Enrollment Process in Healthcare

Client Background

Client is a large health insurance products and services provider for employer groups and members in Central Pennsylvania and the Lehigh Valley, US. It offers medical insurance, Medicare and dental insurance products; health coverage; health maintenance organization products; accidental death and dismemberment coverage.

Industry Landscape

In the current Medicare Advantage environment,there is a need for dynamic adjustments & changes. Under the Centers for Medicare and Medicaid Services (CMS) Star Rating System, health plans are under pressure to attain high customer satisfaction to remain competitive in the market.

Success can be attained by having an exceptional system, expert staff,standardized processes, and advanced policies and procedures. By developing and maintaining a relationship with vendors, health plans have the ability to create an alliance that promotes superior services, knowledge, planning, and results.

Opportunity

Enrollment of new members is of key focus to insurance providers. So, when the client, a large US health plan provider, decided to overhaul their member enrollment system, they turned to their trusted technology partner of over 10 years: Wipro.

One of the key concerns was to enable the system to handle ever growing number of letters required by healthcare regulatory body, CMS, to be sent to members. Increasing pace of reforms has expanded the membership base as well and success was driven by the need for a more user-friendly interface and the necessary system that is future ready for increasing computing demand.

Solution

Wipro’s team quickly identified and streamlined the entire enrollment process, which includes verification and member management, by automating validation and documentation at all input and processing points. This was achieved by implementing one of Wipro’s IP, called Member 360, which is comprehensive membership management solution for Healthcare Payers.

Member360 is Web-based solution delivered over SaaS platform, which had subscription-based costing to the client. This aligned with client’s IT roadmap for scalable applications and infrastructure with reduced total cost of ownership.

With Wipro’s Member360 in-built record keeping module in place, the client was able to access all letters that were generated for members, solving what had been a long-standing challenge for them.Also the user friendly interface was received greatly by the strong client workforce dealing with enrollment.

Several key feature of the solution also included improving CMS Star Rating, enrollment reconciliation, billing, verification using CMS Medicare database, regulation compliant appeals and grievances module etc.

For overall success of the engagement, Wipro ensured deep involvement throughout the design and implementation process to reduce the turnaround time for the client.

Business Impact

With Wipro’s experienced domain team, client was able to quantify the efficiency with a time study. Wherein previously it took 15 to 17 minutes to process an enrollment,it now takes 1.5 to 3 minutes to accomplish the same task. Moreover, staff satisfaction with the system has increased noticeably, including a drastically improved training process.In sum,after implementing Member360,client has seen markers for success on several grounds:

Significantly decreased time to process enrollment requests
Increased automation
Higher staff satisfaction
Improvements in staff training
Decreased costs due to staff reduction
Decreased costs due to paperless transactions

"Wipro helped us to automate 60 percent of our processes, and reduce our staff by 50 percent. Overall, it has been a huge success for us" - Director for Medicare Enrollment, Billing and Reconciliation, large US Healthcare Payer

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