Case Study: Insurance
Driving $70 million in savings for a workers’ comp payer
HGS transforms coding, interest and penalty, and appeal re-evaluation processes
The client has trusted HGS for a widening scope of services, including re-evaluations; complex nurse review for medical necessity, compensability, relatedness/appropriateness; and code review by certified professional coders.
In addition to driving breakthrough savings for this client, HGS has brought innovation, such as our inventory management tool, to proactively manage inventory within state-stipulated timeframes and an accurate coding mechanism, which has detected a 25% rate of coding accuracy opportunity. Today HGS’s consultative, proactive strategy works across siloes to also enhance profitability, provider relations, and member satisfaction—all key to transformation for this client partner.
Throughout our partnership, HGS has demonstrated value that transcends our initial role as a transaction partner. We have provided crucial support to this client’s savings objectives while also co-creating solutions and innovation to support both provider and member satisfaction.
Three key areas of our partnership success:
Three years ago, HGS found the client overpaying claims by 25% compared to their peers in the market. We put together a cost-containment solution, using registered nurses and coders, to strategize more stringent payment integrity to eliminate waste and abuse. To ensure a holistic approach, we focus on two key areas: medical relatedness and accurate coding:
HGS’s end-to-end focus brings this value, to date:
In 2016, HGS initiated a process to solve for a critical workflow gap that resulted in high interest and penalty payments for the client. To address the high interest and penalties incurred by late payments to states, HGS conducted with an analysis to identify gaps in workflow and map dependencies across bill life cycle. This analysis addressed causes of delay and provided avoidance measures. We created a proprietary inventory management tool, customized to the client’s unique workflow set up.
This tool automates assignment, based on aging, with priority assignment based on interest and penalty states. The objective is to identify high-dollar bill assignment, with effective monitoring and escalation through an email trigger.
From 2016-17, the client has achieved a 46% improvement in cost avoidance as a result of interest and penalty reduction. As a result of this interest and penalty avoidance, provider abrasion is decreased. The client’s overall satisfaction is improved, with an enhanced reputation among providers community.
HGS also addressed another provider dissatisfier in the area of re-evaluation appeals. The HGS team used a phased approach over several years to track categories of all re-evaluation appeals. Our technique was to segregate appeals based on provider, system and user issues. We employed real-time feedback for user errors and trend analysis, supported by feedback and coaching. Quality meetings were aligned to consistent communication to the team regarding new error trends.to determine appropriate coding.
Over several years, HGS was able to drive down rework and re-evaluations by 10%.
in three years
in interest and penalty payout