We were brought in to help our client establish an annual strategic planning process that linked business strategy with IT investment decision-making. The goal was to have an IT investment plan that was directly linked to enabling the firm’s business strategy. This included examining the business environment, defining the future state business vision, identifying the new business capabilities required to realize that future state, and, finally, determining what technologies were best suited to enable those business capabilities. The result of our work was not only an IT multi-year strategy that provided a roadmap for the development and deployment of appropriate technologies but also the adoption of an on-going strategic planning and decision-making methodology to guide leadership as new business priorities emerged.
- Business Assessment – An examination of the internal and external business environment to help define the company’s key strategic imperatives.
- Future State Vision – A definition of the desired business outcomes 5-10 years in the future and the associated business capabilities required to achieve those outcomes.
- IT Strategic Plan – A multi-year roadmap that identified sequenced technology development pathways that, upon completion, would support the business’ realization of its future state vision.
- IT Investment Planning Methodology – The annual strategic evaluation process used to assess the merits of competing technical solutions within the context of the larger IT Strategic Plan.
- Performance Monitoring Capability – The deployment of a monthly dashboard that allowed leadership to measure incremental progress in achieving the desired outcomes of the IT strategic plan.
- Strategy – Visioning and future state design
- Business Case – Cost/benefit modeling and securing of necessary resources and funds
- Operational Design – Development of standard operational model, creation of physician pools, identification of in-scope medical conditions, development of call center and web channel content and scripts
- Technology Solutioning – Technical architecture, vendor assessment and negotiation
- Solution Deployment and Support – Creation of a deployment “playbook” to facilitate consistent implementation and adoption of standard operational practices across all deployment sites
- Post Deployment Advise – Strategy formulation and recommendations for service model refinement and expansion of scope of practice to include additional specialties
We worked with our client to reshape their care model from both clinical and patient engagement perspectives. We enhanced the design of the nurse portal so that updated clinical results were available as near real-time as possible. In addition, analytics were designed that assessed current health conditions, results, and levels of patient engagement to suggest prioritized patient visits and nurse schedules. In addition, staff received more extensive coaching, i.e. motivational interviewing techniques to promote patient engagement and thereby realize better medication adherence and other benefits.
Results were immediate and most evident among the care practitioners. Significant improvement in the overall satisfaction of the nursing staff was realized by enabling greater automation with scheduling and work flow management, thereby reducing administrative burdens and promoting more patient-facing time, especially with the most at-risk groups. In addition, some progress is being made with reducing the rate of hospitalization. With better and more timely data, our client is able to assess adjust its program parameters to more cost-effectively realize its care outcomes.
- Vision – Redefined the operating model for the nursing staff by creating a point-of-care portal that identified prioritized cases and customized the care session based most recent clinical data and current level of patient activation.
- Solution Requirements – In addition to defining the point-of-care portal, detailed requirements were also developed for complementary solution elements including biometric data collection, scheduling, alerts management, and knowledge management.
- Operational Design – Streamlined the nurses’ processes by prioritizing appointments and delivering real-time clinical results to guide the care session. Also included more extensive motivational interviewing training to enable better patient engagement.
- Technology Solutioning – Developed point-of-care portal, modified patient scheduling, and enhanced various legacy and third party interfaces.
Over the years, the plan had continued to use clinicians, mostly nurses, to assess claims based on a few simple parameters mostly driven by diagnoses and dollar amounts. Based on claims identified for review, the plan had annually increased its operating review budget, but was experiencing declining savings and recovery opportunities per reviewer. Overall returns were flat i.e. the more resources the plan devoted to their programs resulted in only negligible marginal returns.
We were brought in to help our client establish a new direction, one that would identify and target high-margin opportunities and realize greater savings with a more efficient and lower overall cost review program. By isolating new opportunities highlighted from a best practice review, Artesient’s prior performance engagement experiences, and configuration and rule enhancement sessions with its software vendor, our client was able to reshape the claims review mix with the best potential savings.
The results of our work during the initial year of deployment included a better skilled but smaller review team that delivered 25% more savings than the prior year with an operating budget trimmed by 15%.
- Best Practices Review – A review of various plans’ claims review functions across several dimensions including organization and training, process management, pre- and post-payment review software, operating efficiency, and cost containment. Plan participation was secured by committing to share all survey results (de-identified) with participants.
- Future State Vision – A definition of the desired claims review outcomes 3-5+ years in the future and the associated business capabilities required to achieve those outcomes.
- Multi-Year Roadmap – A multi-year roadmap that identified sequenced enhancements to reviewer skills, software rules configuration and claims samples that, upon completion, would support the realization of its future state vision.
- Organizational and Process Improvements – During the first year of implementation, more skilled code reviewers were added to the team, and work queues were modified to more quickly review and confirm savings while still meeting payment turnaround times.
- Performance Monitoring Capability – The deployment of a monthly dashboard that allowed leadership to measure incremental progress in achieving the desired outcomes, primarily improved operational efficiency and claims cost containment.
- Market Assessment – Segmentation and sizing, value proposition development, ROI analysis
- Capabilities Assessment – Assessed existing ability to partner with and sell through broker community
- Call Center Operations – Infrastructure design and sourcing, budgeting, staffing and training, marketing communications
- Workflow Management – Process development, workflow management and image recognition technology, training and implementation
- Market and Customer Assessment - Technology assessment, customer needs and buying behavior assessment
- Product Strategy and Development – Product/services road mapping, ecosystem/business development opportunities assessment
- Customer Experience – Current process/capabilities/culture assessment, lifecycle process mapping and process optimization across constituent groups, implementation and change management
- Centralized Compliance Tracking System – System design, development and implementation.
- Organizational and Process Restructuring – Current state process definition, future state design, process and organizational change deployment.
- Regulatory Compliance Issue Remediation – Remediation process designed and deployed, including on-going operational management.