Case Study

Greater efficiency and effectiveness in investigating possible cases of medical billing abuse and fraud nets US$37 million

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Leading U.S. expert in recovering healthcare payments made to providers who have been found to have committed medical billing fraud or abuse


Business need addressed:
Building sufficient process capacity to meet an increased inflow of fraud and abuse cases in need of investigation for potential recovery of funds

Genpact solution
Genpact proposed, designed, and implemented:

  • Software to perform deep research and auto-analysis of provider applications submitted to the client
  • Special database manager that helps users with minimal MS Access experience reduce their dependence on experts without compromising detection accuracy
  • Made value stream map to ID and cut redundant workflow steps end-to-end

Business impact:

  • Case investigation “touch time” reduced 30%
  • Per-month backlog trimmed 43%
  • $1.87 million in savings and improved detection

Business challenge

Each year, more than $100 billion in improper medical payments are made in the US. Much of these outlays involve billing fraud and abuse by healthcare providers, with the federal government reporting that dubious Medicare and Medicaid claims account for half the money lost. These numbers will only grow in the decades ahead as the Affordable Healthcare Act mandates that tens of millions of currently uninsured Americans (and many of the larger companies that employ them) obtain the expanded coverage needed to comply with the legislation.

This changing industry and regulatory landscape present a great challenge and a tremendous opportunity for businesses that specialize in recovering illegitimate payments. Once such leading company asked Genpact to help it better manage recent increases in work inflow. The client needed to more quickly, efficiently, and effectively calculate the likelihood of inappropriate conduct by a provider. Doing so would provide “proof of concept” that the company could expand its capacity to identify and investigate more suspects without having to add more Subject Matter Experts (SMEs) to its staff. Complex investigational procedures—including manifold research and data-analysis steps on multiple applications—had produced a huge case backlog. These holdups were in turn leading to delays in payment recovery and, in some cases, causing recovery opportunities to be overlooked entirely.

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Genpact approach

Using analytics, technology, and Lean Six Sigma methodology, Genpact proposed, designed, and implemented a solution that relied on Microsoft Visual Basic Applications, Excel, Access, Structured Query Language, and Visual Basic Scripting. Genpact also used existing client applications to do deep research and auto-analysis to investigate the provider selected for initial process testing. Other IT tools created enabled even the most novice users of MS Access manage their case database with drastically improved accuracy and with appreciably reduced dependency on the SMEs they had heavily relied upon in the past. Finally, Genpact used a series of brainstorming sessions to foster a bias for adaptability and innovation. Those efforts ultimately produced an end-to-end value stream map that identified redundant process steps across workflows, both offshore and on.

Business impact delivered

Diminished dependency on SMEs-along with the implementation of Genpact’s proposed IT automations—cut investigator “touch time” per case from 465 minutes to 325 minutes, an impressive 30% reduction. The backlog of cases per month, meanwhile, was trimmed by 43%. These changes, along with a host of others, had a nearly $2 million efficiency and effectiveness impact on the provider that had been initially tested, and a broader projected impact on the client’s Profit and Loss picture of $37 million annually.

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