BPM in Health Care – Cut Costs While Improving Experience

BPM Streamlines Health Care Appeals and Grievances by 30%

Each day I learn a new reason for BPM. Take the project at Touchstone Health (White Plains, New York, USA), a $200M Health Plan/Insurance provider that serves roughly 20,000 members.

Members (people like you and me) of HMO, PPO, and Medical Savings Account Plans have the right to complain about poor and/or denied services. In 2010, the Maryland Insurance Administration reported 32,320 such appeals and grievances (A&G) of adverse decisions (denials of benefits based on medical necessity determinations).

For Touchstone handling these complaints presents a large operational cost of approximately $30/member/year. Moreover, if the law is not followed correctly, providers can be sued resulting in potentially huge fines (e.g., one provider paid $12M in fines in 2007).

With the implementation of BPM, Touchstone has seen cuts to A&G operational costs of 30%-50% or upwards of $300K annual savings. Just imagine what it can do for the big plans? BPM has also added a layer of governance ensuring case works adhere to policies and procedures so as to prevent stupid mistakes causing bad publicity or big finds.

The team also told me about how integration between the BPM-based apps and imaging platform has improved customer service by giving case workers real time access to documents to validate customer input. And all the data pulled from BPM forms is being sent automatically to the fulfillment house to generate customer correspondence.

BPM presents many angles for creating value. Think more than just cutting costs. Improving the User Experience can deliver big benefits in customer service, compliance, and growth.


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By Garth Knudson @ Bizagi | October 24, 2012

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