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Health care organizations around the globe are facing an urgent, unprecedented need to cut health care costs while improving quality at the same time. Eliminating paper and paper-based processes is the key to achieve these seemingly conflicting goals. Printing, shipping, storing and searching paper documents is not only costly but also makes it impossible to share and access real-time information and make well informed health care decisions.

Healthcare industry is rapidly growing across the globe. However, participants within the industry, especially Healthcare Payer organizations, must ensure compliance with a multitude of regulations to avoid potential penalties.

In order to remain competitive in an industry characterized by dynamic growth and complex regulations, Payer organizations need to focus on meeting the following challenges:

  • Better customer service
  • Compliance to state specific regulation
  • Cost optimization and increase in top-line profit
  • Continuous improvement in claim disbursement ratio
  • Affordable healthcare plans
  • Improved Medical Loss Ratio (MLR)


To address these challenges, Payer organizations need to adopt an integrated approach to efficiently manage business processes, maintain and utilize member / provider information, foster enhanced outbound / inbound communication, and comply with regulations. A combination of Business Process Management (BPM), Enterprise Content Management (ECM), and Customer Communication Management (CCM) would serve as an ideal platform to build solutions for automation of key Payer processes.


  • Claims Repair

Claims Repair solution offers rules-driven automation to optimize the handling of claim exceptions. Based on work type and user skills, the solution prioritizes claim exceptions, and automatically routes the right task and documents to the appropriate staff, while seamlessly integrating with adjudication systems. Any additional information is automatically updated in the case file upon receipt, and automatic update-alerts are sent to claims staff.



  1. Automated Exceptions Handling: Reduce processing time and mitigate risk associated with manual claim exceptions handling
  2.  Auto Case Creation: Auto upload of information from feed files and case creation based on work type
  3. Integrated Platform: Real-time information pulling from Core Systtem
  4. Rules-Driven Case Management: Rule-driven routing of cases based on work types; Auto assignment cases based on user skill matrix; Auto closure of cases based on updates received in feed files
  5. Auto Letter Generation: Acknowledgement letters, denial letters, and claims approval, etc.
  6. Compliance Adherence: Real-time claims lifecycle visibility enabling management to keep track of each claim and ensure adherence to service levels and compliance



  • Complaint Tracking And Management

Solution that enables Payers to track each complaint through its lifecycle from recording and initiation to investigation, reporting, and closure. The solution securely stores all documentation pertaining to the complaints received and simplifies search and retrieval of complaint data, to ensure timely resolution of complaints and reduce risks associated with non-compliance with CMS standards.



  1. Automated Workflow: Auto assignment of received complaints based on skills of the users and complaint types
  2. Visibility: Complete visibility in terms of SLA monitoring for various issue levels; Auto color changing of work items helps identify cases nearing deadlines
  3. Rules Engine: Highly complex validation rules with better analysis & research capabilities enable speedy processing and resolution of complaints
  4. Extensive reporting capabilities: The Business Activity Monitoring tool provides end-to-end process visibility, identifying bottlenecks, and allowing proactive corrective actions
  5. Integration: End-to-end, integrated approach helps populate complainant information into and from the core system, resulting in improved operational efficiencies and speedy resolution of complaints
  6. Audit Trail: Complete audit trail of actions taken
  7. Auto Update: Highlighting of updates and summary received from CMS after each upload, helps speed up the process of resolution of cases that are on hold
  8. Automatic Alerts: Alerts and notifications to management based on nearing/missed SLAs, TAT
  9. Auto Letter Generation: Acknowledgement letters, denial letters, claim approvals etc.



  1. Standardize Operations: Streamline and simplify the complaints management process, to eliminate recurring errors, while ensuring speedy complaint resolution
  2. Lower Costs: Reduce operational and penalty costs
  3. Comply with Regulations: Eliminate the risk of non-conformance with CMS rulings and meet timelines for remediation
  4. Improve Member Satisfaction: Faster resolution of requests and improved quality of service leads to enhanced member loyalty and reduced provider attrition



  • Member Enrollment – Medicare And Medicaid

Solution for Member Enrollment process automation enables healthcare payers to achieve an efficient, productive, and streamlined enrollment process. The monitoring dashboard helps create a visible, measurable and process improvement based ecosystem, allowing management to view the complete process from Lead Generation to Member Enrollment. The solution helps insurers to easily handle the receipt and processing of enrollment applications and supporting documentation using an automated workflow.



  1. Automated processing of applications leading to reduced enrollment cycle time from days to hours
  2. Automated case creation based on application form (TIFF images)
  3. Automated reassignment of applications to marketing representatives in case of any document discrepancies
  4. The dashboard function offers a quick snapshot of key performance indicators, with provision for generating multiple reports for different stakeholders, providing end to- end process visibility to key decision makers
  5. Automated generation of HIES (Health Insurance Eligibility Screening worksheet), based on income, number of applicants, family size; Auto color-changing of data-fields of a case helps business users to identify important information in an application
  6. Auto letter generation for exceptions (kickbacks) saves valuable time that was earlier wasted in searching missing documents and follow-ups
  7. As part of the reengineered flow, every application is tracked through the enrollment lifecycle – client impact seen through dramatic reduction in “lost” applications



·         Provider Contracting Process


Solution enables Payers to securely exchange information both within and outside of the organization; improve operational efficiencies; and provide user visibility into the contract data. The solution integrates with existing critical information systems to facilitate enterprise-wide collaboration, and increases accountability by providing rights-based access at department and user levels.




·         Contract Management -Automated and digitized contract management resulting in faster negotiations & approvals

·         Central Repository - All contract data and documentation stored electronically in a central repository, allowing users to share, collaborate and re-use information seamlessly

·         Auto Routing - Based on the type of transaction, it is routed to the respective state level directors; Rule based routing of contracts for parallel processing by different departments

·         Document Indexing – Automatic indexing of one contract in multiple documents and letter generation based on Lines of Business and mailroom stacking; Auto document classification and quality control

·         Integration - Integration with core application for status tracking and batch upload of transaction data;

·         Synchronization with credentialing and claims systems, eliminating redundancy and ensuring up-to-date and accurate provider data

·         Integrated Communication – Auto generation of welcome letters for every new contract / provider