Our client is a FORTUNE 500 company with headquarters in Tampa, Florida. They provide managed care services for government-sponsored health care programs: Medicaid, Medicare and Medicare PDPs. The client was using manual processes for claims routing and was suffering from issues with manual work load assignment and constant misrouting of claims.
They set off on their journey to automate their claims application, with Virtusa as their partner of choice and trying to sunset their in-house legacy application.
The client was using excel sheets and manual processes for claims routing and exception work distribution. There were several challenges associated with this limitation
- Poor visibility and tracking of claims holds
- No reconciliation ability
- Inability to implement routing rules
- Issues with manual work assignment, and constant misrouting of the claims
Designed and built claims application, powered by Pega Claims Workstation +.
Key features include
- Consumption of all claims holds from the legacy application, Xcelys
- Ability to manage routing rules, priorities and work assignments
- Deliver automated claims routing to internal resources and vendors
- Provide electronic feeds of claims to appropriate vendors
- 99.8% correct hold reconciliation (Pega/Xcelys)
- Implementation of Real Time claims holds routing
- Reduced interest payments for claims by 10%
- Increased productivity and throughput by +30%
- Improved inventory management by ~2hr/day (20%)
• Improvement in accuracy of claims hold routing by +25%