success story

Major dental insurance company reinvents grievance resolution

Modern platform speeds dispute resolution and eases A&G workload

The U.S.-based dental benefits payer faced a troubling irony: Its outdated complaint-resolution system generated too many complaints.

The management and payment of millions of dental claims to members, along with providing timely support to providers, is a complex undertaking for the company, which operates in both the public and private sectors. As a result, disputes are inevitable, which must be resolved through the company’s appeals and grievances (A&G) process. However, over time, this process has been plagued by manual processes, outdated technologies, and inadequate reporting posing a significant threat to its revenue and reputation.

Delays and inaccuracies have led to an A&G backlog, resulting in negative consequences for the payer, the membership, and the service providers. To address this issue, the company partnered with Virtusa to comprehensively overhaul the A&G system. This initiative helped expedite dispute resolution and strengthened the company’s business prospects.

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The Challenge

Backlog of unresolved disputes threatened business outcomes

A massive backlog of unresolved complaints threatened the dental insurance company’s revenue, reputation, and relationship with its members and providers. However, the company’s legacy grievance-management system was not helping.

Manual processes and a lack of standards made it extremely challenging for the management to resolve the sizable backlog quickly and efficiently. With Virtusa's help, the company tackled a host of challenges that were fueling widespread dissatisfaction with the system, including:

  • Inadequacies in case assignment, management, and SLA tracking
  • Error-prone, labor-intensive A&G methodologies
  • Weak reporting, traceability, and trend analysis 
  • Manual processes in outbound correspondence
  • Delays and inaccuracies in case resolutions
  • CMS regulatory compliance issues
The Solution

A&G platform transforms dispute resolution processes

Virtusa and the dental insurance company implemented a comprehensive solution that transformed the A&G processes across multiple lines of business — Medicare, Medicaid, and commercial. 

A&G operations moved to a new platform enabling legacy operations modernized and integrate with all other enterprise applications. Virtusa’s solution:

  • Created intent-driven case workflows and managed cases through a regulatory SLA perspective.
  • Unified all intake channels, including the website hosted in Pega.
  • Skill-based auto-routing of cases using automatic alerts and escalation workflows for managers.
  • Fully automated outbound correspondences via email and mail which integrate with 3rd party print vendors.
  • Integrated with enterprise apps for data consumption and sharing. 
  • Improved reporting with interactive dashboards to help users visualize real-time inventory status and team management.
Major Dental Insurance Company Reinvents Grievance
The Benefit

Faster clearance and lighter workload for case managers

Virtusa’s comprehensive solution addressed the delays and inaccuracies in the company’s A&G processes, clearing the way to work through the case backlog and enabling significant savings.

A snapshot of the transformation drove value by:

The company has approximately saved $9.5Mn in savings (withing 1.5 years of transformation)

A&G department’s case assignment and workload management increased productivity by 33%

Per task routing handle time decreased average from 12 to 5 mins.

Upgrading reporting functions, resulting in the delivery of more useful insights on resource efficiency and regulatory compliance.

Automating case classifications by using a business algorithm to show case data in a standard viewing format, reducing turnaround times and limiting manual errors.

Automating letters and notifications to members and providers by decreasing a 14-day average turnaround time to 1 day

Regulating user roles and access groups to boost security.

Learn how to simplify your appeals and grievances (A&G) processing

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