Client Need

A regional health benefit manager was asked to establish and maintain a provider network, a claims processing and payment facilitation process, a medical administrative management service, and customer support services for its members across 13 states. One of its challenges was to design, develop and maintain an automated solution that would facilitate the scheduling of appointments via the members’ cell phones with no impact to access to community care during this transition.

EXL Health Data Services Solution Approach/Methodology

EXL Health Data Services started with a thorough SWOT analysis of the health benefit manager’s current appointment system and extensive interviews with key decision makers and beneficiaries. Based on the input collected, the Data Services team was able to design a solution that would accommodate members’ desires to make appointments with healthcare providers using their cell phones.

The solution includes:

  • Master Schedule Engine: uses member information to recommend providers for each referral, determined by the best possible match of a provider’s availability, specialty and member’s requirements. The master schedule is using deep learning and artificial intelligence algorithms to bring together the provider requirements, as well as the member’s needs. The engine automatically creates a virtual schedule as the profiles change in real time. It creates a neural central semantic network in the background, generating a real-time cluster to develop a virtual schedule of availability. This virtual schedule is then presented to the member and to the provider, enabling them to confirm that the appointment meets the needs of both parties.
  • Member Facing Application: streamlines the appointment scheduling process and minimizes wait times. This mobile app provides an interactive and responsive method to schedule appointments, receive notifications, chat in real-time, and set up appointment reminders.
  • Provider Portal: enriches the provider’s experience to manage appointments. Appointment requests are forwarded to providers in an email. Providers can decline, accept or reschedule an appointment through the online portal. Any changes made to the appointment will trigger alerts in the mobile application so that the members are informed of all changes.

Including the Master Schedule Engine, the solution is based on the following “layers”:

  • Member Profiles: based on data sourced from a member organization and the health benefit manager, as well as data captured during an active call. Profiles are accessible via the app web interface, and are also linked to the call center system.
  • Provider Profiles: sourced from the health benefit manager, includes the latest contact information and schedule availability stored in the application repository for easy access by the schedule engine and the call-center agents.
  • User Interface (UI): allows the agents to quickly find information about the caller and provide real-time answers.
  • Database: an Operational Data Store (ODS) contains all data elements needed for the system to work, including provider, veteran and schedule information.
  • Analytics: data marts and reporting are available, used by business analysts to monitor system performance, provider capacities, and patient experience

Expected Outcomes

The ultimate goal of this system was putting the member in control of his or her care. The system was also designed to optimize a member’s user experience and satisfaction, including the reduction of DNAs (Did Not Answer) and less back-and-forth communication over the phone. In addition to these and other objectives and associated benefits, the EXL Health-designed solution is expected to provide the following:

  • Optimized scheduling via a rules-based engine
  • A secure communication platform for scheduling and managing appointments
  • An interactive method to manage appointments
  • Increased scheduling efficiency by more than 400%
  • Reduced cost due to automation
  • Removed manual staff risk
  • Flexibility in including new providers and services
  • Highly satisfied consumers and stakeholders


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