Coforge helps a Fortune 500 insurance company become more process efficient.

Challenges.

Our client is a Fortune 500 company with over 6,000 employees managing approximately $214 billion in assets across fixed income, senior loans, equities, multi-asset strategies and solutions, private equity, and real assets with 40 years of experience.

There was no categorization of claim types in Pega by system or the pre-processing teams. Due to this, allocation in teams was becoming a challenge. Complex cases were getting assigned to new members. 

• Duplicate claims were not filtered properly by the system adding to processing time and steps   
• Pega system checked duplicity only in pending cases and not in processed cases.   
• Currently, duplicity is checked only on the policy no. and CIF no. which is approximately 5% of total volume  

Research through multiple sources (SharePoint, Websites, encoderPro.com, Documents) to identify the type of procedure, payment guidelines, drugs, etc. was time consuming. Letter generation for pending and denial cases was time consuming as TM had to search the letter’s content from multiple excel sheets. Claim form had information in free-flowing handwriting, which was difficult to understand, leading to queries by the team members. 

There were knowledge gaps due to different sources of training. Supervisors collectively spent 9 hours daily analyzing reports shared by the client (CFT, Control reports etc). More time was being used for resolution of queries raised by team members adding to processing time. There was a high number of defects leading to rework and 18.43% defects were spotted out of the total monitored. 

There were more inconsistencies in the processes. Web claim forms came as a scanned image. There were inconsistencies with scanned forms received in Pega. Cases were not counted as ‘completed’ even after being processed by the team, due to mismatch in amount and name entered by team members vs processed by the system. There was no mechanism to record the team’s productivity and utilization. Working through CPS was difficult due to smaller size of the window. The processor had to toggle between multiple application windows while processing a claim. 

Solution.

Our team came up with procedures to make the system more efficient. The following changes were introduced. 

• Categorization was to be done by system or pre-processing team which would help in creating an operating model based on skill, experience and claim benefit category. 
• Duplicity was to be checked based on the documents attached. 
• Utility to fetch information from multiple sources based on a keyword search (drug name, surgery, CPT code) 
• Tool to help construct the letter content based on the pending and denial reasons. The objective was to save time as well as to reduce errors. 
• End user to be directed to write the information in capital letters which is easier to understand. 

In addition, Coforge also introduced a few KPIs and Process-checkpoints to improve team and individual performances: 

• Regular Knowledge Assessment Test (KAT) 
• Refresher Training for bottom performers (high AHT) 
• Regular onshore-offshore calibration session between Ops-Quality-Trainers 
• Best practice sharing by top performers 
• Automation tool to analyze these reports to release supervisor’s bandwidth up to 50% and support the team. 
• Create and maintain FAQs for most common or trivial queries and their resolution for easy reference of team members.
• Implement a quality policy along with error categorization and root cause analysis to identify the reasons for the high number of errors. 
• Refresher training for bottom performers 

A few best practices leading to process-reengineering were introduced: 

• The claim form submitted by the customer through Web or App should be a digital form from where information could flow to Pega and could be used for categorization 
• While indexing, the orientation and direction of pages should be correct across all pages without any blanks 
• Digitization of process enabling process automation 
• Tool to sort the blank pages at the back of the document  
• Enhance the system to minimize such cases 
• Implement standardized templates to record data for better monitoring and reporting 
• Enable access for reports in Pega for the offshore team 
• Size of the CPS window to be increased for better visibility and navigation 
• Dual monitor system for ease of processing (Applicable for WFO) 

The impact.

• Overall AHT reduction of 3 mins/case  
• Supervisor bandwidth freed (4 - 5 hours daily) 
• Reduction in processing time of processor and saving of SME’s & supervisor’s time as well 
• Reduction in internal errors by 50% leading to 1.75 FTEs worth saving 
• Efficient reporting and monitoring 
• Faster Processing (Approx. 1 min/case)