HGS Healthcare Payer Competency Presentation
Transcript of HGS Healthcare Payer Competency Presentation
C o r p o r a t e P r o f I l e
Stronger Relationships Deeper Insights
HGS Overview
Who We Are: A global customer relationship management & BPO corporation with its principal North American office in Warrenville, IL
Global Customer Support Services: Global provider of customer support solutions and business process outsourcing by phone, e-mail, chat, and social media with 22,000 employees, and 43 centers located in 7 countries
Leveraging global perspectives: In business for 37+ years; Acclaimed Fortune 100 clients
Consistent Growth: Growing corporation with over $300 million in revenue
Financial Stability: Publicly listed company, financially sound (AA-)
Certifications: Six Sigma, ISO 9001, 27001, HIPAA, GLBA, PCI, eSCM (2012)
At our core...
Clients and their Customers are at the Center of Everything We Do
Vision “To be a globally preferred business process transformation partner for our clients,
creating value in their business through innovative outsourcing solutions”
“To Make Our Clients More Competitive”
Mission
Culture Flexible, Easy to Work With
A “Can Do!” Attitude
Automotive
Banking and Financial Services
Consumer Electronics
Consumer Packaged Goods
Consumer Products
Government
Healthcare
Insurance
Logistics and Transportation
Media and Entertainment
Pharmaceuticals
Publishing
Restaurants
Retail
Technology
Telecommunications
Industry Verticals...
Diverse Industry Experience
Actionable Customer Relationship Management phone | e-mail | web chat | self service | white mail
Customer Care and Product Support
Customer Care Product Support
Member Care Provider Support
Sales Support Analytics and Market Research Satisfaction Surveys
Analytics and Market Research Social Media
Fulfillment and Back Office Processing
Mailroom Services Product and Literature
Fulfillment Imaging Services
Inbound Sales and Order Taking
Inbound Sales Broker Support Order Taking
Service Lines – Actionable Customer Relationship Management
Targeted Services to Meet the Evolving Needs of Our Clients
Business Process Outsourcing
Claims Adjudication Fraud Research
Special Investigation Unit Plan Building
Loading, and Testing
Financial Stability
Diversification to Ensure Both Growth and Risk Mitigation
Employee Strength
Customer Concentration
On-shore/Off-shore Mix
Revenue Distribution : By Geography Revenue : By Billing Currency
Revenue : By Industry
Data Transaction Onshore Calls Function
Claim Services and Support
Mailroom and Scanning
Claims Data Entry
Referral Entry
Claim Audit and
Medical Triage
Claim Payment
and Review 2100 FTEs
Provider Services and Support
Provider Correspondence
Provider Customer
Service
Provider Network
Calls
Pre- Authorization
Calls
Claim Rework
Unit 900 FTEs
Member Services and Support
Benefit and Eligibility
Calls
Claim Dispute Calls
Premium Payment
Plan Renewal
Wellness Care
Support 300 FTEs
Research and Recovery Overpayment
Validation
Overpayment Refund Request
Overpayment Refund Posting
Fraud Research
Refund Calls
500 FTEs
Plan Administration and Support
Sales Support
Underwriting Support
Plan Loading And Setup
Plan Testing
Billing Premium
450 FTEs
Payer Services
Individual HMO Members
Individual Billing Members
Individual PPO Members
5 Processes
Provider Calls PPO
California Member Calls
KANA – Email Support
7 Processes
2 Processes
HMO Small Business
Member Calls
PPO Small Business
Member Calls
2006 2007 2008 2010 – 2011 2009
Group Members Email Support/Provider Dental/ International Middle Market Members Individual Members
10 Processes
Provider Calls HMO
Dental Calls
Global Insurance - Calls
45 FTEs
100 FTEs
260 FTEs
665 FTEs
1200 FTEs
Pre-Authorization
Calls
Provider Network Calls
Overpayment Calls Financial Recovery
HAO and POC
15 Processes
Member Calls –
Middle Market Group
Overpayment Validation
HGS Calls Journey
Leveraging Claims Experience to Deliver Calls
Payer Expertise
Member Services
Provider Services
Plan Sponsor Services
Claim Experience
40 Million Claims
High Dollar and
Complex HCFA / UB04
Claims
Calls Experience
Member Calls –
1.5 Million Calls
Provider Calls –
6.5 Million Calls
Operational Expertise
First in Quality –
All Delivery Centers
99.8% Pay Incidence Accuracy
Compliance
HIPAA
SAS 70
GLBA
Process Enhancements
All Ideas Matter –
AIM
Diet Six Sigma
Sharing Best
Practices – Spark
People and Tenure
200 Claim Associates at 100%
QA in 2010
Average Leadership Tenure of 7 Years
Over a Decade of Healthcare Payer Experience
Scalability
Annual Growth of 60% for Last 10 Years
Blended Shoring
Disaster Recovery
and Business
Continuity Plan
2000
2011
Healthcare Payer Summary
E nga gem ent E xpe r i ence E xpe r t i s e E xce l l ence
Performance Management
System
Business Excellence
Assurance Control Improvement
Organization Capability Group
Compliance and Audit Group Quality Group Continuous Improvement
Group
• International Standards and Regulations • Risk Management
• AIM – ALL IDEAS MATTER • Diet Six Sigma • Six Sigma Projects • QPEP — Quality Professional Excellence Program
• Excellence Frameworks • Perception Management • Brand Building
• eSCM / COPC • 5 Business Methodologies • 250 Processes, Practices and Procedures • SPARK — Best Practices Repository • 360 Available Practices • 6 Papers Published in National and International Forums
• ISO 9000, ISO 2700, HIPAA, GLBA, SAS, PCI • 2300 Risks and 2500 controls in place • Internal Auditor program developed, 18 internal auditors trained • 2 Internal Assessments and Audits • 2 DR Test completed and reported
• Operations Quality • Transition Quality • Shared Services Quality • Quality Tools and Macros Development • Quality Forum
• 1000 Operational part of Central repository • 25 accounts transitioned • 250 Metrics part of Shared Services • 100 Automation tools tracked
• 2600 Ideas, 240 Ideas Implemented • 350 People trained on Diet Six Sigma • 30 BB Trained • 60 Projects , 7 completed • Total saving of $200 K
• 300 QA trained and 75 certified till date
Continuous Improvement and Innovation
QPEP SPARK Concept Training
Let’s Talk Excellence
Performance Improvement
Productivity Tools
Process Changes
Financial Benefits
Business Growth
Voice of Process
Business Feedback
Voice of Customer/Client
AIM (Kaizen)
PCS
8-D
Diet Six Sigma
Six Sigma
Lean
DFSS
TRIZ
• Idea Generation and Processing Tools • Seven Basic Quality Tools • Seven M&P Tools • Decision Making Tools • Project Management Tools • Statistical Tools
• Lean Tools
• DFSS Tools
• Innovation Tools
Process Improvement – Example 1
Re-Routes Reduction from 31.4% in Dec 2005 to 0.11% in Jan 2011
Define • To reduce the Reroute of claims and thereby reduce cost of claim processing
Measure and
Analyze
• Percentage of reroutes were measured during transition
• The categories of edits and reasons were tracked and analyzed
Improve
• Incorrect duplicate edits were identified and eliminated
• Provider function edits and errors were identified and process improvement were recommended
• Reroutes because of skill set gap were identified & team was trained to eliminate the reroutes
• System up gradation issues were tracked, and therefore errors reduced
Control
• The reroutes reduced from 31. 4% to 0.11%
• The edits were continuously monitored to identify opportunities for improvement and process
improvement solutions recommended
Impact
Process Improvement – Example 2
• Purpose and Objective : To reduce documentation errors and standardize the process • The Challenge: Incorrect documentation • The Solution: A documentation tool was developed • Benefit: Tool has been adopted by the client
0
10
20
30
40
50
60
70
80
Jan Feb Mar Apr May Jun Jul
72
34
13
5 3 3 2 2 2
Task element documented Letter Verbiage correct Task created correctly
Correct Letter Sent Letter sent Other
Denial Code Correct Remarks created correctly Task result correct
Jan ’09
~50%Errors due to
Documentation
Jan ’09 to Jul ’09
72 Errors Reduced to 0
Improving Performance with Focused Process Improvement
Process Improvement – Example 3
• Purpose and Objective : To automate the initial phase of rider mapping before loading to Dynamic Plan Load. • The Challenge:
– Manual work – Cycle time – Dup Accumm Errors – Complex process logic
• The Solution: “Rider Mapping Automation Template ” was developed • Reduction in Cycle time
Prerequisites 39 mins
COC CR 28 mins
COC NP CR PAR
32 mins
PLYR CR 20 mins
PLYR NP CR PAR 30 mins
Cycle Time 149 mins
Prerequisites 39 mins
Automated Output 30 mins
Cycle Time 69 mins
Reduction in Rider Mapping Issues from 83.72% to 46.62%!
Process Improvement – Example 4
Increasing Graduation Through put
Transition Team Lead – Ensures support for OJT
Results
Evaluation
• Smoother transition from training to production
• Improved retention during the OJT phase.
• Extensive coaching sessions , dissemination
• Effectiveness of training can be measured
Objective
• Continue Camaraderie from training to Production
• Acknowledge extra focus needed during learning
curve
• Ensure majority pass the OJT phase
50% 55% 60% 65% 70% 75% 80% 85% 90% 95%
100%
HMO TRAD INDIV Dental
Before TTL
After TTL
Process Improvement – Example 5
Impacting Bottom line
Repeat Calls based on Type of Claim Call
• Reduction of Claim Rework
• Reduce repeat calls
TIN Name Claims on Repeat File
Gomez – Garcia, Angel 9
Soar Surgery Center 8
Medical Hyperbarics 2
Florida Dialysis 3
Hall, Lacresha 3
Harvard Surgery Center 1
Month Number of
Agents Number of
Repeat Calls Number of
Unique Claims
January 49 99 69
February 64 144 101
March 78 178 123
April 75 209 130
Top Providers making repeat calls
Trends of repeat calls Vs Seasonality
10%
14%15%
17%18%
26%
0%
10%
20%
30%
Claim Status Clarify/Confirm Payment Appeal Inquiry N/A Rew ork Reimbursement Inquiry
AIM – All Ideas Matter
• New Ideas: 483 feasible ideas from 2,600
• Implemented: 40 of these ideas have been implemented
• Key Impact Ideas: – Reduced rework errors by 40% – Improved CSAT on a Telecom engagement
by 4% within 1 month of implementation – Patient appointment errors reduced by
50% in 4 months – Errors in claim adjudication reduced by
28% in 3 months
Key Improvement and Business Impact
Listening to the Agents – AIM
“Load the billing information on the website such as the premium billed, payment posted date payment post, as well as, plan options if there are rate increases.”
“The benefit packet should be sent together with the ID card, not 60 days from the effective date. It's the member's right to know what their benefits are at the start of their coverage.”
“Regular updates and skill check to make sure that phone reps are always aware of the new policies in their respective departments.”
SPARK - Sharing Practices & Replicating Knowledge
• Knowledge assets shared globally - 365
• 287 Best practices
• 6 White papers
• 72 Case studies
REPLICATION
• 36 Practices replicated across geographies
• Replication Impact
• Impact being calculated for replications
• Impact seen in terms of improvement in call quality, reduction in errors, reduction in complaints.
• Key Impact Metrics
• No of errors committed on call reduced from 9 to 4 errors
• Call Quality increased from 82% to 85% and consistently meeting the target
• Resolving appointment cancellation increased from 95% to 100%.
• "QMC scores are increased from 45% to 51 % • Repeat scores reduced from 28% to 23%
• Fatal Error % decreased from 13% to 9%,
• Customer complaints reduced from 15 to less than 5
• Call Quality increased from 74% to 85%
• Certification % increased by 5% i.e. From 87% to 92%
47
20 21
29
36
0
5
10
15
20
25
30
35
40 Replication
Automation & Efficiency, 9 Corporate Social
Responsibility, 1
Customer Satisfaction
Practices, 39
Employee Satisfaction
Practices, 15
Internal Review Mechanism, 27
Learning and Development, 48
Operational Metrics
Improvement Practices, 86
Performance Management, 22
Quality Metrics Improvement Practices, 100
Resource Management
Mechanism, 13
Value Add to Client, 5
Voice of the Customer
100
75
50
25
+100
+75
+50
+25
7
6
5
4
3
2
1
6
5
7
Industry Average HGS Overall HGS Healthcare
Why HGS
Eric Key Business Development – Healthcare Phone : 1 -309 – 229 – 2857 [email protected]
Anand Natampalli Vice President – Healthcare Phone: (001)-201-286-7717 [email protected]