Healthcare

Member enrollment, the first step in the Member Servicing cycle, is a critical business process that is often fraught with numerous errors and irregularities, due to paper-based, manual processing. This leads to the process often becoming frustrating for the prospective member, and time consuming and costly for the payer.

Operating in the highly regulated healthcare landscape, it is of utmost importance to Managed Care organizations to manage complaint tracking appropriately. The challenge is to resolve the complaints which have come from the Center for Medicare and Medicaid Services (CMS) in the shortest possible time. Moreover, regulatory infractions may cost healthcare payers huge penalties

Claims Repair – addresses those claims that cannot be handled through auto adjudication process. These claims are “error out” from one of the multiple systems during adjudication process. Any delay in claims disbursement leads to high “Penalty Payout”. Moreover, handling claim exceptions is often staff intensive and characterized by manual processes.

Provider Contract Management process deals with end to end tracking of provider contracts throughout the contract lifecycle from creation, negotiation, approval, to termination. Healthcare payers process tens of thousands of contracts each year. Each provider contract is stored on paper and managed manually making the process of updating contracts, variance analysis, and compliance audits time-consuming and erroneous.

Handling appeals and grievances is a rigorous, time-consuming, and costly process – more so when it is done manually. Further, the process is highly regulated, scrutinized and monitored, with non-compliance leading to huge fines and penalties. All this adds to the pressure faced by payer organizations trying to ensure consistency, quality and timeliness in responding to member requests.

Typically, Healthcare organizations face the challenge of processing large volumes with substantial Turn Around Time (TAT) and highly competitive SLA. Critical quality standards need to be met.

The client is a fully owned subsidiary of a leading IT services company from India and provides Business Process Outsourcing (BPO) services. They offer industry specific BPO services for verticals that include Insurance, Healthcare, Banking, Financial Services, Telecom and Retail. The client was facing various limitations in the area of Operational Control such as productivity constraints, manual process prone to errors, no quality checks, decision making processes etc. The Newgen solution helped in moving business processes online in real time. It has delivered impressive results and provided a unique competitive edge to the BPO

The organization wanted to reengineer and automate the back-office member enrollment operations. It wanted to move from the current error-prone manual processes to a more structured, streamlined and automated processes.

The organization wanted to reengineer and automate the appeals and grievance handling process.

The organization identified that automated Complaint Tracking Management (CTM) has become one of the most important processes for higher customer satisfaction and manifolds benefits.

Healthcare is a core focus area across countries all over the world. Providing and improving healthcare facilities to the population ranks amongst the topmost agenda for Governments.