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

Silverskills solution:

Silverskills 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 up to 40%
• Improvement in process productivity by 30%
• Reduction in turnaround time by 70% using “follow-the-sun” approach and Silverskills’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 Silverskills 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