BPO – HEALTH INSURANCE CLAIMS 

Case Study: Imaging, Document Management and web workflow developed for a workers’  compensation TPA

Background:

Health Shield of New Jersey (HSNJ), a not-for-profit organization headquartered in Newark, is the state's largest health insurer. Health Casualty services an affiliate of HSNJ provides employers with low cost workers' compensation insurance options, including specialized managed care and claims administration (TPA) services and allows New Jersey drivers, through designated insurers, access to specialized auto injury management services and discounted provider rates.

The challenge: 

To increase revenues and realize profits early, Health Casualty Services (HCS) needed to decrease the time they take in adjudicating the bills/claims they receive by automating the adjudication process (i.e. by processing the bills/claims in a batch rather than one at a time). HCS required their outsourcing partner to reengineer the process that would result in achieving the desired efficiency cost effectively.

Our solution:

Our innovative solution involved a combination of onsite and offshore deliverables to keep the entire proposition cost effective. We were retained as their prime contractor to work closely with HCS on all deliverables. Our onsite team included a system architect and a project manager to interact with HCS team in developing the over all schema of the new e-work flow.

Our solution comprised of two distinct phases for the claim adjudication process. The solution required Value Momentum system architects to understand the entire process through extensive dialogue with HCS personnel necessary to design and develop web based application "Web Track" enabling access to key data elements of the service providers "database" over the internet. "Web Track" would have "web bill" for delivering intelligent information and web scan for indexing.

 Phase I. Delivering Intelligent Information (D2I) aimed at converting the static / paper data in-to intelligent information. The process involved HCS to scan the bills and ftp the images to our server in India. Our offshore team in India will look at the image files and enter the required information into pre-defined forms available through WebTrak a web based application while entering this information, The offshore team will also access provider information through WebTrak and apply the same where necessary.

Phase II. Webscan for indexing the service provider database on specific fields in this case - claim number and claimant to facilitate updating the required record in the database. HCS will store all claim information in the database. HCS will scan all the bills and ftp the image files to our server. Our operators in India will look at the image file and get the claim number and the claimant name. These values are then entered in the predefined form in WebTrak and a search is done (on the database) to retrieve the claim information. The relevant claim record from the database is then linked to the image file and the link is stored in the database. Elaborate QA procedure was defined to ensure data integrity through the entire process.

Outcome:

HCS is a satisfied customer reaping the twin benefits of a new process that has enabled them to experience increased productivity at reduced costs by a factor of 4X at the same time reducing the time to revenue from a high of 3 weeks to 1 week. The relationship has expanded in HCS retaining us as their out sourcing partners for an extended period of time.