Canada
Puerto Rico
USA
Belgium
France
UK
India
Client Background
Our client is a Fortune 50 multinational health insurance provider that provides diverse Medicaid, Medicare, and Commercial plans across the US.
Client Need
Our client faced challenges consolidating disparate regional plan, member, and pricing data from multiple payers into a single, unified system. Key challenges included:
Siloed data across payers, encompassing enrollment, provider, authorization, and lab claims modules
Manuel contract review required significant time to determine compensation terms and ensure accurate reimbursement configuration in the pricing system
Solution
We took a multi-faceted approach to address these challenges:
Contract Review: Analyzed provider contracts to determine compensation schedules based on LOBs - Medicare, Medicaid, and Commercial
Reimbursement Term Identification: Identified reimbursement types, such as standard/custom and key terms related to provider specialty
Pay Class Assignment: Assigned payclass guides based on reimbursement methodology and provider specialty (Physician, Ancillary, Hospice, Home Health, Ambulatory)
Configuration Management: Created ServiceNow change requests to ensure contract-compliant configurations
Realized Benefits
The solution provided the following benefits:
Pricing configurations aligned with provider contract reimbursement terms
Enabled accurate provider compensation
Improved payment accuracy and strengthened provider relationships
Contributed to a healthy and robust provider network
Improved provider relationships and accurate payments to increase member satisfaction
Tools & Technologies
IBM DataStage
Sybase
Greenplum Database
Emptoris
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