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Case study
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Healthcare case study

Powering business expansion with TriZetto QNXT

The adoption of TriZetto QNXT helped MedPartners automate adjudication, reduce costs and gain the power to grow.

At a glance

Industry
Healthcare

Challenge
Find and implement a claims and referral management platform to drive business expansion

Products and services

TriZetto QNXT
TriZetto QNXT Workflow Engine

Success Highlights

  • Saved $821,240 in annual labor costs
  • Increased auto-adjudication to 75%
  • Achieved 50% automation of referral program
  • Increased operational efficiencies by 50%
  • Redeployed 25% of staff to other key initiatives

The challenge

MedPartners is a managed services organization wholly owned by Clinicas del Camino Real, Inc., a company that delivers healthcare services in Ventura County, California. Clinicas launched MedPartners to expand its revenue streams by offering administrative and claims processing services to central California markets. While MedPartners operated an on-premises core system, it outsourced its claims adjudication services to the core system’s vendor. As the business grew, it became apparent that the initial core administrative system could not support MedPartners’ vision and expansion.

Low automation, expensive manual workarounds

Minimal automation capabilities of the legacy claims processing system resulted in a low auto-adjudication rate, averaging about 40%. MedPartners staff were manually adjudicating the remaining 60% of claims, including all institutional claims. This required significant resources. Any growth in claims volume would require MedPartners to hire dozens of additional employees and acquire office space for them. 

Physician referrals were also creating challenges in the way requests for referrals had to move manually from MedPartners’ utilization management department to its nursing review area. Then, after the referral decision was made, staff had to write, print and mail notification letters to patients and specialist healthcare providers. This process was slow and prone to inaccuracies, leading to friction in provider and patient relationships. 

MedPartners’ system vendor was often late in updating its system with new CPT/DX codes and these outdated codes led to incorrect claims adjudication and attempts to claw back erroneous reimbursements, creating further provider discord. In addition, error-prone, delayed processing put MedPartners at risk for state regulatory fines and was likely becoming detrimental to its reputation.

In short, the existing core system did not enable MedPartners to present a compelling quality or value story necessary to win new business. 

Our approach

MedPartners searched for a modern core administrative platform that could support its business expansion plans. Requests for Proposals (RFPs) and site visits led to the selection of the TriZetto® QNXT™ platform from Cognizant.

QNXT offers the automation and integration capabilities needed to automate critical manual processes and integrate key third-party systems and applications. These capabilities also enable MedPartners to achieve a much higher auto-adjudication rate, streamline referrals and contain costs.

our approach
Improving speed and accuracy

The new integration between QNXT, the provider portal and MedPartners’ electronic medical records (EMR) system resulted in a 34% automatic approval of all authorization requests coming from the EMR. QNXT ingests and processes referrals every 15 minutes. It updates header and service level status, and QNXT microservices automatically generate authorization letters to providers. We integrated a fax application to automate digital faxing to providers while the client’s business team receives completed notifications for review. 

QNXT’s ability to integrate key third-party data and applications saves costs by allowing MedPartners to perform system maintenance in-house versus using an outside vendor. A QNXT API securely obtains physician data directly from the NPI registry, streamlining provider loads. The integrations have improved accuracy and throughput in claims editing and third-party pricing and code maintenance.

“The QNXT system continually enables us to find more efficient ways of working so we can contain costs while improving service quality.” 

—Anwar Abbas, Chief Information Officer, Clinicas del Camino Real, Inc.

“Cognizant’s QNXT claims and referral management services have significantly elevated our managed services operations.  Through their innovative solutions, we have experienced a remarkable reduction in operational costs and administrative burdens, paving the way for enhanced efficiency and excellence in our healthcare delivery.”

—Sean Paul, Executive Director, Clinicas del Camino Real, Inc.

Business outcomes

All MedPartners’ institutional claims now adjudicate automatically. The organization automatically transmits ANSI 835s to providers so they have direct visibility into claims volumes at their clearinghouse. We also helped MedPartners identify and address root causes of pending claims, reducing monthly pended claims to less than 10,000 per month, compared to as many as 30,000 to 60,000 claims previously. Only extremely complex claims now require human attention and manual adjudication.

MedPartners’ auto-adjudication rate improved from an average of 40% to consistently more than 75%.  The referral program, previously 100% manual, has now been automated by 50%.  Operational efficiencies have increased by 50%, enabling MedParters to redeploy 25% of its staff to other key initiatives.

Efficiencies from automation and integration powered by QNXT have generated an annual labor savings of more than $821,240. Provider service calls about claims have dropped by 20%, and provider appeals and disputes by 15%. The overall improvements, coupled with positive reductions in operations, have also raised health plan audit scores by more than 20%.

Accurate, timely claims adjudication results in less friction for health plan members and their providers. Automated referrals expedite members’ access to the health services they need, which should lead to better health outcomes.

Business outcome
About the client

MedPartners is a managed services organization (MSO) wholly owned by Clinicas del Camino Real, Inc. Clinicas provides quality, comprehensive and preventative healthcare services to Ventura County, California. MedPartners offers claims, eligibility and medical management processing services to health plans serving central California markets. For more information visit www.clinicas.org.