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ENABLED IT TRANSFORMATION WHILE ACHIEVING 90% IMPROVEMENT IN PROCESS EFFICIENCY FOR A HEALTH PLAN PROVIDER

THE CLIENT

 

A non-profit health plan provider serving members in Massachusetts offers a range of health care plans in the commercial, Medicaid, and Medicare markets.

BUSINESS CHALLENGES

The essential element in value-based health care is payer-provider payments. The client's aim was to transform its claims and enrollment processing system.

  • To improve operational efficiency, reduced claims processing costs, minimize manual intervention for claims re-work/adjudications, and enhance customer's experience.
  • Minimize the built-in complexity of current systems and improve the flexibility of the claims and other processing systems.
  • Consolidate multiple vendor landscapes to a single vendor while seamlessly abridging application interdependencies for defining rules for the various processes to bring together up-to-date regulatory and compliant data for claims and pricing and editing.

 

SOLUTION

 

The client engaged Mphasis to help them with their business and IT transformation journey, and over the years, this partnership has accelerated the experience for their teams and end customers. To begin with, Mphasis did the gap analysis of the processes to enhance IT and business operations while ensuring security and compliance.:

  • Implemented cloud-based SaaS payment solution and enabled end-to-end configuration for Price EAPG (Enhanced Ambulatory Patient Groupings), Medicare Advantage, Commercial, and MHI.
  • Integrated new single vendor payment integrity solution to validate claim processing while eliminating the dependency on other vendors.
  • Automated client's enrollment hub.
  • Implemented agile and other functionalities to expand trading partners' ecosystem.
  • Automated claims process and created claims auditing with RPA to calculate a claim’s eligibility instantly and retrieve the transaction history in seconds for auditing.
  • Implemented Talend ESB version7.3 Design to allow faster response to business requests.
  • Provided QA Transformation to continuously infuse quality beyond SDLC and enable collaboration and integration, including Quality Intelligence.
  • Implemented Identity Access Management (IAM) & Compliance bolster regulatory compliance, increase productivity with centralized provisioning & access.

BUSINESS BENEFITS

Our innovative implementations delivered the following outcomes:

15k+ claims repriced in less than an hour

Achieved 90% improvement in process efficiency while enabling flexibility for plan configuration and pricing edits

Implemented Enrollment HUB Automation process for small trading partners who are sending enrollment details through excel formats, which led to an over 85% reduction in manual tasks

Enabled a needed layer of flexibility for claims processing

Provided a robust enrollment hub to include 60 trading partners as compared to 16 partners earlier

Automated 70% testing process by using automation tools and process

Automated client's onboarding process by introducing RBAC (Role-Based Access Control) model to reduced paper work