By partnering with Patni, a leading TPA in Health Care Insurance services gained the capability of effectively handling huge volumes of claims with high levels of accuracy
The Client
The client is one of the leading third party administrators of insurance products with assets in excess of $1.3 billion.
The Challenge
With the US government introducing the Healthcare Modernization Act, the healthcare market was set for a complete overhaul. The Act mandated a number of changes including creating a new Medicare Part D prescription drug plan (PDP) providing benefits to senior citizens by subsidizing access to drug coverage. As the policy was extremely attractive to senior citizens, a huge volume of claims was expected to be filed within a short span of time.
To ease the administrative burden of handling these claims, the Center for Medicare & Medicaid Services (CMS) outsourced the requirements of handling these claims to a third party administrator (TPA). While the opportunities were huge, the challenges were unique. As the provision was introduced for the first time in the country, the TPA was unsure on the kind of volumes that would be generated. As the exercise was a time bound activity, the TPA required rapid up-scaling and down-scaling capabilities for managing the fluctuations that were expected in handling claims. This created a challenging situation for the TPA as the process was expected to be completed within a short period with high levels of quality. Further, as these claims contained personal health information of patients, HIPAA compliance was to be followed at every stage of the process.
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The Solution
To effectively handle fluctuating demand and huge volume of claims with high levels of quality, the client decided to partner with Patni. As the process called for deep understanding of the healthcare domain, Patni organized a team of qualified professionals who had prior experience with leading service providers in the industry including TPAs, Underwriters, Pre-Adjudicators, Adjudicators and Claims processors.
In the steady state, Patni performs the following activities independently:
Patni transitioned the process using a well-defined transition methodology based on the Six Sigma framework, ensuring that the processes were fully understood, defined, mapped and implemented as per the requirements. As the enrollment process for the newly introduced PDP was complicated and needed to subscribe to stringent guidelines at every stage of the transition, a structured tollgate review with the client was carried out to ensure that the process was migrated seamlessly. This was done by a transition team comprising of a dedicated process and transition manager.
Post migration, the workflow was designed and further refined to scan the form for Medicare Part D Claims. Further, a customized front-end tool was developed which was used for capturing, validating and comparing data. In case of exceptions, Patni was also involved in checking the CMS database for checking the eligibility of the applicants. Currently, Patni is involved in end-to-end management of the entire process and handles activities which include imaging the enrolment forms, helping members picking the plan based on their eligibility and subsidy levels and doing a data validation of the member's data with the CMS data.
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The Benefits
By partnering with Patni, the client gained the capability to service the claims with high levels of quality. Other benefits include:
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Increased efficiency and effectiveness in service levels due to significant increase in accuracy and turnaround time |
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Significant cost reduction and process optimization. |
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