Putting Medicaid Claims Processing on Fast Track

Wipro helped a Midwestern US State Department of Social Services move to a 99.75% paperless environment for Medicaid claims submission by automating its IT processes

Client Background

The client is responsible for the Medicaid program in a state that has 890,000 Medicaid participants and 38,000 Medicaid providers, covering hospitals, physicians, pharmacies, clinics and nursing homes.

The client processes 100 million claims, worth $6.3 billion annually, touching about 1 million lives of Medicaid beneficiaries.

Industry Landscape

The US healthcare industry is in the midst of a seismic change. There is a need for an immediate and substantial investment in IT systems to ensure that those eligible are brought under the Medicaid expansion program in time.

Healthcare reforms have led the public health agencies to use technology innovation. The focus is to support proactive outreach, facilitate Medicaid enrollments through community initiatives and modernize business processes and technology.

Opportunity

The client wanted to upgrade its Medicaid Management Information System (MMIS) that processes Medicaid claims. The objective was to achieve a paperless and automated system for claims processing.

The existing, complex IT architecture was unable to scale to business demands and lacked operational flexibility. Some of the key challenges that the client faced were longer time to process claims that even took up to two days in some instances, an ineffective self-service channel that deterred electronic submission of claims and led to higher call center volumes.

One of the strategic priorities was to modernize the legacy IT system for keeping electronic records of patient profiles. The idea was to implement a flexible and an agile IT system and business service.

The Wipro team has done excellent work for our client in keeping their system compliant with CMS regulations and making it the first state capable of doing real-time adjudication of all Medicaid claims"- Mohammed Haque Vice President, Healthcare at Wipro

Solution

Wipro partnered with the client to upgrade its entire application landscape for enrollment, verification, point of sale (PoS) and claims payment, with service-oriented architecture.

We replaced the client’s entire legacy IT backbone with Commercial Off-The-Shelf (COTS) system to automate its claims processing.

Our architecture helped the client manage the 100 million claims paid by it annually. The team overhauled the client network capabilities that handled 775,000-plus customer service calls, along with HIPAA privacy and security provisions.

We developed, maintained and upgraded the client’s Medicaid Management Information System and Medicaid Internet site, e-Momed, and related online applications to address paper filing gaps. We also provided a full set of e-submission services to address self-servicing by providers where it has 41,000 registered users.

Business Impact

Real-time auto adjudication capability improved to 100% from 60%
Achieved 99.75% paperless claims submission, covering more than 100 million claims annually
The average time for paper claims processing decreased to 0.69 days from 2 days
Achieved annual savings of $2.9 million by automating provider claims submission
Improved process performance and reliability with reduced clinical and business error rates
Helped process 27 million annual claims via PoS development and maintenance
Helped comply with HIPAA guidelines, including increased security of transaction management

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