Newgen’s Healthcare Payer Practice

Newgen’s Healthcare Payer PracticeAccelerate business performance, control costs, and meet mandates

Healthcare industry is booming across

the globe. However, participants within

the industry, especially Healthcare

Payer organizations, must ensure

compliance with a multitude of

regulations to avoid potential penalties.

Moreover, to remain competitive in an

industry characterized by dynamic

growth and complex regulations, Payer

organizations need focus on meeting

the following challenges:

! Better customer service

! Compliance to state specific

regulation

! Cost optimization and increase in

top-line profit

! Continuous improvement in claim

disbursement ratio

! Affordable healthcare plans

! Smooth transition from ICD 9 to

ICD 10 code

! Improved Medical Loss Ratio (MLR)

To address these challenges, Payer

organizations need to adopt an

integrated approach to efficiently

manage business processes, maintain

and utilize member/provider

information, foster enhanced

outbound / inbound communication,

and comply with regulations. A

combination of Business Process

Management (BPM), Enterprise

Content Management (ECM) and,

Customer Communication

Management (CCM) would serve as an

ideal platform to build solutions for

automation of key Payer processes.

Healthcare Payer Landscape

Over 80% of health plans reported ICD-10 compliance as the primary driver of increased budgets in 2012.

IDC Health Insights 2012

Optimization of processes

Compliance Mandates Drive BPM Adoption For Healthcare & The Public Sector

Public sector & healthcare:“Which of the following have been major drivers for business process management software adoption?”

Support for compliance efforts

Increased productivity for process workers

The ability to provide real-time visibility into key processes

Ensuring consistent process execution across divisional or geographic boundaries

The ability to model business processes

The ability to change processes quickly & easily

Source: Forrsights Software Survey, Q4 201057494

Base: 71 software decision-makers(multiple responses accepted)

72%

59%

56%

52%

49%

41%

39%

SOLUTIONS FOR BUSINESS PROCESS & CONTENT MANAGEMENT

Newgen's solution framework enables

healthcare organizations to effectively

address the challenges originating from

regulatory compliance, cost control

and customer satisfaction. Our

Healthcare Process Automation &

Optimization Suite combines the

power of Imaging, Document

Management, Business Process

Management, and Member/Provider

Communications Management, to

render solutions built to address the

specific requirements of Healthcare

Payers.

Newgen’s Healthcare Payer Spectrum

Collaborative & integrated creation,

capture, organization,archival and retrieval

of documents

Distributed scanning

document capture,image qualityenhancement

Preconfigured letter templates for

acknowledgement,additional info, and finaldisposition with workflow

based validations

A quick snapshot of process, performance,

ageing inventory, types of appeals &

grievances, resolved & escalated/ exception

cases, etc.

Process standardization,auto routing, prioritization of work items, business rules

SLA adherence

Business Configurable Process Automation and Improvement Framework

Fig: Newgen Solution-Component Framework

“Success [of Healthcare Payers] will depend on maintaining focus and assembling the right set of BPM skills. And for the business process executive acting as the change agent, this means a laser focus on the disruptive and transformative aspects of the process improvement initiative.”

Forrester Research Inc.


Case Compliance Ageing Report

Management Dashboards

Leading US Healthcare Payer transforms multiple processes with Newgen's Solutions

Appeals & Grievances

· Increase in user efficiency by 50% due to data integration in single UI for Member/

Provider/ Claims/ Pharmacy etc.

· Auto redirect of appeals within department thus reduction in loss of cases

· Complete audit-trail of case history maintained for Management view

Claims Repair

· Productivity improvement – Organization saved approximately 5K to 7K man-hours

monthly due to automation

· Auto generation of Letter to the Provider for any claims communication

· Integrated platform – auto Member and Provider data pulling from core claims

application, thus making the process faster

Enrollment Process

· Reduced time spent on administrative tasks by sales force by 67%, driving huge

revenues

· Reduced TAT on new member enrollment applications by 76% - from 17 to 4 days

· Reduced error rate in applications by 35% by minimizing manual intervention in the

enrollment process

Complaint Tracking

Provider Contracting


· Compliance Improvement - Compliance level up by 25%

· Reduction in complaint resolution time

· 78% resource optimization

· 60% reduction in TAT - from 25 to 10 days, to activate a new Provider contract

· Auto generation of Welcome Letter to the Provider on new contracts

· Auto alerts for “Contract Renewal”

Claims Repair

Challenges

Solution HighlightsHandling claims is often staff intensive

and characterized by manual processes.

Moreover, any delay in claims

disbursement leads to high “Penalty

Payout”. This puts payers under

constant pressure to improve

operational performance and reduce

costs. While claims auto-adjudication

has become common place now-a-days,

yet many payers are still processing a

considerable proportion of claims

manually. Claims Repair – addresses

those claims that cannot be handled

through the auto adjudication process.

These claims are “error out” from one

of the multiple systems during

adjudication process.

! Time-consuming and erroneous

processing of claim exceptions due to

manual handoffs between

departments

! Lack of process visibility; Inefficient

Managed Care Center operations and

need to minimize provider abrasion

! No real-time integrated performance

management system and on-line

performance metrics for productivity,

turnaround time and analytics

! Need to retrieve data from Core

Application in real-time for faster

processing

! Compliance with state and federal

regulations

Newgen's Claims Repair solution offers

rules-driven automation to optimize the

handling of claim exceptions. Based on

work type and user skills, the solution

prioritizes claim exceptions, and

automatically routes the right task and

documents to the appropriate staff,

while seamlessly integrating with

adjudication systems. Any additional

information is automatically updated in

the case file upon receipt, and

automatic update-alerts are sent to

claims staff.

� Automated Exceptions Handling -

Reduce processing time and mitigate

risk associated with manual claim

exceptions handling

� Auto Case Creation - Auto upload

of information from feed files and case

creation based on work type

� Integrated Platform - Real-time

information pulling from Core

System

� Rules-Driven Case Management -

Rule-driven routing of cases based on

work types; Auto assignment cases

based on user skill matrix; Auto

closure of cases based on updates

received in feed files

� Auto Letter Generation -

Acknowledgement letters, denial

letters, claims approval, etc.

� Compliance Adherence - Real-time

claims lifecycle visibility enabling

management to keep track of each

claim and ensure adherence to

service levels and compliance

Appeals & Grievances

Challenges

Solution Highlights

Handling appeals and grievances is a

rigorous, time-consuming, and costly

process – more so when it is done

manually. Further, the process is highly

regulated, scrutinized and monitored,

with non-compliance leading to huge

fines and penalties. All this adds to the

pressure faced by payer organizations

trying to ensure consistency, quality and

timeliness in responding to member

requests.

! Highly regulated, scrutinized and

monitored process with significant

fines and penalties for non-

compliance

! Need to commit to the consistency,

accuracy, and standardization

requirements

! Difficult and time-consuming

process of retrieving case

information from disparate sources

! Providing status to appellants on

their appeals /grievances in real time

! Each line of business

(Claims/Pharmacy/Core

Appeals/Grievance) has its own

different mandated Service Level

Agreement (SLA) and corresponding

turnaround time (TAT)

! Need to adapt to dynamic process

changes and regulatory requirements

! Inefficient, manual complaint

processing with no provision for

automated alerts, notifications and

escalations to managers about the

cases with expired due dates

Newgen's solution for appeals and

grievances process automation enables

payers to resolve member requests

within specified timelines, reduce

operational costs, enhance operational

efficiency and demonstrate compliance

– ultimately leading to improved levels

of member satisfaction and higher profit

margins.

� Automated and Streamlined

Workflow: Elimination of data entry

errors and process compromises due

to reduced manual handoffs; Process

standardization and consistency

across intake channels, result in

improved quality and timeliness of

decision making

� Rules Engine: Automatic due date

calculation, validations for doing the

work right the first time, escalations,

email-based alerts, and exceptions

management

� Content Management: Supporting

documents such as signature forms,

physician reports, etc. automatically

detected upon arrival and attached to

the corresponding case file; Reduced

cases of misplaced and lost documents

� Case Prioritization: Based on

compliance due date, expedited

request and other set of configurable

variables

� Monitoring Dashboard: End-to-end

process visibility with real-time

reports, allowing management to

gauge efficiency

� Audit History: All changes made to

any data field tracked along with user,

date and, time information

� Auto Routing: Immediate routing

and redirection of files between

departments

� Auto Letter Generation: Automatic

faxes and letters to members and

providers; all correspondence record

maintained along with the case file


Member Enrollment

Challenges

Solution Highlights

Member enrollment, the first step in the

Member Servicing cycle, is a critical

business process that is often fraught

with numerous errors and irregularities,

due to paper-based, manual processing.

This leads to the process often

becoming frustrating for the prospective

member, and time consuming and costly

for the payer.

! High turnaround time between

submission and approval of an

application

! Significant error rates in application

processing

! Inefficient use of staff with a

significant amount of staff time

wasted in managing administrative

tasks

! Lack of a robust tracking mechanism

to monitor each application through

the enrollment lifecycle leading to

high loss rates for applications

! Difficulty in managing applications

tracking sheet and orphan documents

! Complex business logic for processing

member enrollment business process

! Ineptness to effectively and efficiently

handle exceptional cases

Newgen's end-to-end solution for

Member Enrollment process

automation enables healthcare payers

to achieve an efficient, productive, and

streamlined enrollment process. The

monitoring dashboard helps create a

visible, measurable and process

improvement based ecosystem,

allowing management to view the

complete process from Lead

Generation to Member Enrollment.

The solution helps insurers to easily

handle the receipt and processing of

enrollment applications and supporting

documentation using an automated

workflow.

� Automated processing of applications

leading to reduced enrollment cycle

time from days to hours

� Automated case creation based on

application form (TIFF images)

� Automated reassignment of

applications to marketing

representatives in case of any

document discrepancies

� The dashboard function offers a quick

snapshot of key performance

indicators, with provision for

generating multiple reports for

different stakeholders, providing end-

to-end process visibility to key

decision makers

� Automated generation of HIES

(Health Insurance Eligibility Screening

worksheet), based on income,

number of applicants, family size; Auto

color-changing of data-fields of a case

helps business users to identify

important information in an

application

� Auto letter generation for exceptions

(kickbacks) saves valuable time that

was earlier wasted in searching

missing documents and follow-ups

� As part of the reengineered flow,

every application is tracked through

the enrollment lifecycle – client impact

seen through dramatic reduction in

“lost” applications

Complaint Tracking & Management

Challenges

Solution Highlights

Operating in the highly regulated

healthcare landscape, it is of utmost

importance to Managed Care

organizations to manage complaint

tracking appropriately. The challenge is

to resolve the complaints which have

come from the Center for Medicare

and Medicaid Services (CMS) in the

shortest possible time. Moreover,

regulatory infractions may cost

healthcare payers huge penalties.

! Difficulty in monitoring the status of

compliance to TAT SLA

! Measurement and monitoring of

process performance

! Manual search in multiple core

applications for member

demographic and eligibility

information

! Manual allocation of work

! Integration of people, workflow and

core system

! Manual routing of complaints to

concerned departments (Pharmacy/

Billing/ Claims/ Enrollment) for

resolution

! Absence of a mechanism to track

member correspondence

Newgen's complaint tracking and

management solution enables Payers to

track each complaint through its

lifecycle from recording and initiation to

investigation, reporting, and closure.

The solution securely stores all

documentation pertaining to the

complaints received and simplifies

search and retrieval of complaint data,

to ensure timely resolution of

complaints and reduce risks associated

with non-compliance with CMS

standards.

� Automated Workflow - Auto

assignment of received complaints

based on skills of the users and

complaint types

� Visibility - Complete visibility in

terms of SLA monitoring for various

issue levels; Auto color changing of

work items helps identify cases

nearing deadlines

� Rules Engine - Highly complex

validation rules with better analysis &

research capabilities enable speedy

processing and resolution of

complaints

� Extensive reporting capabilities -

The Business Activity Monitoring tool

provides end-to-end process visibility,

identifying bottlenecks, and allowing

proactive corrective actions

� Integration - End-to-end, integrated

approach helps populate complainant

information into and from the core

system, resulting in improved

operational efficiencies and speedy

resolution of complaints

� Audit Trail - Complete audit trail of

actions taken

� Auto Update - Highlighting of

updates and summary received from

CMS after each upload, helps speed

up the process of resolution of cases

that are on hold

� Automatic Alerts - Alerts and

notifications to management based on

nearing/missed SLAs, TAT

� Auto Letter Generation -

Acknowledgement letters, denial

letters, claim approvals etc.


Provider Contract Management

Challenges

Solution Highlights

Provider contracting process deals with

end to end tracking of provider

contracts throughout the contract

lifecycle from creation, negotiation,

approval, to termination. Healthcare

payers process tens of thousands of

contracts each year. Each provider

contract is stored on paper and

managed manually making the process

of updating contracts, variance analysis,

and compliance audits time-consuming

and erroneous.

! Paper-based process, with information

stored in disparate databases and

isolated filing cabinets

! Time-consuming manual process of

searching various sections of the

contract for relevant information

! Document access based on the user's

and department's rights

! No real-time tracking of the contract

status (active/inactive) by Provider

Relationship Representatives (PRRs)

! Missed renewal dates, and data entry

errors due to manual processing

! Time consuming activity of Provider

Contracting document creation and

approvals

! Manual process of compliance

auditing

Newgen's Provider Contract

Management solution enables Payers to

securely exchange information both

within and outside of the organization;

improve operational efficiencies; and

provide user visibility into the contract

data. The solution integrates with

existing critical information systems to

facilitate enterprise-wide collaboration,

and increases accountability by

providing rights-based access at

department and user levels.

� Contract Management -

Automated and digitized contract

management resulting in faster

negotiations & approvals

� Central Repository - All contract

data and documentation stored

electronically in a central repository,

allowing users to share, collaborate

and re-use information seamlessly

� Auto Routing - Based on the type of

transaction, it is routed to the

respective state level directors; Rule-

based routing of contracts for parallel

processing by different departments

� Document Indexing - Automatic

indexing of one contract in multiple

documents and letter generation

based on Lines of Business and

mailroom stacking; Auto document

classification and quality control

� Integration - Integration with core

application for status tracking and

batch upload of transaction data;

Synchronization with credentialing and

claims systems, eliminating

redundancy and ensuring up-to-date

and accurate provider data

� Integrated Communication - Auto

generation of welcome letters for

every new contract / provider

Business Process Management Suite

OmniFlow is a platform-independent, scalable Business

Process Management Suite (BPMS) that enables automation

of organizational business processes. OmniFlow is designed

to ease the creation, deployment, modification and

management of Business Processes. Built using open

technologies, it has seamless integration abilities allowing it

to be introduced into any IT infrastructure.

™

OmniDocs is an Enterprise Content Management (ECM)

Suite for creating, capturing, managing, delivering and

archiving large volumes of documents and content.

OmniDocs manages Scanned Document Images, Electronic

Documents and Emails as records. It also supports

seamless integration with other enterprise applications.

Enterprise Content Management Suite

™

OmniScan is a production and distribution software scanning

for document image capture. It supports distributed

scanning, image quality enhancement and delivery of

documents to business systems.

Production and Distributed Scanning Suite

™OmniReports stores trillions of computer-generated output

pages and reports in a highly compressed form. It has a high-

speed ingestion process with simple interactive definitions,

enables instant access to terabytes of reports independent of

business application, and is fully searchable at field/row/page

levels. OmniReports is ideal for sun-setting of business

applications as well as optimizing core system performance by

purging historical reports.

Enterprise Reports Management and Archival

™

Newgen's Omni Output Management System (O2MS)

delivers smarter & targeted communications for better

customer experiences. It offers the capability of leveraging

prime paper space for customer centric inline advertisement,

consolidation across multiple products. It enables secure

communication on improved templates with rich designs and

graphical representation of analytics across multiple

distribution channels. In addition easy archival & retrieval of

correspondences for presentment & efficient customer

request resolution is achieved using this enterprise application.

Customer Communication Management

™

Newgen’s Invoice Processing System, with automatic data

verification and validation capability, is a solution for

automatic data capture from semi-structured invoice

documents. It also supports seamless integration with SAP

and other ERP’s.

Invoice Processing System

™

OmniExtract is the data capturing solution which extracts

business-critical information from image documents and

forms. It can extract all possible kinds of information like

Hand-printed/ Handwritten Characters, Optical Marks,

Barcode, Machine-printed Characters and MICR Fonts.

Forms Processing Engine

™

Compliance Manager is an integrated solution for

Governance, Risk and Compliance that’s geared to ensure

compliance with standards, best practices and guidelines of

various regulatory acts.

Governance, Risk & Compliance

™

Newgen’s ChequeFlow is an image based Cheque Processing

solution for inward and outward clearing. Advanced and highly

configurable sub-systems for Automatic Signature Verification,

FOREX Cheque Processing, PDC Management, ECS/ACH

mandates, add-ons for Cheque Deposit Machine/ Kiosks.

Image-Based Check Clearing & Payment

™

Our Products


About Newgen• Leading Global Provider of Business Process Management (BPM), Enterprise Content

Management (ECM) & Customer Communication Management (CCM)

• 850+ installations across 45 countries

• Solutions for Banking, Insurance, Healthcare, BPO/SSCs, Telecom and Government

• Credited with some of the world's largest implementations

• Innovative culture, consistent R&D investments, 35 patents

• Employee strength 1100+

• Certified for ISO 9001:2008, ISO 27001:2005 and CMMI Level3

Value for Money

2011 BPM Decision Matrix

2010 BPMS & 2011 ECM MQ

Reports

®

Proven for Large volumes

Flexible andCost Effective

2011, DOCCM Wave Report

What Analysts Say Investors
