A leading US healthcare payer enhanced its provider outreach with 18.4% improvement in letter accuracy and 20% decrease in turnaround time in sending letters, leading to savings of USD 254K

Client Background

The client is one of the largest healthcare payers catering to about 68 million individuals in the United States. Ranked among the top Fortune 500 US companies, it offers a broad spectrum of products and services. 

Industry Landscape

The total US healthcare expenditure is expected to soar to $3.78 trillion by 2018. The industry incurs additional cost due to inaccurately processed claims, which in turn affects the overall cost of healthcare policies. The need of the hour is to reduce the additional cost incurred by healthcare companies because of increased re-work, interest expense and overall turnaround time.

Opportunity

It was crucial for the client to provide flawless information to healthcare providers describing the decision taken on claim adjustments and indicating the need for any additional information. This was carried out through letters, which did not follow any standard format and contained free form text. As a result, provider comprehension was significantly affected and led to clarification calls to the customer service team, which increased the call volume and provider dissatisfaction. The major challenge was inconsistency in responses across the claims process due to manual intervention for drafting letters, which was further affected by selection of wrong letter formats and interpretation issues.

Solution

Wipro changed the client’s traditional way of communicating with providers with advanced process restructuring and automation. Wipro had been partnering with the client to help manage its shared services domain in IT and back office operations.

Solution highlights:

•  Detailed study of process maps to identify opportunities for automation was conducted
•  Assist Bot, which automatically determines the correct standard letter to be sent based on the scenario, was deployed
•  Governance model was deployed for the usage and maintenance of the Bot
•  The list of standard letters was enhanced by including new scenarios. Post successful pilot, Bots were deployed across locations
•  Near real-time custom reports were enabled to monitor defects by location and individual

Business Impact

Deployment of effective solutions resulted in flawless execution of provider outreach practice, leading to reduction in error and re-work. Also, a standard communication procedure was established.

•  Letter accuracy improved to 99% against baseline performance of 80.6%
•  USD 254K benefit due to reduction in rework
•  Turnaround time reduced by about 20% from 88 to 60 seconds
•  Improved provider satisfaction