OUR MISSION
We team with healthcare customers and help them optimize operations by successfully implementing full-cycle digital transformation projects.​ 


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CASE STUDY
 

Investing in IT: Help a Healthcare Insurance Enterprise Create a New and Efficient Quality Assurance (QA) Organization 

  • Sub-optimal organizational QA design will likely impede the efficiency of an organization and underutilize systems, and human capital 
  • Faced with industry concerns, and pressures from the federal, and state legislature, public healthcare insurance brought in OMS to assess its QA organizational structure to maximize full-cycle automated ICD-10 execution efficiency, and effectiveness of its suite of core claims applications, systems, processing engines, and operational business functional areas 
1. $4.8M+ in hospital provider claims (ICD-9, and ICD-10) successfully processed 

​2. 36% reduction in QA positions 

Situation

OMS's partnered with a client, a public healthcare insurance with lean QA staff and tight budget constraints, seeking opportunities to reallocate QA personnel in order to improve the efficiency and effectiveness of its suite of core operational claims processing applications, and systems data. The federal and state commission that provides legislative oversight recently issued a mandate and guidance that all healthcare insurance plans, providers, payers systems, and core processing applications should be assessing their organizational claims performance data with respect to enabling new technologies to allow the dual processing of ICD-10, and ICD-9 HIPAA compliant claims. Complicated by previously failed migrations, inaccurate EMR data, and QA workforce that experienced unusually high turnover, executive leadership brought in Olu and OMS to analyze the current-state of the organization and work with individual business units to optimize IT resources. ​​

Approach

Over the course of six+ months, the OMS team led the full-cycle QA Program successful ICD-10 implementation and met with key members of 29 different operational business functional areas across the enterprise to gain baseline understanding of the IT software ICD-10 data element changes required for the newly defined products Agile user stories. The team elicited, defined, and updated ICD-9, and ICD-10 scenarios mapped to historical hospital claims, specific primary, and secondary procedures to create an accurate, and appropriate picture of the current-state of the enterprise, in addition to identifying areas of risk that could result in higher than expected payout with short and long-term financial impacts. Furthermore, OMS identified for senior executive management new revenue opportunities and areas that were not initially represented on the enterprise roadmap due to financial limitations. 

Results

The team was able to identify, and successfully process over $4.8M in claims efficiencies that could be reallocated to fund new enterprise initiatives, or support existing ones that lacked adequate IT, and business resources. In addition to generating new efficiencies, the team helped to define over 360+ new ICD-10 hospital claims scenarios, 120+ user products stories, and restructuring the insurance's individual business units to function at a more optimal level. Executive leadership agreed, and categorized the deliverables, recommendations, milestones successfully met, and full-cycle implementations over the course of the program to be high-impact and requiring minimal change-management. The team also developed a new reporting tool to help the insurance health plan track bi-weekly sprint progress towards these ICD-10 backlog items over time, manipulated existing claims data so the future ICD-10 claims calculations match industry expectations, and more accurately depicts user stories progress. 

Lead Project Leader Consultant