Facing multiple challenges in processing large volumes of claims, a leading home healthcare third-party administrator looked to Chenoa to help them through an enterprise-wide transformation. Our team helped increase claims processing speed by 95%, increased throughput while maintaining 90% accuracy while decreasing costs. Together, these drastically improved overall business operations and created opportunities for new business models.
The Problem
The client was hampered by a legacy system that prevented them from processing large volumes of claims accurately and at a competitive price. We analyzed the existing system with the goal of eliminating manual adjudication of claims and enabling the implementation of multiple complex rules dynamically and accurately. The client wanted a modern, rules-based, automated adjudication application that would scale and enable them to grow their business.
The Approach
The first thing our team zeroed in on was creating a system design optimized for high throughput and fast processing times, especially at the database layer. We utilized in-memory databases to meet our performance needs. The next step was to perform “rules harvesting”, where we mined and extracted business rules from their legacy systems and procedures. With the right design and rules identified, our team delivered a business rules management tool that put business decisions and enabled self-service configuration by the business. This also included a multi-view user interface to ensure that the diverse group of users (customer care agents, business governance, payers, and physicians) were able to take advantage of the new platform.
The Results
Within the first 30 days, the new system reduced the average claims processing from 20 days to less than 24 hours. The volume of claims processing exceeded 50,000 claims per hour at a 90% accuracy rate and dropped the cost per claim to .95 cents. In effect, the automation of their claims adjudication process eliminated the organization’s claims backlog and put them in control of their commitments to the claimants, physicians and payers.