GDI helped an innovative healthcare company with systems and process integration to achieve accurate identification of the dollar liability amount and claim counts for all claims received.
The Challenge
Client Background
GDI’s client is a leader in delivering innovative healthcare products, services and information to more than 3 million members. It has several divisions, including Commercial and Government Operations, Finance, Healthcare, Human Resources, Information Services, Office of the Executive Vice-President, Office of General Counsel and Sales & Marketing.
Project Objective:
The project objective was the development of two new IT applications for internal use to accomplish:
- Integration of a new eBenefits system to Legacy HR and Payroll software
- Development of a solution that supports the actuarial data requirements
- Build of daily updates to all claims history and inventory database to meet the requirements of commercial operations
- Support in other areas of the company such as Claims Throughput, HIPAA and Coordination of Benefits (COB)
The Solution
Project Details:
The project was undertaken for systems integration, as well as for design and development of a solution that supports the actuarial data requirements of the Claims Analysis and Risk Assessment department. The developed system facilitates accurate identification of the dollar liability amount and claim counts for all claims received but not processed for monthly reserve valuation purposes.
The HR/benefits/payroll project was defined with a short timeline and early rollout to 3500 employees, followed by regular bi-weekly utilization with payroll. The Claims project was mandated in part because the company’s external audit had recognized a potentially important weakness.
- The existing system had an unsatisfactory level of accuracy (+/-7%), which is critical to the company's financial stability and profitability.
- The existing system was missing two key components of claims information: claims inventory at month-end and claims by type of service. This information is needed within 48 hours of month-end to deliver financials on schedule.
For the HR/benefits project, GDI’s expert developed a solution that met the needs of the client both with respect to goals and timeline. All critical risks were assessed and obviated working in partnership with the client’s business stakeholders.
For the Claims project, GDI provided both analysis and project leadership. A 10-month overlapping phase project plan was implemented, including analysis and specification phases to gather all requirements and evaluate the feasibility of complete implementation; a proof of concept phase to test the validity of the proposed approach; and execution phase to implement the solution.
The overall goal was to achieve better than +/-2% accuracy and greatly speed availability of results, as well as to make data available across other constituent groups of the company. This project significantly improved corporate financial statements and provided improved forecasting of medical expense claims. Ancillary benefits included improved and accelerated claims handling, and greatly expanded analyses of Claims inventory data.
Key Responsibilities:
- GDI consultants collaborated with the client teams for identification of different problem areas.
- We deployed highly specialized analysts with both extensive technical and business domain experience.
- Our consultants applied expert business analysis skills in design and development of proposed solutions to ensure that the solution met client requirements.
- We closely collaborated with client stakeholders to carefully determine end-point goals and the resources required to reconcile these with feasible technical solutions.
- The developed solutions were analyzed and tested continually and project plans were tracked with regularity to deliver the solution on time.
The Results
- The project led to improved efficiency in project implementation and a unified version control approach.
- The audit process caught defects before production, reducing downtime and the cost of re-work.
- GDI helped the client to establish a professional management approach to support projects, which directly translated to well-managed IT operations.
GDI’s expert developed a solution that met the needs of the client both with respect to goals and timetable. All critical risks were assessed and addressed. This project significantly improved corporate financial statements and provided enhanced forecasting of medical expense claims.