Ultera/P8 for Complaints and Appeals

Business Challenge
Customer complaints and appeals concerning medical services are among the most difficult and timesensitive requests that insurers must handle. Due to increasingly aggressive operational performance requirements, these highly regulated and sensitive requests demand both accuracy and timeliness.

Traceable and timely workload management across the enterprise, without risk of loss or delay, is difficult to accomplish due to dependencies on paper-based transactions and work processes to resolve customer complaints and appeals. The inefficiencies and inconsistencies associated with these processes often result in exponential increases to the time and costs associated with managing the complaints and appeals process. Additionally, because this process is frequently the subject of litigation, legal discovery becomes more costly, time consuming and resource intensive due to the volumes of associated documentation that must be reviewed.

Insurers need comprehensive solutions that enable them to efficiently and cost-effectively process complaints and appeals requiring medical and other interdepartmental reviews; support rapid member access to authorized care in the case of prospective services; and comply with contractual and regulatory obligations. The solution must also support legal discovery requests and associated documentation.

Solution
IPD’s Ultera/P8 for Complaints and Appeals enables insurers to manage these processes in a timely, accurate and cost-effective manner.

With Ultera/P8 for Complaints and Appeals,manual case file assembly, searching and sorting are eliminated. Instead, to ensure the completeness of case files, the solution captures, catalogs and stores all case-related documents, host system data and task completion capabilities within an IBM Enterprise Content Management (ECM) repository. The solution also simplifies the review process via easy navigation to all pertinent case-related information; presenting documents at the desktop; and, consolidating decision-making data into a single case file view. Additionally, all information from other business systems is presented within Ultera/P8 for Complaints and Appeals interfaces using industry-standard integration techniques that leverage and revitalize legacy business systems.

Through configurable process management, designed to meet the unique business requirements of each insurer, Ultera/P8 for Complaints and Appeals creates, distributes and prioritizes tasks. The solution’s comprehensive audit trails track completed and outstanding cases, providing end-to-end information about the status of work-in-progress and reporting cycle times, productivity and other performance metrics. For complaints and appeals pending the receipt of additional documentation, an Attachment Handler suspends work until requested information is received and then automatically matches responses with the pending case file, reactivates the case and notifies the assigned personnel of its receipt.

In addition, Ultera/P8 for Complaints and Appeals provides a utility for automatically printing the entire case file of documents and related information in response to legal discovery and regulatory requests.

Value Proposition
Ultera/P8 for Complaints and Appeals is scalable from the smallest to largest numbers of users across geographically dispersed operations, offering insurance-specific capabilities to improve performance, reduce costs, and efficiently respond to legal discovery requests. The solution streamlines the complaint and appeals process, delivering a significant competitive advantage, and lowering risk via process consistency.

The solution’s interfaces increase productivity and accuracy by allowing claims and appeals personnel to work within a single, consolidated view of all the information available needed to meet underwriting requirements, in the order in which they need to be fulfilled. In addition, IPD clients report dramatic performance improvements and business returns, including cycle time reductions of up to 50 percent or more, productivity increases of as much as than 45 percent, and processing cost reductions that often exceed 40 percent, with assured compliance, and within a fully configurable solution.