Abstract

A leading healthcare organization needed to quickly re-engineer spending account processes. SDLC’s approach promoted an environment for continual improvement and re-engineering by transferring knowledge acquired on the project to not only claims management personnel but all applicable stakeholders such as business process re-engineers, compliance personnel, and risk managers.

The Challenge

The client needed to quickly consolidate its key subsidiary of spending account operations to align with the market’s move to consumer driven healthcare and associated health reform mandates. SDLC Partners was called upon to update the existing spending account processes that were resulting in duplicate entry, input error, rework, processing delays, compliance deficiencies, and overall customer dissatisfaction.

The Solution

SDLC Partners deployed a team of four healthcare business transformation consultants, blending the client’s and leading practice methodologies in process improvement and risk management (e.g., Lean Manufacturing, Six Sigma, Carnegie Mellon Software Engineering Institute Capability Maturity Model Integration (CMMI), Public Company Accounting Oversight Board (PCAOB), Auditing Standard 5 (AS5)) into an innovative claims process maturity framework and approach to document AS-IS and TO-BE claims lifecycles.

SDLC focused on results, business objectives and expectations rather than just budget, cost, milestones, resources, etc., to ensure that the project delivered real, tangible business benefits. SDLC developed action-oriented project plans to integrate process owners, business process re-engineering specialists, business intelligence/operational metrics personnel, information technology experts, and business analysts. These project plans aligned the aforementioned key stakeholder’s expectations and provided project leadership with information to address issues and risks in a timely manner.

The Results

Coupling a unique approach, practical tools, and years of health plan expertise, SDLC was able to deliver a strategic roadmap and approach in less than twelve weeks:

  • Reduce claims processing costs by approximately 11,000 man hours or four FTEs across thirty-four processes
  • Reduce claim processing time by more than seven days
  • Increase claim processing productivity by more than twenty-five percent
  • Improve customer service by reducing call-backs and providing quick access to information
  • Reduce over two hundred and fifty controls down to two key controls by addressing the most significant risk exposures

These benefits were attributed to reductions of errors and rework by:

  • Limiting hundreds of variations in processes and claims forms
  • Reducing multiple touches of the same information
  • Integrating systems to eliminate manual intervention
  • Moving exceptions contact processes closer to the customer to improve service
  • Performing a top-down risk assessment to address significant process exposures
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