The way Operating Partners facilitate on-the-ground value creation has transformed tremendously over the course of 2020 in response to the pressures of the pandemic.
Drive continuous improvement, become a top performer
Implement operational strategies that stand the test of time and deliver critical business outcomes by driving underlying process efficiencies. Our Core-Admin services support your System of Engagement (SoE) and System of Records (SoR) with transformative digital-first services, driving process effectiveness, strategic agility, and enhanced service efficiency.
Backed by digital technologies such as Process Mining, AI/ML, Automation, and Analytics, our services are designed to help you grow, innovate, and improve both the Member and the Provider experience. The result: drive sustained growth to advance your business in an ever-evolving market.
Claims Operations
Frictionless claims operations for transformational experiences
Combat inefficiencies and eliminate bottlenecks with Digital + AI + Analytics
Don’t lose millions of dollars to inaccuracies, errors, incorrect billing, overpaid medical claims, missed discounts, and other issues. Keep expenses under control while providing accurate reimbursements to providers. Our expert team with over 20 years of experience can help you navigate complex claims processing and enhance transparency leveraging digital technologies, including process mining, predictive analytics, visual dashboards, AI/ML, and intuitive workflows.
Our Robotic Process Automation (RPA) based workflow solution enables you to assess claims with greater accuracy, proactively detect fraudulent and erroneous claims, and prioritize high-value claims.
Leave a lasting impression, kindle customer loyalty
As the demand for exceptional customer experience continues to grow amidst an ever-changing industry and regulatory environment, promptly and accurately addressing member needs and concerns will be key to success.
Take the stress out of member eligibility, enrollment and billing with the help of our agile operating model that allows you to flex your core operations. Our associates, empowered by leading-edge technology and Intelligent Automation solutions, are skilled in enrolling and assisting members, monitoring and pursuing revenue, and managing government interactions around federal benefits.
Our automation intake solution draws upon our decades of experience in working with large Health Plans, HIX, Medicare, and Medicaid enrollment programs. It provides a touchless, paperless on-demand system to slash your cost of operations. The convenient, multichannel solution spans Public Exchange, Private Exchange, Member Portal, Online Sales and IVR (Interactive Voice Response).
Digitally Empowered Contact Center for a brilliant customer experience
Turn customer interaction insights into enriched experiences
Improving data inaccuracy and response times is fundamental to reducing customer frustration and improving satisfaction. Rapidly access your customer’s intent across the customer journey to synchronize interactions across channels and deliver a seamless experience. Our Digitally Empowered Contact Center (DECC) solution enables you to better understand the customer journey across touchpoints to offer a seamless omnichannel experience.
Solution features
Omnichannel (voice, chat, email, text, portal, social media), biometric authentication, digital self-service channels for Members, Providers and Brokers, enabled with AI/ML capabilities.
Associate desktop solution includes unified screen desktop with automated call summary, next best action, call and screen recording, and sentiment analysis.
Other technology components include cloud-powered platforms and CRM solutions, outbound call solutions, visual analytics, predictive and prescriptive analytics, sentiment analytics, agent productivity tools for remote and in-office monitoring, and customer 360 views.
Build customer trust while meeting compliance and quality mandates
Don’t let bad Provider data cost you millions
Bad Provider data impacts multiple aspects – Provider directories, claims processing, compliance, and Provider communication – and ultimately, customer trust. Improve the quality of your Provider Information and Credentialing through proactive management, Six Sigma processes, and the right technology solution.
Our Robotic Process Automation solution GetRight, underpinned by AI/ML and expert associates, helps automate and streamline credentialing/recredentialing, contracts, demographics, and delegated provider types. Suitable for multiple platforms, the solution validates data against NDB and identifies mismatches between NDB and platforms.
Harness digital synergies to transform complaint resolution
Meet the twin goals of boosting customer satisfaction and compliance
Constantly changing demands, regulatory uncertainties, compliance burden, SLA requirements, risk of penalties, and lack of visibility and reporting – all of these make healthcare appeals and grievances (A&G) management a complex and intensive process. All the more so when handled manually. Reimagine the process with digital operations comprising multiple automation and analytics-based interventions.
Intelligently allocate complex A&G requests
Predict which claims and Prior-Auth rejections will turn into an appeal
Assess the propensity of an appeal to go to Level 2 & 3 due to an inaccurate disposition
Forecast volumes and capacity management
Avoid missing regulatory SLAs with a TAT prediction model
Reduce human intervention through automatic document classification, routing and case creation
Expedite priority cases, reducing wait-time and bottlenecks
Enable proactive compliance and reporting with ad-hoc analytics as well as “one-click” access to standard reports
Digitize broker support. Empower them to do what they do best
Shift from cookie-cutter to personalized experience
Provide a personalized, contextual, 360-degree view of customer data and plan information, ensure a smooth buying process, and support ongoing education of brokers. Our Digital Broker solution brings together data from disparate sources to streamline processes and provides a comprehensive view of customers’ plans and choices, enhancing productivity and building a loyal customer base. A cost-effective, one-stop portal for customer and policy information, history of activities, follow-up schedules and marketing analysis, the solution offers:
Customized plan comparison supports more than 5000 plan combinations
Intuitive support for plan recommendations, claims assistance, and negotiations of premium
Easy integration with enterprise systems
End-to-end support for sale of policies
Full cycle trading from quote to insurance, endorsement, claims, renewals
Unified workflow for each customer
Dashboard to analyze and evaluate reports and offer comprehensive insights into the conversion process
Simplify benefits plan management and accelerate speed to market
Modernize benefits plan configuration
Create accurate and competitive health plans. With extensive expertise in analyzing Benefit Grids and configuring Benefit Rules on various platforms, including homegrown core systems, we enable accurate product build and improve cycle time, accuracy, and compliance. Our “Do it once, do it right” methodology delivers a better first-pass rate to consistently reduce audits. Our services across the spectrum of benefit coding, benefits testing, and narratives across LOBs, plan geographies, and prioritized configuration for special groups help manage and reduce costs.
RPA & Analytics-Driven processes for accurate benefit plans
Core-Flex Agile Operating Model to address the seasonality of operations
Experienced staff with a deep understanding of Benefits Grid, benefit coding and testing
Drive revenue integrity and compliance across Medicare and individual lines of business
Ensure accurate and compliant compensation for your Members’ risk share
Risk levels rise in tandem with the growth in new market opportunities, making it crucial to modify Risk Adjustment programs across Medicare and individual lines of business. We offer end-to-end risk adjustment solutions to identify and optimize risk adjustments that impact your revenue while effectively managing multiple systems and ensuring stringent compliance. Our services include:
Prospective and retrospective risk adjustments
Record retrieval, submission and reporting
Coding services
Forecasting of risk trends and care interventions
Support for Risk Adjustment Data Validation (RADV) Process
Frictionless claims operations for transformational experiences
Combat inefficiencies and eliminate bottlenecks with Digital + AI + Analytics
Don’t lose millions of dollars to inaccuracies, errors, incorrect billing, overpaid medical claims, missed discounts, and other issues. Keep expenses under control while providing accurate reimbursements to providers. Our expert team with over 20 years of experience can help you navigate complex claims processing and enhance transparency leveraging digital technologies, including process mining, predictive analytics, visual dashboards, AI/ML, and intuitive workflows.
Our Robotic Process Automation (RPA) based workflow solution enables you to assess claims with greater accuracy, proactively detect fraudulent and erroneous claims, and prioritize high-value claims.
Leave a lasting impression, kindle customer loyalty
As the demand for exceptional customer experience continues to grow amidst an ever-changing industry and regulatory environment, promptly and accurately addressing member needs and concerns will be key to success.
Take the stress out of member eligibility, enrollment and billing with the help of our agile operating model that allows you to flex your core operations. Our associates, empowered by leading-edge technology and Intelligent Automation solutions, are skilled in enrolling and assisting members, monitoring and pursuing revenue, and managing government interactions around federal benefits.
Our automation intake solution draws upon our decades of experience in working with large Health Plans, HIX, Medicare, and Medicaid enrollment programs. It provides a touchless, paperless on-demand system to slash your cost of operations. The convenient, multichannel solution spans Public Exchange, Private Exchange, Member Portal, Online Sales and IVR (Interactive Voice Response).
Digitally Empowered Contact Center for a brilliant customer experience
Turn customer interaction insights into enriched experiences
Improving data inaccuracy and response times is fundamental to reducing customer frustration and improving satisfaction. Rapidly access your customer’s intent across the customer journey to synchronize interactions across channels and deliver a seamless experience. Our Digitally Empowered Contact Center (DECC) solution enables you to better understand the customer journey across touchpoints to offer a seamless omnichannel experience.
Solution features
Omnichannel (voice, chat, email, text, portal, social media), biometric authentication, digital self-service channels for Members, Providers and Brokers, enabled with AI/ML capabilities.
Associate desktop solution includes unified screen desktop with automated call summary, next best action, call and screen recording, and sentiment analysis.
Other technology components include cloud-powered platforms and CRM solutions, outbound call solutions, visual analytics, predictive and prescriptive analytics, sentiment analytics, agent productivity tools for remote and in-office monitoring, and customer 360 views.
Build customer trust while meeting compliance and quality mandates
Don’t let bad Provider data cost you millions
Bad Provider data impacts multiple aspects – Provider directories, claims processing, compliance, and Provider communication – and ultimately, customer trust. Improve the quality of your Provider Information and Credentialing through proactive management, Six Sigma processes, and the right technology solution.
Our Robotic Process Automation solution GetRight, underpinned by AI/ML and expert associates, helps automate and streamline credentialing/recredentialing, contracts, demographics, and delegated provider types. Suitable for multiple platforms, the solution validates data against NDB and identifies mismatches between NDB and platforms.
Harness digital synergies to transform complaint resolution
Meet the twin goals of boosting customer satisfaction and compliance
Constantly changing demands, regulatory uncertainties, compliance burden, SLA requirements, risk of penalties, and lack of visibility and reporting – all of these make healthcare appeals and grievances (A&G) management a complex and intensive process. All the more so when handled manually. Reimagine the process with digital operations comprising multiple automation and analytics-based interventions.
Intelligently allocate complex A&G requests
Predict which claims and Prior-Auth rejections will turn into an appeal
Assess the propensity of an appeal to go to Level 2 & 3 due to an inaccurate disposition
Forecast volumes and capacity management
Avoid missing regulatory SLAs with a TAT prediction model
Reduce human intervention through automatic document classification, routing and case creation
Expedite priority cases, reducing wait-time and bottlenecks
Enable proactive compliance and reporting with ad-hoc analytics as well as “one-click” access to standard reports
Digitize broker support. Empower them to do what they do best
Shift from cookie-cutter to personalized experience
Provide a personalized, contextual, 360-degree view of customer data and plan information, ensure a smooth buying process, and support ongoing education of brokers. Our Digital Broker solution brings together data from disparate sources to streamline processes and provides a comprehensive view of customers’ plans and choices, enhancing productivity and building a loyal customer base. A cost-effective, one-stop portal for customer and policy information, history of activities, follow-up schedules and marketing analysis, the solution offers:
Customized plan comparison supports more than 5000 plan combinations
Intuitive support for plan recommendations, claims assistance, and negotiations of premium
Easy integration with enterprise systems
End-to-end support for sale of policies
Full cycle trading from quote to insurance, endorsement, claims, renewals
Unified workflow for each customer
Dashboard to analyze and evaluate reports and offer comprehensive insights into the conversion process
Simplify benefits plan management and accelerate speed to market
Modernize benefits plan configuration
Create accurate and competitive health plans. With extensive expertise in analyzing Benefit Grids and configuring Benefit Rules on various platforms, including homegrown core systems, we enable accurate product build and improve cycle time, accuracy, and compliance. Our “Do it once, do it right” methodology delivers a better first-pass rate to consistently reduce audits. Our services across the spectrum of benefit coding, benefits testing, and narratives across LOBs, plan geographies, and prioritized configuration for special groups help manage and reduce costs.
RPA & Analytics-Driven processes for accurate benefit plans
Core-Flex Agile Operating Model to address the seasonality of operations
Experienced staff with a deep understanding of Benefits Grid, benefit coding and testing
Drive revenue integrity and compliance across Medicare and individual lines of business
Ensure accurate and compliant compensation for your Members’ risk share
Risk levels rise in tandem with the growth in new market opportunities, making it crucial to modify Risk Adjustment programs across Medicare and individual lines of business. We offer end-to-end risk adjustment solutions to identify and optimize risk adjustments that impact your revenue while effectively managing multiple systems and ensuring stringent compliance. Our services include:
Prospective and retrospective risk adjustments
Record retrieval, submission and reporting
Coding services
Forecasting of risk trends and care interventions
Support for Risk Adjustment Data Validation (RADV) Process
The pandemic is further straining Health Plans and healthcare delivery systems already under pressure from exploding administrative costs, growing staff burnout, and evolving member and provider expectations. Upend traditional healthcare delivery with our Intelligent Automation solutions that integrate Robotic Process Automation (RPA) with Artificial Intelligence (AI) to drive unparalleled operational efficiencies, productivity and patient care.
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