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Newgen’s Healthcare Payer Practice

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Newgen’s Healthcare Payer Practice - Accelerate business performance, control costs, and meet mandates

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Newgen’s Healthcare Payer Practice

  1. 1. Newgen’s Healthcare Payer PracticeAccelerate business performance, control costs,and meet mandates
  2. 2. Healthcare Payer LandscapeHealthcare industry is booming across ! Continuous improvement in claim Content Management (ECM) and,the globe. However, participants within disbursement ratio Customer Communicationthe industry, especially Healthcare ! Affordable healthcare plans Management (CCM) would serve as anPayer organizations, must ensure ! Smooth transition from ICD 9 to ideal platform to build solutions forcompliance with a multitude of ICD 10 code automation of key Payer processes.regulations to avoid potential penalties. ! Improved Medical Loss Ratio (MLR)Moreover, to remain competitive in anindustry characterized by dynamicgrowth and complex regulations, Payer To address these challenges, Payerorganizations need focus on meeting organizations need to adopt anthe following challenges: integrated approach to efficiently manage business processes, maintain Over 80% of health plans reported and utilize member/provider! Better customer service ICD-10 compliance as the primary information, foster enhanced! Compliance to state specific driver of increased budgets in 2012. outbound / inbound communication, regulation and comply with regulations. A! Cost optimization and increase in combination of Business Process IDC Health Insights 2012 top-line profit Management (BPM), Enterprise
  3. 3. Compliance Mandates Drive BPM Adoption ForHealthcare & The Public Sector Public sector & healthcare: “Which of the following have been major drivers for business process management software adoption?” Optimization of processes 72% Support for compliance efforts 59% Increased productivity for process workers 56% The ability to provide real-time visibility into key processes 52% Ensuring consistent process execution across divisional or geographic boundaries 49% The ability to model business processes 41% The ability to change processes quickly & easily 39% Base: 71 software decision-makers (multiple responses accepted)57494 Source: Forrsights Software Survey, Q4 2010 SOLUTIONS FOR BUSINESS PROCESS & CONTENT MANAGEMENT
  4. 4. Newgen’s Healthcare Payer SpectrumNewgens solution framework enables power of Imaging, Document “Success [of Healthcare Payers] will dependhealthcare organizations to effectively Management, Business Process on maintaining focus and assembling theaddress the challenges originating from Management, and Member/Provider right set of BPM skills. And for the businessregulatory compliance, cost control Communications Management, to process executive acting as the changeand customer satisfaction. Our render solutions built to address the agent, this means a laser focus on theHealthcare Process Automation & specific requirements of Healthcare disruptive and transformative aspects of theOptimization Suite combines the Payers. process improvement initiative.” Forrester Research Inc. Business Configurable Process Automation and Improvement Framework Preconfigured letter A quick snapshot of Collaborative & Distributed templates for process, performance, Process standardization, integrated creation, scanning acknowledgement, ageing inventory, auto routing, prioritization of capture, organization, document capture, additional info, and final types of appeals & work items, business rules archival and retrieval image quality disposition with workflow grievances, resolved & SLA adherence of documents enhancement based validations escalated/ exception cases, etc. Fig: Newgen Solution-Component Framework Management Dashboards Case Compliance Ageing Report SOLUTIONS FOR BUSINESS PROCESS & CONTENT MANAGEMENT
  5. 5. Leading US Healthcare Payer transforms multipleprocesses with Newgens Solutions Claims Repair · Productivity improvement – Organization saved approximately 5K to 7K man-hours monthly due to automation · Auto generation of Letter to the Provider for any claims communication · Integrated platform – auto Member and Provider data pulling from core claims application, thus making the process faster Appeals & Grievances · Increase in user efficiency by 50% due to data integration in single UI for Member/ Provider/ Claims/ Pharmacy etc. · Auto redirect of appeals within department thus reduction in loss of cases · Complete audit-trail of case history maintained for Management view Enrollment Process · Reduced time spent on administrative tasks by sales force by 67%, driving huge revenues · Reduced TAT on new member enrollment applications by 76% - from 17 to 4 days · Reduced error rate in applications by 35% by minimizing manual intervention in the enrollment process Complaint Tracking · Compliance Improvement - Compliance level up by 25% · Reduction in complaint resolution time · 78% resource optimization Provider Contracting · 60% reduction in TAT - from 25 to 10 days, to activate a new Provider contract · Auto generation of Welcome Letter to the Provider on new contracts · Auto alerts for “Contract Renewal” SOLUTIONS FOR BUSINESS PROCESS & CONTENT MANAGEMENT
  6. 6. Claims RepairHandling claims is often staff intensive need to minimize provider abrasion Solution Highlightsand characterized by manual processes. ! No real-time integrated performance Ÿ Automated Exceptions Handling -Moreover, any delay in claims management system and on-line Reduce processing time and mitigatedisbursement leads to high “Penalty performance metrics for productivity, risk associated with manual claimPayout”. This puts payers under turnaround time and analytics exceptions handlingconstant pressure to improve ! Need to retrieve data from Core Ÿ Auto Case Creation - Auto uploadoperational performance and reduce Application in real-time for faster of information from feed files and casecosts. While claims auto-adjudication processing creation based on work typehas become common place now-a-days, ! Compliance with state and federal Ÿ Integrated Platform - Real-timeyet many payers are still processing a regulations information pulling from Coreconsiderable proportion of claims Systemmanually. Claims Repair – addressesthose claims that cannot be handled Newgens Claims Repair solution offers Ÿ Rules-Driven Case Management -through the auto adjudication process. rules-driven automation to optimize the Rule-driven routing of cases based onThese claims are “error out” from one handling of claim exceptions. Based on work types; Auto assignment casesof the multiple systems during work type and user skills, the solution based on user skill matrix; Autoadjudication process. prioritizes claim exceptions, and closure of cases based on updates automatically routes the right task and received in feed files documents to the appropriate staff, Ÿ Auto Letter Generation -Challenges while seamlessly integrating with Acknowledgement letters, denial! Time-consuming and erroneous adjudication systems. Any additional letters, claims approval, etc. processing of claim exceptions due to information is automatically updated in Ÿ Compliance Adherence - Real-time manual handoffs between the case file upon receipt, and claims lifecycle visibility enabling departments automatic update-alerts are sent to management to keep track of each! Lack of process visibility; Inefficient claims staff. claim and ensure adherence to Managed Care Center operations and service levels and compliance
  7. 7. Appeals & GrievancesHandling appeals and grievances is a Agreement (SLA) and corresponding Ÿ Rules Engine: Automatic due daterigorous, time-consuming, and costly turnaround time (TAT) calculation, validations for doing theprocess – more so when it is done ! Need to adapt to dynamic process work right the first time, escalations,manually. Further, the process is highly changes and regulatory requirements email-based alerts, and exceptionsregulated, scrutinized and monitored, ! Inefficient, manual complaint managementwith non-compliance leading to huge processing with no provision for Ÿ Content Management: Supportingfines and penalties. All this adds to the automated alerts, notifications and documents such as signature forms,pressure faced by payer organizations escalations to managers about the physician reports, etc. automaticallytrying to ensure consistency, quality and cases with expired due dates detected upon arrival and attached totimeliness in responding to member the corresponding case file; Reducedrequests. cases of misplaced and lost documents Newgens solution for appeals and grievances process automation enables Ÿ Case Prioritization: Based onChallenges payers to resolve member requests compliance due date, expedited! Highly regulated, scrutinized and within specified timelines, reduce request and other set of configurable monitored process with significant operational costs, enhance operational variables fines and penalties for non- efficiency and demonstrate compliance Ÿ Monitoring Dashboard: End-to-end compliance – ultimately leading to improved levels process visibility with real-time! Need to commit to the consistency, of member satisfaction and higher profit reports, allowing management to accuracy, and standardization margins. gauge efficiency requirements Ÿ Audit History: All changes made to! Difficult and time-consuming Solution Highlights any data field tracked along with user, process of retrieving case date and, time information Ÿ Automated and Streamlined information from disparate sources Workflow: Elimination of data entry Ÿ Auto Routing: Immediate routing! Providing status to appellants on errors and process compromises due and redirection of files between their appeals /grievances in real time to reduced manual handoffs; Process departments! Each line of business standardization and consistency Ÿ Auto Letter Generation: Automatic (Claims/Pharmacy/Core across intake channels, result in faxes and letters to members and Appeals/Grievance) has its own improved quality and timeliness of providers; all correspondence record different mandated Service Level decision making maintained along with the case file SOLUTIONS FOR BUSINESS PROCESS & CONTENT MANAGEMENT
  8. 8. Member EnrollmentMember enrollment, the first step in the ! Ineptness to effectively and efficiently representatives in case of anyMember Servicing cycle, is a critical handle exceptional cases document discrepanciesbusiness process that is often fraught ŸThe dashboard function offers a quickwith numerous errors and irregularities, Newgens end-to-end solution for snapshot of key performancedue to paper-based, manual processing. Member Enrollment process indicators, with provision forThis leads to the process often automation enables healthcare payers generating multiple reports forbecoming frustrating for the prospective to achieve an efficient, productive, and different stakeholders, providing end-member, and time consuming and costly streamlined enrollment process. The to-end process visibility to keyfor the payer. monitoring dashboard helps create a decision makers visible, measurable and process Ÿ Automated generation of HIESChallenges improvement based ecosystem, (Health Insurance Eligibility Screening! High turnaround time between allowing management to view the worksheet), based on income, submission and approval of an complete process from Lead number of applicants, family size; Auto application Generation to Member Enrollment. color-changing of data-fields of a case! Significant error rates in application The solution helps insurers to easily helps business users to identify handle the receipt and processing of important information in an processing enrollment applications and supporting application! Inefficient use of staff with a documentation using an automated Ÿ Auto letter generation for exceptions significant amount of staff time workflow. (kickbacks) saves valuable time that wasted in managing administrative was earlier wasted in searching tasks Solution Highlights missing documents and follow-ups! Lack of a robust tracking mechanism Ÿ Automated processing of applications Ÿ As part of the reengineered flow, to monitor each application through leading to reduced enrollment cycle every application is tracked through the enrollment lifecycle leading to time from days to hours the enrollment lifecycle – client impact high loss rates for applications Ÿ Automated case creation based on seen through dramatic reduction in! Difficulty in managing applications application form (TIFF images) “lost” applications tracking sheet and orphan documents! Complex business logic for processing Ÿ Automated reassignment of member enrollment business process applications to marketing
  9. 9. Complaint Tracking & ManagementOperating in the highly regulated ! Absence of a mechanism to track validation rules with better analysis &healthcare landscape, it is of utmost member correspondence research capabilities enable speedyimportance to Managed Care processing and resolution oforganizations to manage complaint Newgens complaint tracking and complaintstracking appropriately. The challenge is management solution enables Payers to Ÿ Extensive reporting capabilities -to resolve the complaints which have track each complaint through its The Business Activity Monitoring toolcome from the Center for Medicare lifecycle from recording and initiation to provides end-to-end process visibility,and Medicaid Services (CMS) in the investigation, reporting, and closure. identifying bottlenecks, and allowingshortest possible time. Moreover, The solution securely stores all proactive corrective actionsregulatory infractions may cost documentation pertaining to the Ÿ Integration - End-to-end, integratedhealthcare payers huge penalties. complaints received and simplifies approach helps populate complainant search and retrieval of complaint data, information into and from the coreChallenges to ensure timely resolution of system, resulting in improved! Difficulty in monitoring the status of complaints and reduce risks associated operational efficiencies and speedy compliance to TAT SLA with non-compliance with CMS resolution of complaints! Measurement and monitoring of standards. Ÿ Audit Trail - Complete audit trail of process performance actions taken! Manual search in multiple core Solution Highlights Ÿ Auto Update - Highlighting of applications for member Ÿ Automated Workflow - Auto updates and summary received from demographic and eligibility assignment of received complaints CMS after each upload, helps speed information based on skills of the users and up the process of resolution of cases! Manual allocation of work complaint types that are on hold! Integration of people, workflow and Ÿ Visibility - Complete visibility in Ÿ Automatic Alerts - Alerts and core system terms of SLA monitoring for various notifications to management based on! Manual routing of complaints to issue levels; Auto color changing of nearing/missed SLAs, TAT concerned departments (Pharmacy/ work items helps identify cases Ÿ Auto Letter Generation - Billing/ Claims/ Enrollment) for nearing deadlines Acknowledgement letters, denial resolution Ÿ Rules Engine - Highly complex letters, claim approvals etc. SOLUTIONS FOR BUSINESS PROCESS & CONTENT MANAGEMENT
  10. 10. Provider Contract ManagementProvider contracting process deals with ! Missed renewal dates, and data entry Ÿ Central Repository - All contractend to end tracking of provider errors due to manual processing data and documentation storedcontracts throughout the contract ! Time consuming activity of Provider electronically in a central repository,lifecycle from creation, negotiation, Contracting document creation and allowing users to share, collaborateapproval, to termination. Healthcare approvals and re-use information seamlesslypayers process tens of thousands of ! Manual process of compliance Ÿ Auto Routing - Based on the type ofcontracts each year. Each provider auditing transaction, it is routed to thecontract is stored on paper and respective state level directors; Rule-managed manually making the process based routing of contracts for parallel Newgens Provider Contractof updating contracts, variance analysis, processing by different departments Management solution enables Payers toand compliance audits time-consuming Ÿ Document Indexing - Automatic securely exchange information bothand erroneous. indexing of one contract in multiple within and outside of the organization; improve operational efficiencies; and documents and letter generationChallenges provide user visibility into the contract based on Lines of Business and! Paper-based process, with information data. The solution integrates with mailroom stacking; Auto document stored in disparate databases and existing critical information systems to classification and quality control isolated filing cabinets facilitate enterprise-wide collaboration, Ÿ Integration - Integration with core! Time-consuming manual process of and increases accountability by application for status tracking and searching various sections of the providing rights-based access at batch upload of transaction data; contract for relevant information department and user levels. Synchronization with credentialing and claims systems, eliminating! Document access based on the users Solution Highlights redundancy and ensuring up-to-date and departments rights and accurate provider data! No real-time tracking of the contract Ÿ Contract Management - Ÿ Integrated Communication - Auto status (active/inactive) by Provider Automated and digitized contract generation of welcome letters for Relationship Representatives (PRRs) management resulting in faster every new contract / provider negotiations & approvals
  11. 11. Our Products ™ ™Business Process Management Suite Forms Processing EngineOmniFlow is a platform-independent, scalable Business OmniExtract is the data capturing solution which extractsProcess Management Suite (BPMS) that enables automation business-critical information from image documents andof organizational business processes. OmniFlow is designed forms. It can extract all possible kinds of information liketo ease the creation, deployment, modification and Hand-printed/ Handwritten Characters, Optical Marks,management of Business Processes. Built using open Barcode, Machine-printed Characters and MICR Fonts.technologies, it has seamless integration abilities allowing itto be introduced into any IT infrastructure. ™ ™ Invoice Processing SystemEnterprise Content Management Suite Newgen’s Invoice Processing System, with automatic data verification and validation capability, is a solution forOmniDocs is an Enterprise Content Management (ECM) automatic data capture from semi-structured invoiceSuite for creating, capturing, managing, delivering and documents. It also supports seamless integration with SAParchiving large volumes of documents and content. and other ERP’s.OmniDocs manages Scanned Document Images, ElectronicDocuments and Emails as records. It also supportsseamless integration with other enterprise applications. ™ Image-Based Check Clearing & Payment ™ Newgen’s ChequeFlow is an image based Cheque ProcessingCustomer Communication Management solution for inward and outward clearing. Advanced and highlyNewgens Omni Output Management System (O2MS) configurable sub-systems for Automatic Signature Verification,delivers smarter & targeted communications for better FOREX Cheque Processing, PDC Management, ECS/ACHcustomer experiences. It offers the capability of leveraging mandates, add-ons for Cheque Deposit Machine/ paper space for customer centric inline advertisement,consolidation across multiple products. It enables securecommunication on improved templates with rich designs and ™graphical representation of analytics across multiple Governance, Risk & Compliancedistribution channels. In addition easy archival & retrieval ofcorrespondences for presentment & efficient customer Compliance Manager is an integrated solution forrequest resolution is achieved using this enterprise application. Governance, Risk and Compliance that’s geared to ensure compliance with standards, best practices and guidelines of various regulatory acts. ™Enterprise Reports Management and ArchivalOmniReports stores trillions of computer-generated output ™pages and reports in a highly compressed form. It has a high- Production and Distributed Scanning Suitespeed ingestion process with simple interactive definitions, OmniScan is a production and distribution software scanningenables instant access to terabytes of reports independent of for document image capture. It supports distributedbusiness application, and is fully searchable at field/row/page scanning, image quality enhancement and delivery oflevels. OmniReports is ideal for sun-setting of business documents to business systems.applications as well as optimizing core system performance bypurging historical reports. SOLUTIONS FOR BUSINESS PROCESS & CONTENT MANAGEMENT
  12. 12. About Newgen• Leading Global Provider of Business Process Management (BPM), Enterprise Content Management (ECM) & Customer Communication Management (CCM)• 850+ installations across 45 countries• Solutions for Banking, Insurance, Healthcare, BPO/SSCs, Telecom and Government• Credited with some of the worlds largest implementations• Innovative culture, consistent R&D investments, 35 patents• Employee strength 1100+• Certified for ISO 9001:2008, ISO 27001:2005 and CMMI Level3 What Analysts Say Investors Proven for Flexible and Value for Money Large volumes Cost Effective ® 2010 BPMS & 2011, DOCCM 2011 BPM 2011 ECM MQ Wave Report Decision Matrix Reports SOLUTIONS FOR BUSINESS PROCESS & CONTENT MANAGEMENT