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Case study

The challenge

A major U.S. healthcare organization with more than one million members in its government programs had difficulty modernizing the systems and capabilities required to comply with the emerging regulatory requirements of the Centers for Medicare and Medicaid Services. Its systems were outdated and expensive. Low automation rates, extensive manual processes and non-standardized data structures resulted in inadequate claims processing turnaround times and claims pricing inaccuracies. Antiquated customer service tools and minimal interactive voice response capabilities resulted in poor user experiences that hurt the brand and its standing with CMS.

The payer turned to Cognizant's healthcare technology experts for a comprehensive yet cost-effective solution that would solve its immediate need for a modern, end-to-end solution and provide a foundation for thriving under value-based care.

Our approach

We deployed our Business Process-as-a-Service (BPaaS) solution for government programs, delivering a comprehensive TriZetto Facets core administration platform as a hosted service operated by Cognizant and overseen by the client. To begin with, Cognizant addressed the root causes of claims and encounter issues by collaborating with the payer’s senior operations executives and drawing on their extensive experience in government health plan administration. Facets enabled streamlined maintenance, standardized processes and improved system capabilities to reduce claims backlog. The solution also enhanced provider-matching rates by 3% to 4%, eliminating the chances of authorization rejection by plans due to invalid procedure codes.

A separate project introduced the Encounter Data Management module of Facets. It not only improved encounter utilization monitoring acceptance rates from 83% to 92% in just a month but also enabled the submission of more than $450 million in backlogged encounters, improving the payer’s revenue stream. Automating HIPAA authentication and self-service claims helped reduce call volume by 15% and call time by 30 seconds for remaining 51% of the call volume. 

Facets core administration solution boosts revenue streams

Cognizant helped the healthcare payer meet regulatory compliance levels and position itself for success under a value-based care model and emerging mandated interoperability requirements by improving processing speed and data accuracy. Integrating Facets features like NetworX Pricer helped the client achieve over 99% pricing accuracy through automation. We not only helped the payer enhance member and provider experiences but also boost its revenue.


reduction in plan administration TCO


reduction in call volume


claims pricing accuracy