Transforming Member Experience with a Next-gen Digital Engagement Model

Challenge

Traditionally, members would call agents to check if a medical procedure needed pre-certification, which was time-consuming. The goal was to cut costs by making agents more efficient and redirecting some inquiries to self-service channels

Solution

• Created a digital assistant to quickly determine pre-certification
• Set up a self-service channel for members/ providers
• Hired talent with both clinical and calling experience to process pre-certification calls
• Managed inbound pre-certification calls with a team of 350 associates across the Philippines and India
• Handled 1.5 million calls annually

Outcomes

• 25 percent of member and provider pre-certification calls deflected to self-service channels
• 20 percent improvement in agent’s productivity through digital assistant
• Improved member and provider experiences through digital interventions

Challenge

The client was looking to reduce the operating costs of the ‘Nurse Triage’ contact center and improve the injured worker / employer’s experience. Additionally, the company wanted scalability with a flexible staffing model and the ability to transition to a new care management platform (Salesforce CRM)

Solution

• Business Process Re-engineering (BPR)
  • Process decoupling between clinical staff and non-clinical staff
  • Piloted an onshore-offshore hybrid model for nine months
• Digital Transformation
  • Designed workflows and enabled a seamless migration and roll-out to Salesforce
  • Deployed ‘Live Video Nurse Triage’ delivery (onshore) during COVID-19
• Nurse Workflow Tool
  • Incorporated in-house automated quality and complaint management tool – TruAgent
  • Implemented knowledge management tool – iSpring for process training and updates

Outcomes

• Reduction of operational cost by ~43 percent
• Reduction in average handle time by 37 percent
• Complaints rate reduced from 7.8 to 0.4 percent
• Added 6 new employer clients to the portfolio at ‘zero’ incremental cost

Challenge

The client was looking for a solution to manage its healthcare customer support and claims management across channels

Solution

• Processed orders for DME and ancillary services
• Provided telephonic support to injured workers, providers and adjusters
• Intake / order triaging, scheduling, service authorization, retro authorization / re-pricing
• Provider data verification, out-of-network bills Preferred Provider Organization (PPO) status and / or rate Federal Employment Program (FEP) rejects, fee schedule denials, re-evaluations

Outcomes

• USD 5.2 Million annual transaction
• More than 50 percent reduction in handling irregular volume fluctuations
• 98 percent DPU on accuracy
• Improvement in accuracy by 15 percent through scheduling tasks automation
• Gain of 50 percent in turnaround time across functions