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HEALTHCARE

Accelerated Migration Expedites Claims Pricing Efficiency

The Challenge

A large, not-for-profit health plan wanted to streamline its outdated multi-system pricing methodologies into a single unified model. The health plan had been using three different legacy platforms, operated by independent teams, to price and process its preferred provider organization and health maintenance organization claims. This separation resulted in different payment methodologies being assigned to identical services. In addition, the outdated systems affected the health plan’s ability to accommodate newer pricing models to keep pace with the evolving market. The health plan reached out to Cognizant for a solution to transform its costly and inefficient pricing into an effective and efficient model.

Our Approach

We implemented the TriZetto NetworX Pricer® and NetworX Modeler® solutions for the health plan’s three core legacy systems. This provided a single source of claim pricing across all lines of business, as well as greater consistency and accuracy. In addition, we helped the health plan with a transformational project to reassess and simplify all its payment policies and procedures in concert with its system migration. This accelerated migration expedited operational and medical cost savings and reduced the duration of running multiple systems in parallel.

Increased Accuracy and Efficiency Improved Provider Satisfaction

Using the TriZetto NetworX Pricer and NetworX Modeler solutions, the health plan significantly reduced the instances of both over- and underpriced claims—resulting in a net medical expense reduction of 1%. Its claims are now priced with greater precision and consistency to deliver operational and medical cost savings and improved provider relations.

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Reduced

CMS/Optum update implementation time from approximately three months to one week

Compressed

2,500+ default fee schedule tables to 48

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