Ultera/P8 for Healthcare Claim Exceptions

Business Challenge
Faced with rising healthcare expenditures and weaker profitability, administrative expenses represent increasingly important and controllable cost reduction opportunities for insurers. Competition and regulatory requirements are also driving insurers to improve worker productivity, cycle times and service levels and address compliance requirements with new and enhanced measures for securing, controlling and measuring operational processes and sensitive content (e.g., applications, claims, correspondence, etc.)

As insurers introduce new products, outsource processing (often offshore) and continue to modify business processes, they need supporting systems that can quickly respond to the change.

With today’s mandated turnaround times for decisions, companies must collaborate with customers, agents and other providers of information with unprecedented speed.

Cycle time reductions are difficult to achieve for claims that do not autoadjudicate. Claims that fail first-pass processing are the most expensive claims to manage and the most prone to inaccuracies due to manual tasks and inconsistent resolution procedures. Poor claims processing performance increases the volume of duplicate submissions and reduces customer satisfaction.

Unfortunately, many claims adjudication systems are also slow to adapt to changing markets and business conditions. Insurers need a comprehensive solution for claims processing to optimize work processes, streamline decision making and reduce costs, which can respond as needed to change.

Solution
The IPD Ultera/P8 for Healthcare Claim Exceptions solution offers a complete work process and automation solution to optimize the handling of exception claims. The solution delivers the right work and documents to the appropriate staff at the right time, creating and distributing electronic work items for exception claims in priority order, while remaining synchronized with adjudication systems. If additional information must be requested from external sources, Ultera/P8 for Healthcare Claim Exceptions automatically associates it with the case file immediately upon receipt and alerts claims staff that work is ready to re-commence. The solution offers workload management tools to manage inventory and backlogs.

Claims staff receives work within Ultera/P8’s for Healthcare Claim Exceptions optimized processing interface, which provides the documents, data and task completion features needed for resolution at each step of the exception handling process. The interfaces also provide automations and integrations for tasks that would otherwise have to be performed manually or with inefficient systems.

Built on the IBM Enterprise Content Management (ECM) suite of products, Ultera/P8 for Healthcare Claim Exceptions provides secure content storage and retention, enabling claim and claim-related documents to be managed as records. It provides role- and step-based security permissions and authorizations, creates comprehensive audit trails of all document and process related activities.

Value Proposition
Designed and built by insurance industry experts, and based on real-world customer requirements, IPD’s Ultera/P8 for Healthcare Claim Exceptions supplies multiple and specific features for processing exception claims.

IPD clients have successfully leveraged the Ultera/P8 Enterprise Application suite of products to immediately reduce costs and optimize work processes, while responding to new business needs over time. In combination, the Ultera P8 interfaces, automations, and integrations significantly reduce costs by enhancing staff productivity, allowing staff to focus on high value-added, rather than administrative and clerical, activities.

Ultera/P8 for Healthcare Claim Exceptions provides an agile environment to quickly respond to changing business needs and host system limitations, and can be readily modified and extended – by business analysts as opposed to Information Technology resources – to support new products, new staff members, new adjudication system rules, or processing alternatives, as business circumstances dictate.

The solution is scalable from the smallest to largest numbers of users across geographically dispersed operations, and is proven to implement faster and with lower risk than custom- and integrator-built solutions. Many IPD clients required no coding effort to implement solutions for their highly specific requirements.