AI driven Compliance automation for a Large Health Care Organization
Overview.
A leading vision care administrator with 39+ million members across Medicare, Medicaid, and Commercial lines of business lacked industry best practices and was becoming uncompetitive.
Challenges.
The administrator needed help in multiple areas:
Lack of industry best practices across operations management and customer service.
High dissatisfaction with providers and members.
Consistently non-compliant with CMS regulations.
Missed contractual SLAs with Health Plans.
Outdated technology stack with no automation.
Solution.
Coforge came up with a multi-step roadmap for the client:
Implemented a platform for best-in-class Member/ Provider Experience including AI driven automation for Compliance management.
Re-engineered and streamlined traditional processes and workflows to align with new platform.
Augmented staffing solutions consisting of domain experts in Member Services, Appeals & Grievances and Provider Disputes.
Provided ability to prepare for audits and proactively manage potential NONC issues.
The Impact.
47%
Reduction in Total Cost of Ownership
28%
Reduction in headcount
15,000
Backlogged cases were resolved
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