Case Study: Healthcare
Deploying smart automation to re-engineer leading payer’s collections, enrollment, and eligibility
Costs, turnaround times, and manual errors significantly decreased through digital solutions
98% of claims processed in 10 days or less
3 hours average turnaround time, down from 3 daysThe solution
Sagility provides a broad array of claims management and member lifecycle services for this client, including international claims service to process healthcare claims filed abroad by client members. This site processes claims from 90 countries. Sagility has supported a key client objective of a turnaround time service level expectation of processing 98% of claims in 10 days. To ensure this success, Sagility deploys expertise at every stage of the lifecycle. Sagility works with the client’s premium collection and eligibility platform. This claims adjudication system and client/server application is used for the client’s end-to-end operations.
We use this application for all the following functional attributes toward claims adjudication:
- Authorization – Pre-authorizations of medical services
- Claims – Claims adjudication
- EDI Claims – Electronic claims adjudications system
- Letters – Correspondence system to send letters for members and providers
- Benefits – Plan benefits coding and updates
- Members – Subscriber master database
- Premium – Premium records and database
- Pricing – Pricing logic and contracts
- Providers – Provider master database
- Reports – In-built reporting system
- Security – Security systems for personal health identification (PHI) / national provider identifier (NPI)
- Support – Customer support
- Systems – System records and updates
Sagility’s team continues to build on the expanding portfolio of solutions built for the client, with intelligent automation and analytics solutions identified for the client’s premium collections, member enrollment, and eligibility groups.
Premium collections
Sagility developed a solution with process re-engineering to maximize outcomes for 70% process automation, for a potential savings of $650,000. The bot conducts premium cash posting of appropriate remittances received, as well as posting of fallouts, 5500 tax processing, and premium reconciliation.
Member enrollment
Sagility is currently testing for this 50% automated process solution, with a potential savings of $500,000. The Sagility bot automates enrollment for new members with bulk form submission.
Eligibility
Sagility is currently designing a solution targeting an automation outcome 50% or higher, for potential savings of $500,000. This automation increases efficiency for the automated eligibility and benefits administration process, including focus areas of enrollment, termination, reinstatement, additions, and changes.
Reporting dashboard
Additionally, Sagility’s bot creates a reporting dashboard to track incoming cash, postings, and fallouts on eligibilities, with extensive enrollments tracking. This is a value-added consultative service, as the client uses these insights today to ensure operational efficiencies and refocus their financial forecast.
Results
With all three processes in various states of launch, Sagility estimates up to 50% cost reduction in EDI member enrollment and member eligibility and up to 50% cost reduction in premium collections. Additional benefits will include decreased turnaround time and decreased manual error. We have already delivered labor savings of approximately 60%, reducing staff from 25 to 10 team members. Additionally, we have significantly reduced TAT from 3.5 days to only three hours, a 96% reduction.
Cost reduction in member enrollment premium payment and member eligibility:
50% projected
Cost reduction in electronic data interchange (EDI), manual eligibility
50% estimated
Smart automation innovation:
96% reduction in TAT
Healthcare LLC, doing business as Sagility™). All rights reserved.
