As government organizations continue to deal with budget cuts, IT solutions can often save money while improving efficiencies and productivity. Automation of manual processes can deliver real results, quickly.
The automation of case management processes in the healthcare field is an example of this, as dealing with manual processes leads to many problems with visibility and control. Successes from the corporate world in this area translate easily to the government arena, particularly for large enterprise organizations where security, agility, and the ability to serve a significant constituent base are imperative.
For example, Touchstone Health, a $200M Health Plan/Insurance provider that is currently serving approximately 20,000 members, chose dynamic BPM to automate their Appeals and Grievance (A&G) process. Founded in 1998, this HMO works with Medicare, and operates primarily in the NYC area. By law, members of health insurance providers (e.g. HMO, PPO and Medical Savings Account plans) have the right to appeal any decision made by the provider. For example, if Medicare does not pay for an item or service that has been given, or if an item or service thought necessary is denied, members may appeal. Members may also submit grievances expressing dissatisfaction with any aspect of the operations, activities or behavior of a Medicare health plan, or its providers, regardless of whether remedial action is requested. Providers who do not strictly follow the laws involving A&G’s are subject to regulatory fines. In 2007, United Healthcare paid $12 Million to 36 states for improperly processing Appeals and Grievances. In 2009, Arizona regulators fined another health provider, Health Net, $236,500. On average, providers allocate $2.50 per member per month to process A&G’s. Annual costs for a company such as Touchstone can easily reach as much as $600,000, which was one of the reasons the company decided they needed to automate.
Touchstone faced a huge challenge when it came to their A&G process, as they were managing 1,500 A&G cases per month through a largely manual case management process. In addition, regulatory compliance requirements called for timely and auditable records to be provided to avoid potential fines. The primary users, the A&G case managers, were dealing with a highly manual process that required data gathering from multiple systems and departments. They had to manually reconcile all reporting, and manually generate and track the required correspondence and deadlines. Additionally, the case managers often lost visibility and control when assigning cases throughout the organization. The need for case management automation is also commonly found in the government arena – it’s imperative to have a system that can easily and efficiently help organizations to serve their mission.
Touchstone Health adopted a new Adaptive Case Management (ACM) approach that greatly improved the productivity of the company’s knowledge workers and ensured compliance to regulatory requirements. The ACM approach provided an automated system that ensures all correspondence is automatically sent and meets regulatory timing requirements. The impact that resulted from Touchstone’s A&G process automation was widespread. The automation greatly improved the productivity of the A&G case managers, while ensuring compliance with regulatory requirements. The approach has saved eight hours of manual work weekly on reporting reconciliation alone. Additionally, countless hours are saved on the generation and tracking of correspondence. Now, instead of A&G case managers having to gather data from multiple systems and multiple departments, they only need to learn and access one system for all relevant data and documents.
The automation ensures adherence to CMS regulatory requirements on reporting, auditing and correspondence timelines. It has also reduced the learning curve and skill level needed for processing A&G’s, by consolidating all required systems into a single case management tool (SDS Document Management, Claims Data, Enrollment Data and A&G Data). The automation has improved overall case handling, allowing the case manager to retain control, while tasking others for input.
Prior to automation, when a call came in with a complaint or question from a provider or beneficiary, A&G case managers would have to gather data from multiple systems and multiple departments in order to handle the claim. It was very difficult to keep track of each claim and handle it efficiently and effectively, as everything was done manually.
After the project, cases are much more streamlined and easy to handle. The case manger opens the system to input basic information about the claim. The system then determines where and who the necessary information should come from. The claim can easily be tracked in the system all the way through to completion.
The A&G process automation has greatly improved the experiences of not only the A&G stakeholders, but also the providers and beneficiaries who are contacting Touchstone with a question or complaint. Now, when a call comes in, the A&G case manager opens the one and only system necessary to use, and notes all relevant details of the case. This determines what personnel they need to obtain data from. The automation makes it possible for these assignees, in turn, to sub-delegate the work as well. Keeping everything in one system makes it much easier to train A&G case managers, decreases the number of mistakes, and reduces the skill level needed to complete the job. The automated system dynamically adapts on a case-by-case basis – this provides flexibility, while allowing the case manager to maintain control and visibility.
Touchstone believes the exponential gains in productivity, visibility and reporting achieved by the A&G process automation will set the industry standard for A&G systems. Touchstone plans to sustain competitive advantage by automating more processes, and eventually taking the automation to other companies. Necessary automation such as this ends up meeting the needs of employees, stakeholders and the public, while also meeting the budget. This success would deliver similar savings for a government organization in productivity, visibility and reporting. It’s an approach worth investigating.