Salesforce Helps Virtusa Transform the Injured Worker’s Comp Order and Billing Lifecycle for Large US Health Insurer

The customer was a large insurance company in the US which focuses on the administration of injured worker’s comp related claims by working with providers on behalf of clients to ensure that injured workers get the products and services they need at the best possible price. The operations contact centre had been using a legacy on-premise application for over 10 years which had been heavily customized to meet the business needs and which provided very little adaptability to change and which still required a very large amount of manual user inputs, including re-keying information between screens and using offline tools to find providers and price products and/or services.

The customer needed an application which could help them provide their clients with a superior experience, improve and expand their provider network and make life easier for the large team of contact center agents who processed orders and bills. Virtusa proposed Salesforce Service Cloud, the worlds leading cloud-based contact center application with a host of out of the box features to enable the management of complex contact center workflows and to act as a front office integrating with the various systems which are required to process an Order from inception through to billing. On top of this, Virtusa recommended Salesforce Customer Communities to enable the insurer’s clients and providers to create, view and authorize orders and manage their billing digitally for the first time.

On top of all this, the insurer wanted to reduce its dependency on the company IT resources and move on to the cloud while ensuring internal and external regulatory compliance in the healthcare space. Virtusa enabled this through the use of Salesforce and Informatica Cloud as the integration tool of choice on the program, allowing the customer to move toward a flexible and scalable subscription-based pricing model on their IT investment. Salesforce Shield ensured that PHI/PII information remains encrypted at a database level without the need for the complex integration of 3rd party encryption tools.

  • The Challenge

    The insurer was operating on a 10-year- old legacy application which could not meet the demands of their business. This included:

    • Large number of manual processes with extensive documentation required to complete an order
    • Poor agent productivity due to manual validations and re-keying between systems
    • Use of multiple disjointed applications required to complete an order
    • Data and process errors causing down stream exceptions due to manual processes
    • Reduced turn around time on order requests in a competitive market space
    • Heavy reliance on parent company’s IT infrastructure and release cycles
    • Lengthy and costly staff onboarding process due to complexity of business processes and the technologies that support these
  • The Solution

    Virtusa built an E2E claim, order and billing platform on Salesforce Service Cloud for the Contact Centre, while empowering clients and providers through Communities to revolutionize the way things were done:

    • Complete front office contact center application based on Service Cloud providing claim management, order management and billing/payments functionality
    • Re-engineering of business processes and an introduction of large-scale automation to improve productivity, remove room for errors and reduce order turn around time
    • Optimized integration architecture with 15+ internal and external systems through APIs and scheduled file- based integrations with Informatica Cloud
    • Data model transformation & data migration of 20+ million records of master data, including state fee schedules and U&C pricing data
    • PHI/PII encryption at REST achieved through Shield to ensure regulatory compliance
    • Complex provider search and product pricing interface built on Lightning
    • Custom outbound Fax capability
    • Custom document classification & management feature
    • Customer Communities for clients and providers to manage their orders and payments digitally, from any device, for the first time
  • The Benefit

    Extensive benefits were achieved for the business by migrating on to Salesforce including:

    • Significantly reducing the time it takes to complete many operational processes. For example:
      • Creating a Provider Auth PDF from 15 minutes to 5 seconds
      • Creating a Provider Denial Letter from 20 mins to 3 seconds
    • Improved agent productivity as the system does the hard work of assessing the Order and processing it as per business rules developed
    • Reduced data discrepancies due to validations and automation
    • Internal and external security compliance achieved
    • Seamless integration between a customer facing portals and the contact center application for order management between Coventry and clients
    • Significantly improved user experience with very positive agent feedback
    • Reduced TCO due to cloud-based solution and reduced dependencies on company IT
    • Staff onboarding time and cost
    • Flexibility to adapt and update business logic and pricing rules with minimal IT involvement due to data model design and maximum usage of configuration

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