Case Study

Leading healthcare services provider enhances member satisfaction, boosts compliance, and reduces costs with Lean DigitalSM

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Client:
A leading US-based integrated pharmacy benefits manager (PBM) and health care services provider

Industry:
Healthcare

Business need addressed:

  • Long wait times for policy enhancement and claims processing resulted in higher customer query volumes and member dissatisfaction
  • Delays in regulatory reporting exposed the organization to compliance risks and penalties
  • Existing technology infrastructure required a high degree of manual intervention and consumed vital resources from other subsystems and processes

Genpact solution:
Using Lean DigitalSM principles, the PBM transformed claims query and reporting process to eliminate redundancies, and deployed a custom utility to perform data validation

Business impact:

  • Improved business agility as the availability of data now allows the PBM to generate insights, respond to changes in market, and introduce innovative products and new services faster
  • 86% reduction in claims processing time (from 36 hours to 5 hours), leading to enhanced user experience, growth, and compliance
  • $13.86 million of savings every year through efficient utilization of technology infrastructure and support resources

A leading US healthcare PBM was facing low customer satisfaction, stagnant growth, and increasing costs due to a claims processing and reporting process that relied on legacy technology and processes. Targeted technology interventions and process redesign helped reduce claims processing time by 86% and generate $14 million in annual business impact, in addition to boosting compliance, customer satisfaction, and growth.

Business challenge

In an increasingly dynamic market, healthcare plans face growing demands on compliance and reporting, as well as increased competition, rising input costs, and greater consumer choice in health coverage and care decisions. In response, organizations have continued to invest in technology, yet a proliferation of legacy processes and technology has trapped many of them into merely maintaining the requirements of technology rather than enabling urgent operation transformation. As a result, most of the investments directed at the front-end, without reimagining how middle- and back-office processes are run, lead to suboptimal returns and wasted opportunity in unmet business and customer expectations.

Claims processes generated large volumes of data, but relied on outdated query tools and logic, causing longer wait times for policy enhancements and claims processing, leading to higher number of customer queries and increased member dissatisfaction

This PBM faced similar challenges. Critical business processes required daily feeds of accurate member, policy, and claims data. The data also needed to be fed into multiple downstream systems, vendors, and regulatory authorities. Massive volumes of data to be queried with outdated tools and query logic significantly delayed the availability of data to dependent processes. This led to long wait times in cases of policy enhancement and claims processing, causing higher call volumes and inquiries for the contact center as well as increased member dissatisfaction. Due to the delay, the PBM also struggled to meet the mandated one-day window for regulatory reporting, leading to compliance issues. Delays in providing participant data to downstream vendors and federal bodies exposed the organization to a possible risk of litigation/ damage claims, which would have been highly detrimental to the bottom line and reputation of the company. The underlying systems also required greater manual intervention and support from administrators and consumed vital resources from other subsystems/processes.

Genpact solution

The PBM had invested in the latest database technology, which has advanced capabilities, yet the incumbent claims system relied on an outdated database query logic that was causing long execution times and placed inordinate load on the technology infrastructure and support resources. The existing business logic was complex with many redundant steps. The organization’s IT teams were also not fully aware of the system’s capabilities.

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Genpact’s technology and process experts worked with the PBM’s IT team to use the advanced capabilities of the current database version that allowed querying of the data in a more time- and resource-efficient way while operating on existing storage and processing infrastructure, thus optimizing technology investments without resorting to a “rip-and-replace” intervention. The team redesigned the process to eliminate redundant steps and deployed a utility that then validated the data according to the business logic.

A Lean DigitalSMapproach helped identify the source of value, make focused use of technology for maximum impact, and leverage existing technology infrastructure optimally to avoid disruption and generate impact faster

This enabled a stable and robust system that delivered high processing speeds (~99.5% improvement), low systems usage (~99% reduction), reduced cycle time (36 hours to 5 hours), and adequate storage space availability (~99.9% reduction) for running other critical processes. Customers now have real-time access to data, boosting customer satisfaction and reducing the volume of customer queries, resulting in lower costs and higher growth. Federal agencies and downstream systems receive the data within the mandated time period, boosting compliance and business agility.

With data now available instantly, the organization transformed their legacy claims processes to implement a cashless claims process for end users in case of new inclusions and policy enhancements. This further eliminated paperwork, and enabled a superior customer experience across all touch points in claims processing, while reducing costs and enhancing compliance.

Business impact

  • 86% reduction in claims processing time (from 36 hours to 5 hours), leading to enhanced user experience, growth, and compliance
  • $13.86 million of savings every year through efficient utilization oftechnology infrastructure and support resources
  • Improved business agility as the availability of data now allows the PBM to generate insights, respond to changes in market, and introduce innovative products and new services faster

For more information, contact, healthcare.solutions@genpact.com and visit, genpact.com/what-we-do/industries/healthcare-payer

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