Making utilization and case management leaner, more efficient
How DigiCA added value, speed, and efficiency in utilization and case management and saved over $2 million for a client in two years.
Client profile
A leading national health plan
Client need
Nurses were performing manual extraction, validation, and verification of member information, reviewing, and taking decisions on clinical reviews of pre-certification requests. With 15-20 different screens for each review, 20 different fields reviewed for verification, multiple scenarios across commercial and Medicare eligibility verification, 8-10 multiple manual tasking spreadsheets for work tracking, and more than 80 case types and tasking rules, the manual effort involved was overwhelming and inefficient – resulting in high operating costs.
Objectives
- Reduce this manual effort for non-value add tasks so that nurses could concentrate further on improving quality of care.
- Increase efficiency in the extraction, validation, and verification process – making it easier to review and make decisions on clinical reviews of pre-certification requests
- Streamline the tasking of cases to nurses.
DigiCA™ is a data driven automated clinical audits solution that improves clinical excellence in case review, care management (CM), and utilization management (UM). It helps reduce authorization cycle time, standardize clinical documentation, and minimize manual tasks and systems to navigate, by automating and standardizing case management, the eligibility and verification of member, provider and CPT codes, and MD review.
EXL utilized DigiCA’s capabilities to task cases to nurses –based on their skill set – and assisted them in member verification by extracting specific information for case summarization and facilitating decision-making. DigiCA capabilities ensured:
Key features
- Highly replicable solution across various lanes of business (i.e., concurrent review and retro review)
- Highly customizable solution
- Integrated digital dashboard
- Reduced learning curve and improved accuracy
Outcomes
By leveraging DigiCA, the client digitally transformed its UM and CM functions.
