A New IT System For A New Window Of Opportunity

A New IT System For A New Window Of Opportunity

A reimagined solution for a leading regional healthcare payer.

Overview

Even before COVID-19, our Client saw the importance of leveraging new technologies to improve operational efficiency, empower customer-centricity and timely meet regulatory requirements. The leading regional TPA identified the need to modernize their legacy IT system as a crucial step to fulfilling these requirements, made correctly through a broader, digital-first, data-driven transformation strategy.

Challenges

1

Provide Advanced Digital Customer Experience

For the Client, it was imperative to improve customer interactions and enable self-service. Quality was of utmost importance, especially when the company was moving towards a more customer-centric and competitive services.

2

Widen The Partnership Eco-System

The process of integrating partners into the Client’s system took time, money and efforts. The company needed to create the ability to seamlessly and easily integrate into a growing network of partners. Thus, improving services to members.

3

Respond Swiftly to Regulatory Requirements

With changing regulatory requirements and increasingly complex implementations, the Client had to break the shackles of the past and revamp their legacy system.

4

Offer Higher-Value Missions to Employees

With automation, new and higher value opportunities were thought to emerge; the Client needed to engage individuals, help them reach their full potential and reduce remedial low value administrative costs and work.

What We Did

Core System

We developed a new core system offering full end-to-end automation and visibility. It covers eligibility management, provider management, approvals processing and claims adjudication, payments, customer care, reporting and analytics, with a fully automated integration with regulators.

Members Portal

We created a web portal and a mobile app to increase transparency and provide instant updates for pre-authorization and claims. Members can submit their requests and documents, manage their policies, and benefit from additional VAS. The portal enables members engagement through tailored communication and content.

Providers Portal

The new web portal enables contracted healthcare providers to manage their operations through multi-user accounts, from eligibility to pre-authorizations and claims submissions, with the ability to submit batch claims using EDI.

Partners Portal

We created a web portal to manage the Client’s collaboration with a growing and diversified network of partners, from policies and claims management, to billing, reconciliation, and reporting, with a hierarchical structure and the ability to develop customized communications and VAS.

The Impact

Higher Operational Efficiency

Higher Operational Efficiency

Enhanced turnaround times, reduced waste, standardized processes, data governance from core to portals, and a reduction in human error collectively contributed to higher efficiency. At the same time, the Client obtained a single customer and operations view across the new system, benefitted from data-driven actionable insights, and strengthened their capabilities to implement innovative solutions that support the wider business and deliver new value.

Improved Engagement

Improved Engagement

A more efficient and effective workforce further boosted the company’s attractiveness to external players, driving stronger partnerships and presenting new opportunities. Stakeholders benefitted from greater visibility and transparency, while all employees, customers, providers, employers, and members were introduced to an enhanced digital experience in every instance.

Security and Compliance

Security and Compliance

Enhanced security and compliance in terms of internal procedures and external regulatory requirements were ensured through the approach, which drove greater confidence between stakeholders, members, and regulators. In addition, integrated, secure, and properly governed data exchange became a certainty in every instance, while adjusting to the evolving healthcare regulator’s ecosystem became a formality.

IT System Visibility

A Future-Proof IT System

The new core system and portals architecture and technologies enable the Client to evolve and accommodate changing business demands. Scalability is achieved with a modular architecture, seamless integration through API economy, high availability through containerization, with the ability to embrace new and emerging technologies such as machine learning and IoT.

CME Customers

Our Clients

Long-Standing Customer Relationships

We aspire to create a holistic and goal-oriented long-term relationship with our partners. This approach allows us to have deep-rooted industry and company knowledge and connections.

Our clients’ list is our pride and joy. Since our earliest days, we have served everything from start-ups to Fortune 500 companies with the same dedication and partnership approach.

9 out of 10 customers have been working with us for more than 5 years.

CME Customers

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Whether you need help with day-to-day operations, professional support in a specific area of technology, a spearhead on a new innovative project, or anything in between, our technology services have you covered for your near and long-term goals. ​ ​ For more information, explore our tech services overview below.

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