Digital Innovation in US Healthcare Claims_ Digital Transformation

Customer - A leading not-for-profit US East-Coast-based health plan, serving 3+ million members.

Business Problem: The client has a low Claim Auto adjudication rate of 59% (vs. benchmark of 80%) and Payment accuracy rate of 93% (vs. benchmark of 99%). This sub-optimal performance was resulting in contractual SLA misses, along with interest and service credits, provider dissatisfaction, and high call volumes in the contact center.

Root Cause: Configuration issues faced during migration from Legacy to a new platform.

Solutions Implemented

• Analyzed and corrected configuration errors with a direct impact to Auto adjudication rate
• Deployed 150 bots, processing 9% of new day & rework claims end to end using, UI Path - RPA solution
• Applied SQL scripts to hold claims from 48 error prone categories for accurate claim payment
• 838 employees trained & certified to build & use of digital assistants using UI Path

Business Impact delivered

• Savings of $30 M delivered across last 3 years
• Around 440K Claims identified and $57M overturned with Interest savings of $2M
• Improvement in AA rate to an avg of 87% with help of RPA BOTs & scripts
• Reduction in Claims adjustments (Rework) from 12% to 9%
• Provider Survey on CSAT improved from 89% to 96%
• Achieved 100% compliance with SLA Targets on Financial, Procedural and Payment metrics
• All BOTs built uploaded in “Bot Library” for easy of adoption by entire Healthcare BU at Cognizant
• Same BOTs already replicated for new businesses

In Addition, the following levers were also implemented to improve the overall efficiency and customer experience -

1) Robotics Process Automation (RPA) using UI PATH

• Identified claims that cannot be processed using systemic Auto Adjudication
• Built a total of 150 BOTs processing claims day 1 & rework claims end to end using RPA solution from UI Path

2) Predictive Process Modelling (Random Forrest technique)

• Analyzed data of claims paid late with Interest penalty
• Derived the propensity of higher Interest penalty by claim types using analyzed historical data
• Designed SQL scripts which would trigger the new platform to pend high interest propensity claims for manual adjudication.

3) Citizen Developer Program

• Institutionalized a framework of training & certifying employees to build employee assisted BOTs
• Completed Training & Certification of 214 employees to build such BOTs
• 838 employees trained & certified to use such BOTs

4) HMS Eliza’s & Single user Interface for Contact Center & Automated Outbound calling

• Identified list of systems and applications used by contact center CSRs while troubleshooting Provider enquiries
• Worked with the Engineering teams to develop a Single User Interface (SUI) that takes feed from other (most)applications used by CSRs
• Designed & deployed Automated Outbound calling using HMS ELIZA for welcome calls of newly enrolled members

Replication & Reuse of Solutions

• All BOTs built have been uploaded in “Bot Library” (KM portal) for easy replication
• Solution with Predictive modeling of claim arrival patterns highlighting payment accuracy propensity showcased & shared across the enterprise
• HMS Eliza User interface has been evaluated by other healthcare engagements at Cognizant DBO