
Turning business vision into real value styles-h2 text-white
Turning business vision into real value
A large payer client tried for nearly two years to modernize a legacy claims system to improve user experience and stakeholder relations. The executive team had identified specific target metrics, including a 2% increase in the auto-adjudication rate, a 10% increase in operational efficiency and a 15% reduction in total cost of ownership for IT operations. While these objectives were clear, development and operations teams faced competing deadlines. Most decisions about which activities to prioritize were also ad hoc rather than aligned with the project business case and program roadmap.
Our team measured the legacy system performance to provide clear evidence to the client teams of the gaps between the current state and management’s targets. Then, we collaborated with the client teams about how to achieve those targets. It was critical to coordinate dependencies across workstreams, as each affected a different aspect of the healthcare claim lifecycle.
For example, in the current state, the intake team was responsible only for the initial security and structural edits for claims transactions. In the future state, the intake team was responsible for additional checks to prevent bad claims from entering the core adjudication system. This required the intake team to work closely with product, member and provider workstreams to ensure they had the right data available to do all edit checks at the point of intake. The BVR team helped facilitate this collaboration and ensured that all dependencies were identified and addressed.
A large national payer client shifted a set of development work to a captive/internal group, expecting to realize substantial cost savings. However, executives did not consider the impact of this shift on quality or account for the time required to enable new teams to deliver with the same velocity. The external vendor teams were delivering story points in three weeks or less. The new captive teams, spread over several time zones and still coming up to speed, could not match that performance. The BVR dashboards that our team developed clearly captured this disparity. When senior executives questioned why the cost savings were below projections, the operations manager was armed with data clearly depicting where the issues were and how to mitigate them efficiently.
Another important feature of BVR is continually reviewing data to reveal additional project-related opportunities to generate value. One of our durable medical equipment clients used its revenue cycle management solution to perform denials management. The metrics showed that denials were continuing to rise. On investigation, our team realized the client was not using all the data generated by the system to understand the root causes of denied claims. For example, the team identified that when a specific field was skipped on the form, a denial was triggered. As a mitigation, the team made the field mandatory, leading to substantially decreased denials, increased cash flow and reduced costs.
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