Case Study: Healthcare

Deploying clinical process outsourcing to drive down medical costs

for large health insurance plan

Overview

This large health insurance plan was looking for a solution that helped in controlling member medical costs. The Sagility Case Management Program helped to drive down medical costs and increase case management referrals.

48% Increased case management
referrals over 3 years

Client background

The client is one of the world’s largest healthcare payers. The client works closely with brokers and consultants to develop innovative programs; help individuals and families improve their health, well-being, and sense of security; and lower their medical costs.

Business challenge

The client’s members were incurring significant medical costs based on conditions that required long-term medical care. They approached Sagility about controlling member medical costs through clinical process outsourcing.

The solution

The Sagility Case Management Program engages customers who are incurring significant medical costs based on either a chronic condition or a condition that requires long-term medical care.

Improving population health while reducing costs

The solution aimed to drive two key client and member outcomes: improving population health and reducing costs. Five hundred nurses (140 of whom are U.S.-certified) engaged with members/patients to educate them about case management. These nurses educated members on how nurse case managers could assist the member/patient on providing alternate methods of treatment. The team members could keep track of patient treatment plans so that additional costs were not incurred. Education was also provided on cost-effective providers.

Providing care assessment and advice to patients

Sagility provided support for neonatal ICU, chemotherapy/radiation, cardiac rehab, and maternity patients. For members, Sagility nurses answered symptoms-related calls on the client’s health information line. These nurses conducted a level of care assessment and advised when or under what circumstances to seek medical attention. Care associates worked with members who had high-dollar claims in the past to minimize future claims. They also offered preventative coaching on how to improve and monitor health, medical services options, and how to ensure productive visits.

Results

Over the past three years, the percentage of members who enrolled in case management steadily increased from 7% in year 1 to 48% in year 3. This significantly reduced the medical costs of the client and their members.

48% Increased case management
referrals over 3 years

Global locations

USA • India • Philippines • Jamaica • Colombia

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