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Case Study

Improved the enrollment process a leading health payer based out of US and removed duplicate applications for thereby reducing the inventory by 2-5%.

Client Background

The Client is a leading health payer based out of US. Client was using the legacy systems for on-exchange and off-exchange enrolments. Client wanted to modernize their existing systems to process applications from various channels including CMS, online sales, paper based, from agents and private exchanges.

Client Need

  • Build an enrollment system to accept and validate large volumes of applications
  • Assign an incoming enrollment application to existing members based on their availability and generate new member IDs
  • Validate large volume of enrollment applications at the rate of 10k per hour during the open enrollment period
  • Integrate with third party applications to generate policy fulfillment kits and improve the ID card generation rate to speed up the process

Our Solution

  • Built a pre-enrollment orchestration process to identify incoming application type and removes duplicates from processing
  • Implemented multithreading in Windows services to process large volumes of CMS applications
  • Implemented a member match logic with 5 sets of rules and a logic to accommodate U65 and O65 data in member match and member ID generation
  • Built a configurable business rule engine with 120+ member eligibility and application data validation rules from Federal, State and Payer sources
  • Implemented asynchronous communication to increase the application performance
  • Enhanced existing integrations with third-party systems (Silver pop, RR Donnelley, Fiserv, etc.) from a service call to FTP through IBM Content collector

Tools & Technologies entity framework, Angular JS, jquery, ASP.Net MVC4, Bootstrap, IBM DB2, Java, Microsoft SQL Server, SQL Server Integration Services

Key Benefits

  • Improved the enrollment process and removed duplicate applications, thereby reducing the inventory by 2-5%
  • Handled large volumes of applications without any issues and processed 10k applications in 1 min 30 sec
  • Reduction in match exception inventory from 15% to 3%
  • Reduced manual effort from 21 man-days to 4 man-days
  • Configurable business rule engine helped in reducing overall rule exceptions from 14% to 4%
  • Improved enrollment application processing speed from 6K to 18K in an hour
  • Increased fulfillment kit generation rate by 15%
  • Improved ID card generation rate from 80k per hour to 320k per hour
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