Business Challenge

A prominent healthcare payer sought to enhance its utilization management (UM) process, focusing on specific case types. The objective was to improve efficiency and accuracy across various case types, including:

• Prior authorizations
• Retrospective reviews

Traditional processes relied heavily on local resources and manual workflows, which limited scalability and productivity. The payer sought to leverage offshore clinical resources and explore digital automation opportunities. The primary objectives were to:

• Enhance the productivity and capacity of the UM process.
• Upskill offshore teams to handle specialized case types efficiently.
• Identify opportunities for digital tools and automation.
• Maintain superior quality and compliance standards.

EXL solution

The payer chose EXL as its digital transformation partner due to our expertise in healthcare operations and its ability to integrate cutting-edge AI-driven solutions. The collaboration resulted in a multi-layered approach to revamp the utilization management process.

Validation of clinical information

EXL implemented a robust workflow to validate clinical information and provide determinations based on medical policy and benefit coverage. This ensured accurate and swift case resolution while adhering to compliance standards.

Offshore clinical resources

By leveraging the expertise of clinical nursing staff EXL offered cost-effective yet high-quality UM reviews. These professionals were trained to manage specialized case types, ensuring seamless integration into the payer’s operations.

Collaboration with medical directors

For cases that don’t meet criteria or need further review, EXL ensures clinical notes are thorough and include all essential information for medical directors to make accurate decisions. This approach guarantees that complex or sensitive cases receive the careful attention they deserve, all while maintaining efficiency and precision.

Upskilling and service expansion

EXL executed successful upskilling initiatives, enabling offshore teams to handle unique case types such as speech therapy, chiropractic therapy, retrospective reviews, and Ancillary and durable medical equipment. This not only expanded the scope of services but also created a more versatile workforce.

Focus on Automation

EXL proposed workshops to identify opportunities for automation and digital solutions to support the payer’s drive to process an increase per day

Results and achievements

Significant operational gains

1. Productivity:

• Exceeded capacity by 8% compared to initial goals through effective real-time volume and performance management.
• Enhanced daily capacity, supporting the payer’s drive achieved increase in productivity.

2. Quality assurance:

• Achieved an outstanding Year-To-Date Quality Assurance (QA) score of 96.37%.
• Maintained a monthly attendance rate of over 95%, ensuring consistency in service delivery.

3. Specialization expansion:

• Successfully upskilled resources to cover additional case types efficiently.
• Expanded beyond the initial specialty program footprint, enabling the payer to manage diverse UM requirements.

4. Foundation for automation:

• Conducted workshops to identify areas for digital transformation and automation, fostering long-term operational excellence.

Future focus areas

The payer and EXL identified critical focus areas for the next 90 to 180 days to further enhance operational efficiency and innovation. These include:

• Scaling automation technologies to support the payer’s UM goals further.
• Expanding the existing program beyond current specialty case types.
• Strengthening coordination between offshore teams and the payer’s internal stakeholders to maintain synchronization.

Why EXL

The healthcare payer’s collaboration with EXL underscores the value of partnering with experts who combine technological innovation with industry-specific expertise. EXL’s ability to tailor its solutions to their unique requirements, coupled with a strong focus on compliance and quality, has positioned the payer as a leader in efficient and scalable utilization management processes.

A proven partner for healthcare payers

With over 6,000 dedicated healthcare professionals and a robust ecosystem of partnerships with leaders like Databricks, NVIDIA, and AWS, EXL is at the forefront of healthcare transformation. By combining data-driven insights, advanced AI, and experienced clinical resources, EXL helps healthcare payers drive sustainable growth, improve patient outcomes, and deliver exceptional value.

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Transform your utilization management processes and achieve operational excellence with EXL. Contact us today to learn more about how our tailored solutions can empower your organization to succeed.