Coforge Transforms Back-Office Operations for an American Insurance Giant

Challenges.

After a detailed study of client processes, our consultants diagnosed the following major issues and challenges:

• There was no categorization of claim types in the system by either the system itself or the pre-processing teams. This lack of categorization made it difficult to allocate claims appropriately, often resulting in complex cases being assigned to new team members.
• The system did not filter duplicate claims effectively, which added to the processing time and steps. The system only checked for duplicity in pending cases, not in the processed ones. The duplicity checks were limited to the parameters of policy numbers and CIF numbers, covering only about 5% of the total volume.
• The system did not filter duplicate claims effectively, which added to the processing time and steps. The system only checked for duplicity in pending cases, not in the processed ones. The duplicity checks were limited to the parameters of policy numbers and CIF numbers, covering only about 5% of the total volume.
• Several manual processes were time-consuming and prone to errors. For instance, researching multiple sources to identify procedures, payment guidelines, and drugs to respond to a claim. Then, to generate letters for pending and denial cases, team members had to search for content across multiple Excel sheets.
• The claim forms often contained information in free-flowing handwriting, which was difficult to decipher and led to numerous queries.
• Processes were inconsistent in almost every aspect. Web claim forms were received as scanned images, and there were discrepancies with the scanned forms in Pega. Cases were not marked as ‘completed’ even after processing due to mismatches in the amounts and the names entered by team members versus those processed by the system. Moreover, there was no mechanism to record team productivity and utilization.
• Working through the existing claims processing system was challenging because the software only gave claim processors a small window size to work from, requiring them to toggle between multiple application windows while handling claims.
• There were significant knowledge gaps due to inconsistent training sources. Moreover, senior members/experts spent an enormous time resolving team member queries, further adding to the processing time. The high number of defects, with 18.43% of monitored cases showing issues, necessitated rework.
• Supervisors invested around 9 hours daily analyzing client-shared reports.

Solution.

ProcessGym™ consultants studied the entire claims process for 6 weeks and came up with the opportunities across people, process and technology. The client agreed to the solutions our consultants recommended, and the team devised an implementation roadmap.

The following solutions were a part of the implementation plan:

• Created digital claim forms to replace physical forms.
• Automated task categorization. This helped create an operating model based on skill, experience, and claim benefit categories.
• Rule-based automated duplicity checks were established to perform on all the submitted documents.
• Created a utility to obtain information from multiple sources based on a keyword search (drug name, surgery, CPT code).
• Implemented a tool to generate customer letters based on the claim status like ‘pending’ and ‘denial’.
• Created and implemented KPIs and process checkpoints to improve teams’ and individual performances.
• Implemented a knowledge assessment framework to help bridge the knowledge gaps of new team members.
• Implemented an automation tool to analyze daily performance reports to release all the supervisor’s time up to 50% and support the team.

The impact.

• 46% reduction in AHT leading to increased productivity in 6 months through implementing short and medium terms recommendations
• 11% efficiency gains due to reduction in errors· Automated allocation of tasks based on skills and priority
• Automated allocation of tasks based on skills and priority
• > 70% freed-up supervisor bandwidth· 20% improved training time
• 20% improved training time