success story

Leading healthcare payer improves provider directory accuracy with Virtusa's unified PLM platform

Provider directory inaccuracy has been a common issue for healthcare payers. The third-largest for-profit American health insurance company and one of the top 60 Fortune 500 companies,faced painstaking issues with conflicting provider data. The client required a dynamic solution that could automate its roster file management process and increase provider data accuracy. To succeed in this initiative, the payer required a comprehensive and robust solution that could help automate data mapping, validation and verification of roster records and create a more accurate provider directory.

In partnership with Virtusa, the $50 billion global healthcare client experienced a unified provider lifecycle management robotics solution that managed end-to-end provider onboarding process, take more informed decisions, reduce operational inefficiencies, and improve the quality of data.



The Challenge

An Optimum Data Management Strategy

A large percentage of provider data updates (Rosters) was received in the form of excel spreadsheets from Providers (Delegated and Non-Delegated, 3rd Party vendors, States). The rosters had multiple formats and required a lot of manual effort to review and identify the intent of the request, validate if the request had all the required information, verify the request against multiple sources of truth (Internal & External) and make a final decision to process the request.

Hence, there was a need to have a solution that can take the information coming in from different formats of the roster, convert the data into a standard format and compare it to the systems to determine if work was actually needed to reduce manual time spent looking up each provider and performing a demographic audit compared to what is available in the roster.

In the current state, the client took 60-65 hours to verify roster data in the system for about 500 provider records. Thus, the manual update was ineffective, time consuming, error prone and expensive. The client realized the need for an integrated solution that could utilize the information received from the roster and analyze its authenticity, perform a demographic audit, and avoid manual intervention wherever possible.

The Solution

A streamlined process on provider update work that was fast, automated, accurate and cost effective.

Add agility to remove complexity

It didn't take long for the client to join forces with Virtusa and transform the provider operations platform with an efficient, scalable solution. Broadly, the client required three main issues to be addressed in the future state:

  • Experience streamlined data management from a single point of intake for provider data for all provider data updates (Rosters, Provider Portal, Public Web Portal, Email, Phone, Fax and In-Person)
  • Reduction of manual intervention with development of a Smart Rules & Decisioning Engine (Roster File Processing & Bulk Provider Maintenance)
  • Reporting and audit capabilities to provide transparency and visibility to the external and internal stakeholders

  Leveraging Pega systems' leading enterprise platform capabilities, the client addressed the various challenges Payers face in Prospecting, Contracting, Credentialing, and Pricing Configuration for Providers. Our deep-expertise based solution streamlined operations across the provider lifecycle thereby ensuring increased Payers satisfaction, improved efficiency and reduced onboarding time.

Virtusa's automated solution for the client's Roster File Processing enabled a futuristic end-to-end automation of their Provide Life Cycle Management (PLM).

This effectively covered the multiple dynamics of provider data management and enabled efficient and intelligent workflow management to meet the business objectives.

The Solution
The Benefit

Unified lifecycle management capabilities to simplify provider relationships

  • 90% reduction in lead time through automated workflows and reduced manual intervention
  • 40% boost in throughput with automated processes, reduced redundant checks and near zero paperwork
  • Significant costs savings to the tune of $10 million with staffing productivity, resource optimization, and operational efficiencies
  • Improved provider engagement with interactive dashboards, visible workflows and faster response timrs
  • Agile orchestrated architecture that ensures high data fidelity to meet fast-emerging compliance and legal disruptions
The makeover with the right technology

As payers continue to invent new and better business processes to expand their reach to providers, automated and digitized PLM solution will be the need for clients to create traceable, risk-free and accurate services for their customers.

Unified Lifecycle Management Capability to Simplify Provider Relationships

A versatile solution for accurate data, reduced cost, faster time-to-market, and end-to-end on-boarding process.

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