The Client

The client is a third-party administrator of health insurance claims (TPA).

The Opportunity/The Problem

The client receives thousands of claims from partners each day and certain claims require further review from the customer service team. These claims are often potential new revenue streams. However, the problem was that the claims were simply listed each day on a report. The processing of each claim was then handled manually via calls, emails and extensive, time-consuming use of Excel. The customer service team spent a disproportionate amount of time re-keying data from emails and reports into spreadsheets. Furthermore, no data analysis, reporting, or metrics could be built to analyze the operation. The client was inefficiently handling a huge stream of revenue.

The Solution

After reviewing the requirements and needs with the client, Logan Consulting recommended Microsoft Dynamics 365 CRM Case Management and Customer Service. Design sessions were held to define the process and ensure that Microsoft Dynamics 365 was able to properly support the business requirements. In addition to these sessions, the design included determination of the metrics and dashboards required for data analysis. The design of the final solution included:

  • Integration to a Data Warehouse that analyzes all claims and determines the appropriate claims to be reviewed
  • Integration that creates the case record in Dynamics 365 Customer Service
  • Ability to capture notes and activities for further review and action by the team
  • Tracking time on each case for billing purposes
  • Integration of information back to the data warehouse for integration to the ERP system for revenue recognition
  • Extensive security design to ensure HIPPA compliance

The Results

Ultimately, the company was able to significantly increase the number of claims processed each day, helping to generate more revenue for the firm overall. The client was also able to process an increased volume of claims which proved especially important during healthcare crises such as the COVID-19 pandemic. The client now holds a singular system that can track all of their cases, and can generate extensive and detailed reports and metrics for stronger management and analysis. Reporting was also automated, meaning partners were automatically notified of any resolution to their case.

Next Steps

Improving your insurance claims processing can be easy. Logan Consulting, your Chicago-based consulting firm, has helped clients across the nation find their full potential every day. Stop losing revenue opportunities and start managing your company efficiently. Talk to us and watch your digital transformation begin.