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Case Study

Reduced administrative cost for a leading health payer in the US by 10% to 15%

Client Background

The client is a leading health payer based out of the US. They were using a legacy system (Mainframe) for MA, MAPD & PDP administrative operations, and needed help in migrating the applications to a web-based platform in order to reduce existing manual operations.

Client Need

  • To migrate existing legacy system for Medicare advantage enrollments and billing operations
  • To reduce manual interventions for multiple operations for enrollments, membership and billing
  • System to accept claims from multiple trading partners, generate responses for all requests, accumulators, adjudication of claims and submitting EOB/Remittance advice
  • Need an integrated workflow system to handle errors and user requests from enrollment, billing and claim modules

Our Solution

  • Developed a rule based online channel and premium billing solution for MA, MAPD & PDP plans
  • Suggested and built solutions to identify delinquent members, cash transfers and refunds
  • Increased the resolution rate for BEQ Request and Response process by configuring rules for Election period and Effective date determination. Manual intervention was eliminated for 18 TRC’s under DTRR file processing
  • Built a claim system to accepts, adjudicate and send remittance advices for EDI 837P, I and D electronic claims
  • Streamlined the business operations by developing an integrated workflow portal

Tools & Technologies

Microsoft SQL Server, Bootstrap, Angular JS, Microsoft ASP .Net MVC4, jQuery, Microsoft SQL Server Integration Services

Key Benefits

  • Moving from legacy solution to a web-based solution reduced the administrative costs to 10% to 15%
  • Configurable rule engine helped in reducing overall rule exceptions from 14% to 4%, reduced application down time by 95% and increased application availability
  • Automation of TRC’s helped reduce manual intervention and saved on an average 10k man hours in a reporting year
  • Automated workflow assignment system helped in streamline the flow, identifying the aged tickets and improved business operations efficiency
Case Study KeyPoints

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