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Case Study

Improved payment accuracy & relationship with providers for a major health insurance provider

Client Background

The client is a diversified, multi-national FORTUNE® 50 major health insurance provider in US, providing various health insurance plans under Medicaid, Medicare and commercial line of business.

Client Need

  • As a corporation which has multiple payers in the same region, the customer wanted to integrate plans, members and health plans pricing arrangements of same region into a single system
  • To achieve this, there was a need to integrate entire region data from one payer to another payer. The customer wanted to integrate below modules such as enrollment, provider, authorization, lab claims
  • Client wanted to review the provider contract to identify the compensation terms based on the LOB like Medicare, Medicaid, Commercial etc. and assign the Pay class that needed to be configured in the Amisys /DST
  • Client needed an accurate reimbursement configuration to be done in pricing system which would pay accurately to providers

Our Solution

  • Reviewed provider contracts to identify the compensation schedule terms based on the LOB like Medicare, Medicaid, Commercial etc
  • Identified reimbursement terms Standard versus Custom and key terms on the provider specialty
  • Assigned the payclass guide based on the reimbursement methodology and provider specialty ( Physician, Ancillary, Hospice, Home Health, Ambulatory etc.)
  • Created Change Requests in service now to make sure the configurations are being done as per the contract

Tools & Technologies

IBM Datastage, Sybase, Greenplum Database, Atomic, Emptories, Ambulatory

Key Benefits

  • Pricing configurations are being done as per the provider contract reimbursement terms
  • Health plan would be able to accommodate/ pay accurately to their providers
  • Improved payment accuracy & relationship with providers
  • Helped them to ensure a healthy network of providers
  • Improved member satisfaction
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