Driving Improvement in Medical Review Productivity

Client

Our client provides Medicare claim review and processing services for CMS. They process and review millions of claims annually involving tens of thousands of providers and suppliers across multiple states.

Challenge

The first problem? Significantly lower operating costs related to Medical Review. The client had completed several incremental improvements, but nothing seemed to work permanently.

Background

The client sought ways to optimize their operations and achieve reduced operating costs. EXL Consulting completed a Medical Review Operations BluePRINTTM.

Results

  • 25 %+ productivity improvement
  • New performance paradigms in Medical Review
  • Increased employee satisfaction
  • Improved competitive position in the MAC space

Solution

During the 8-week engagement, EXL identified major pain points:

  • Insufficient claim review categories and asso-ciated performance targets
  • Excessive effort measuring and analyzing claims review performance
  • Large variations in performance across nurse review staff
  • Inconsistent and uncertain allocations of time reserved for conducting claim reviews

EXL Consulting helped the client refine processes for scheduling and maximizing claim review time. We piloted the ideas, measured impact, rolled them out to the entire organization, and then co-designed a plan to ensure long-term sustainability.

In less than 3 months, these actions led to in-creased claims review productivity by over 25% and reduced the level of effort to track these re-sults. Also, the nurse and other staff affected by these changes embraced the new ways and ex-pressed higher satisfaction in their work.
 

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