Health insurer automates and standardizes processes to clear Medicare audit backlog and reduce costs by 60%.

Process quality issues gave this major U.S. health insurer a major backlog of tedious manual audits, and threatened to render it noncompliant with Medicare requirements. Atos got the process back on track with an efficient and scalable Knowledge Process Outsourcing (KPO) solution, and reduced the cost per audit by more than 60%.

The challenge

A leading U.S. healthcare payer was facing issues complying with Medicare audits for maximum out-of-pocket (MOOP) payments.

MOOP is the amount a Medicare member is required to pay during a calendar year. After this limit is reached, the insurer pays all additional medical expenses for the year.

Unfortunately, two of the insurer’s back-end healthcare and pharmacy claims systems were out of sync, preventing accurate accounting of each Medicare member’s out-of-pocket payments. This led to a two-year backlog of unaudited claims, no mechanism to prioritize them, and no scalability to keep up with a steady inflow of new claims.

Atos was engaged to quickly audit the backlog of Medicare transactions, examine the existing process and make recommendations to improve ongoing process efficiencies.

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The solution

Atos identified three error-prone manual processes that were good candidates for automation, including:

Line-by-line comparison of every mismatch in the claims and pharmacy systems
A simple code to categorize every expense mismatch as either “deductible” or “out-of-pocket” in the claims system
Pre-loading pharmacy claims data that matches the claims system

Atos proposed these changes and the insurer’s team implemented them to increase the speed of the audits, reduce costs and boost productivity.

The ongoing work is being executed by a team of Atos associates in Pune working closely with the insurer’s staff in the U.S.

Business benefit

By employing an offshore team to execute the work, the insurer reduced costs, increased scalability, and achieved greater staffing stability and predictability. Atos KPO services reduced the cost to complete each audit by more than 60%, and the offshore team is able to rapidly scale up or down to manage variations in volume.

The process improvements also saved $1.3 million in costs and accelerated claims audit resolution time by 40%-50%. Total productivity has jumped by 45%, and several long-term benefits have been realized, including:

Detailed process data capture, for use in trend analysis and quality control
Improved process documentation available in the insurer’s knowledge repository
Proactive resource forecasting based on past trends

Since the project transitioned to ongoing support, the insurer has engaged Atos to provide similar KPO services for several other government healthcare products and business lines.