Healthcare Claims Operations
Generating Healthcare Impact
The healthcare payer industry is faced with the challenge of reducing the cost of operations while improving the customer experience and simultaneously negotiating changing regulations and customer preferences.
Genpact helps healthcare payers design, transform, and run end-to-end claims operations to achieve greater efficiency in back- and front-office operations, while reducing the administrative cost of claims and claims leakage and improving provider and member satisfaction.
- Consulting and transformation solutions for risk mitigation, database solutioning, value stream mapping, IT transformation, and Smart Enterprise Processes (SEPSM) diagnostics assessment
- Process solutions for claims submissions and setup, adjudication and adjustments to enable determination of pre-benefit edits, pricing/benefit edits payment obligations, exception management, and payment integrity and review
- Analytics solutions such as operational analytics, overpayment analysis, predictive fraud modeling, and call center analytics
- Technology solutions including automation robots, claims testing, and migration services
Our solutions can be implemented through a virtual captive operating model consisting of on-shore and off-shore resources that will be responsible for all core administrative processes as well as related upstream processes. Genpact is the exclusive business process services partner for NASCO, a leading provider of healthcare solutions. The partnership will help Blue Cross® and Blue Shield® companies optimize business operations with an end-to-end shared services model combining NASCO’s technology platform with Genpact’s Lean DigitalSM approach.
Our SEPSM proprietary framework helps healthcare organizations reimagine claims operations by integrating effective Systems of EngagementTM, core IT, and Data-to-Action AnalyticsSM to realize tangible business outcomes such as reductions in the administrative cost of claims, claims leakage due to over-payments, and call volumes, while improving customer satisfaction scores, compliance with statutory benefit regulations, and the operational first-pass rate.
A leading U.S. pharmacy benefit manager saved more than US$400 million by improving claims processing and customer service efficiency through process streamlining and optimization across multiple U.S. locations
A diversified managed healthcare company achieved 90% acceleration in claims processing, 98% accuracy in clinical reviews, and an overall business impact of US$160 million in the first year by redesigning end-to-end claims management operations by integrating advanced analytics, delivered globally through an advanced operating model