Total Health Care Enhances Membership Data Quality and Visibility with Precisely Solution
公司规模
Mid-size Company
地区
- America
国家
- United States
产品
- Precisely Solution
技术栈
- Cloud-based Solution
实施规模
- Enterprise-wide Deployment
影响指标
- Customer Satisfaction
- Cost Savings
- Productivity Improvements
技术
- 平台即服务 (PaaS) - 数据管理平台
- 分析与建模 - 实时分析
适用行业
- 医疗保健和医院
适用功能
- 商业运营
服务
- 云规划/设计/实施服务
- 数据科学服务
关于客户
Total Health Care is a Michigan-based managed care organization that offers a variety of health plans, including group health, ACA exchange, and Medicaid plans, to approximately 100,000 members. The organization operates in the health insurance industry and is focused on providing comprehensive healthcare coverage to its members. Total Health Care's operations are characterized by a complex structure involving multiple internal systems, external vendors, and CMS, which has historically impacted its data management efforts. The company is committed to improving its membership processes and data quality to enhance the member experience and ensure compliance with industry standards. With a focus on member satisfaction and operational efficiency, Total Health Care is dedicated to leveraging technology solutions to address its data challenges and improve overall business performance.
挑战
Total Health Care faced significant challenges due to the disjointed structure of its membership processes, which involved multiple internal systems, external vendors, and CMS. This fragmentation limited the company's visibility into membership data, preventing leadership from gaining a complete and accurate understanding of key membership analytics. The lack of insights and quality control posed financial risks, led to inaccurate quality of care reporting, and missed opportunities to improve the member experience. The company's CIO, Noah Monro, recognized the need for a single platform to provide complete visibility across disparate systems, improve membership analytics, and make better business decisions. Duplicate membership files, resulting from members frequently switching between exchange and Medicaid plans, further complicated the situation by providing an inaccurate view of care gaps and quality measures, ultimately lowering HEDIS scores and health plan reimbursement.
解决方案
Total Health Care implemented the Precisely solution to address its data management challenges and improve membership data quality. The solution provided enterprise-wide visibility and automated membership data reconciliation, identifying duplicates, discrepancies, and other data issues across disparate systems. It featured real-time dashboards for viewing membership analytics, tracking enrollment files, and reporting on exceptions. The reconciliation workflow allowed users to easily view process statuses, obtain reports, and resolve potential issues. As a cloud-based solution, it offered financial advantages and enabled rapid implementation. The Precisely solution provided end-to-end reconciliation of membership system extracts and daily 834 enrollment transactions at over 30 key data points. It reconciled the Medicaid population with the monthly Medicaid audit file at more than 18 unique data points, creating exception lists and appropriately dispositioning them. Members were assigned unique identifiers enterprise-wide to reconcile between different business lines and systems. The solution included a queued workflow where suspect matches were investigated to consolidate duplicates and properly identify unique members.
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