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Case study

The challenge

Our client, a large regional health plan serving more than two million members in the midwestern United States, was operating on a 30-year-old legacy system that lacked the flexibility and scalability needed to keep pace with changing regulations, high claims volumes and consumer expectations. The existing system failed to support the plan’s core business and was unable to deliver due to a lack of automated processes, inaccurate benefits configuration and sluggish, inaccurate provider reimbursements. As a result, it faced adverse business consequences such as fiscal penalties and reduced credibility and trust with providers and members alike.

Our approach

The client turned to Cognizant for solutions to address its immediate challenges, as well as gain needed flexibility to adapt to new regulations—such as data interoperability and price transparency. The company also needed scalability and power capabilities to meet new industry opportunities as they arise. The client entered a multiyear contract with Cognizant to address these key business needs.

Two key strategies were outlined to achieve the client’s goals, migrating to the TriZetto® Facets® platform—Cognizant’s next-generation core administration system that integrates consumer, care, claims and revenue management in a single, flexible platform—and optimizing processes. The critical focus areas included automation, process reengineering, best practices and standards, data simplification and proven configuration methodology. Once Cognizant migrated the client to Facets, a business process optimization plan was initialized, and a benefits automation center of excellence (BCoE) was created. This was the starting point to automating the client’s internal processes and ultimately improving brand reputation.

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Rebuilding brand reputation from the core

The client saw meaningful improvements across all target areas within the first year of migrating to Facets. Customer feedback validated the improvements in end-to-end configuration turnaround time, quality and system operations. Each of the client’s leading metrics had a direct impact on the quality of its member and group experiences. For example, at the end of year one, auto-adjudication rates had improved to reach 95%, first-pass accuracy improved to 98%, and the number of backlogged claims decreased by more than 97%.  Productivity improvement continued in the second year with several notable improved efficiencies. Year-over-year productivity improved, allowing a 50% staffing reduction in three years. Peak period inventory decreased by 94%. The client was also able to quickly ramp up processes for managing individual policies and renewals during the coverage upheavals that resulted from the economic effects of COVID-19. By adopting a modern core platform that powers more automation and best practices, the company is not only regaining credibility but also poised to retain and grow its market share.

95%

auto-adjudication achieved

97%

reduction in claims backlog

98%

first-pass accuracy achieved

60%

decrease in number of claims remediated by year two