Our client, a Fortune 500 company, is the largest disability insurance provider in North America and the United Kingdom, offering affordable access to disability, life, accident, critical illness, dental, and vision benefits through the workplace. Benefit solutions include benefits communication, enrollment services, claims support, absence management, and vocational rehabilitation services. Over 182,000 businesses in the U.S and the U.K offer benefits provided by the client, while 1 in every 3 fortune 500 companies offer benefits to their employees, protecting 39 million people worldwide.
The client partnered with Virtusa to streamline case processing and elevate business value across its claims management business.
Effective claims management for larger volumes of policyholders and dependents is critical when providing employee benefits solutions to the workforce of large corporations and groups.
Claims management involves multiple touchpoints across systems and processes – from the point of intake; through the meticulous research into each individual claim; multiple follow-ups with agents, health care providers, employers, legal councils, the claimant and the policyholder itself; right up to claims adjudication and disbursements of payments. It is imperative to deliver an efficient, accurate, and seamless experience to the end customer.
The legacy system did not allow for simple routing rule changes and took almost 3 months to develop even minor changes. The system did not provide intelligent routing and, more importantly, configurable routing rules, changeable by non-IT business managers.
In this extremely complex process, our client wanted to address the following prioritized concerns;
- Claims examiner has to toggle between more than 07 different applications and portals
- Manager scours over multiple queues to assign claims to examiners
- Claims cases are assigned manually
- Inability to invoke a simple claim case routing rule
- No direct access to reports or productivity matrix
- Claims examiners scour through multiple lists, but unable to identify significant or prioritized claims or tasks
- Examiners are overwhelmed with claim cases being pushed by managers
- Limited search capabilities and visibility to historical data
- Multiple applications and inconsistent research methods were used by individual examiners to make claim determinations
Our client’s key focus was to achieve an outcome of;
- Ease – Consistency, simplicity to get data, easier to train and learn adjudication process
- Accuracy – Standardize claims processing
- Speed – Reduction of initial claims processing time by 10% or 2 minutes, from 20 minutes to 18 minutes
- Cost – Automation and integration to provide a cost reduction span over 5 years
Virtusa developed a two-phased approach to address the complex claim life cycle and massive claims volume.
During the study period, the client recorded a total of 400,000 new claims received, not including recurring claims. This is an average of almost 1,000 new claims per day to be processed. Processing time for a single claim took approximately 20 minutes, thereby requiring almost 333 hrs to process 1000 claims a day.
In phase 1, Virtusa implemented the Pega Single View application, which centralized and brought together multiple systems and portals into a single interface providing ease, accuracy, and speed to the claim decisioning process. The processing time was expected to reduce by 10% or 2-3 minutes through optimization and centralization of multiple applications, although the actual time reduction is potentially much higher. Phase 2 wrapped the end-to-end claims workflow management around Phase 1 implementation, thus providing a seamless, efficient single interface for the management of claims.
Key highlights of the solution included:
- Integrating 7 applications and portals to a single interface
- 360 access to policy and claim data for claims decisioning, not limited to; ICD Search, Disability period calculators, Internal Medical Guidelines based on diagnostic codes, Physicians Relative Value calculators
- Managers empowered to configure intelligent routing rules in real-time
- Managers empowered to easily pre-configure user skills, expertise, and processing channels, thus eliminating the need to push work
- Efficient and effective bulk transfer capabilities
- Dashboards with real-time productivity matrix
- Self-assignment of work based on the skill of claims examiners and work priority
- Improved diarizing and follow-up capabilities with modern UI features
- Access to historical claim and work data
- Intelligent informed transfer capabilities
- Advance claim search capabilities
- Business-critical activity and audit history tracking
Virtusa helped elevate business value by speedily and seamlessly deploying the Pega Customer Service framework solution, under 4 months.
- Reduction of claim research for decisioning time by 10% or 2 minutes
- Net cost reduction of USD 2.2 million
- Decommissioning of old legacy workflow and its maintenance
- Modern UI capabilities and trends
- Pega platform provides
- High scalability to combat evolving market demands and trends
- Quicker time to market
- Empowerment of configurable rules eliminating IT dependency