EMR’s customized technology tools closely
interfaced with the clients’ claims processing system.
• Accuracy of payouts is 99%+
• Productivity enhancement up to 20%
• Cost savings of 40-50%
• Access to large pool of domain experts
• Access to latest IT tools & process innovations
• Business agility to tide over surges & spikes
• Automated workflow system incorporating Imaging created
by EMR which helps all associates in being updated on
the process progress on a minute-to- minute basis
• Implemented an active first pass quality control system
to minimize errors
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