Optimizing Operations and Improving the Provider Experience through End-to-end UM: Your questions, answered

UM and prior authorization, which is the most commonly practiced form of utilization management, are both highly regulated, and health plans can face high penalties and fines when they are out of compliance. The existing US nursing shortage is another factor exacerbating the pain for payers who struggle to render decisions in a timely manner. At our December 6 AHIP-hosted webinar, key insights into the value of UMaaS were shared by Sagility’s Senior Vice President of Clinical Practice Krithika Srivats and Mike Van Den Eynde, Managing Director at Deloitte, including:

  • Transformational intelligent automation and technologies
  • Comprehensive UM process that maximizes efficiency, improves clinical care quality, and improves compliance to CMS mandates
  • Clinician shortage mitigation
  • Leveraging organizational capabilities in provider network quality
  • End-to-end solution for a seamless provider experience and lower cost-per-auth

As part of the webinar, Sagility polled attendees and shared results representing key UM trends:

  • For our poll regarding “What is your readiness to meet the CMS electronic and interoperability mandate?,” 75% of respondents are “In planning,” while 25% of attendees have a program “in development.”
  • For poll two, “Do you have a comprehensive approach to your UM program?,” our attendees were evenly split, with one-third answering “Yes,” a third answering “No,” and the remainder with a “Partial approach.”
  • Finally, with Poll 3, “Have you considered outsourcing your UM in full or part,” we determined that 50% of our attendees are not outsourcing but would consider doing so in the future.

With our post-webinar QandA session, Krithika and Mike provided critical insights into attendees’ questions.

Question: What are the technology requirements of the entity using the solution?

Response: We do think there are going to be some new capabilities needed to make this all work. There is more interoperability, and FIHR-based intake is going to be needed. Second, rules engine capability can do a range of components and get to making decision on subcomponents of the prior authorization, versus just in total. So it will take some doing to get there. We don’t think too many health plans have that level of rules sophistication to do all of this right off the bat.

Question: Our organization offers both government-sponsored products and commercial. The nursing shortage and clinical costs have really affected us greatly in staffing and spend. For our government-sponsored product, we can’t offshore clinical review. But for commercial product, we can. How can we address these issues?

Response: I think there are a couple of questions in that. Outsourcing has steadily increased over the past 8 to 10 years, and more and more commercial plans have offshored in that time. But we are also seeing in the past 3 to 4 years that many Medicare Advantage plans have also taken to outsourcing, particularly offshoring. Especially because of the recent nursing shortage—that demand has grown significantly. Where we do see hesitation is in the state-sponsored or Medicare-managed Medicaid plan, especially because there are two parts to that restriction—one is coming from their commitment to leveraging their in-state resources, but also finding the right nursing licensure offshore can be sometimes challenging. So in those cases, there are a couple of different options. The first thing is having automation built in for some of the clinical reviews. That is actually very beneficial with resource optimization. A clinical decisioning engine takes the burden off what falls into a clinician’s bucket. And then there are other creative ways to leverage some of the global talent in that you could decouple the process and have an onshore licensed clinician do an audit and 100% of the cases and release. There are other creative ways, as well, but I would say technology and having a tier one and tier two automation process would be the first pass at that.

Question: Like all government-sponsored plans we did not prior authorize services during Covid-19 and had reinstituted the prior authorization requirement in January 2023. For nearly a year now, we have been really struggling with both SLAs and a significant increase in volume of cases to handle. Can you offer three things we need to do to improve our operations?

Response: A full UM program really starts by looking at what are the trends driving the volume. Historically, I think plans have used a catch-all mechanism for prior authorization. But hopefully in this webinar we looked at UM as more than just managing volume. So how do we comprehensively look across the trends and use provider behaviors—look at network case rate optimization, etc—to become a full program? That way you aren’t just looking at the volume increase, you are looking at the trends in cost of care. I would say that would be one way to look at it. Again, using automation is one way to address the volume directly. So if you can automate some of the high-volume cases with clinical criteria that can support at least 60 to 70% of that process, there is management capability that comes from there. I would say auto approving those procedures that are not yielding high value helps keep an eye on trend without putting high cost to manage volume. So that is probably one way to look at managing the post-Covid volume.
It’s really analysis, analysis, analysis, from an ROI standpoint. From an operational perspective, look at how many you take in and is there any way to reduce the denominator, so you request less of them? And keep the subset so there is more opportunity of improving outcomes and think about it more from the clinical standpoint than you have in the past. Understand by category where you have more clinical impact than less, and base where less clinical value and more clinical value.

To view the replay of this compelling webinar, go to : https://sagilityhealth.com/post-ahip-webinar/

Visit www.Sagilityhealth.com to learn more.

BPO, Supercharged: Business Process as a Service Drives Scale, Savings While Exponentially Enhancing Outcomes

BPO, supercharged: business process as a service drives scale, savings while exponentially enhancing outcomes

By Srikanth Lakshminarayanan, , Senior Vice President, Center of Excellence for Healthcare Engagement Services; Umesh Chandorkar, Vice President of Solutions for Sagility’s payer segment;  and Nikki Henck, Senior Director, Utilization Management

Health plans have long understood the benefits of business process outsourcing (BPO). Faced with the heightened prioritization of customer needs, experience, and value stream impact, these health organizations are now looking to drive more positive business outcomes through service providers on an “As a Service” model rather than the traditional transactional models.

Simply defined as the delivery of Business Process “As a Service,” (BPaaS) supercharges benefits — with end-to-end advantages from breakthrough cost savings and predictability of spend to enhanced competencies focus, risk management, and access to new technologies. 

Health plans are well suited to taking the benefits of BPaaS solutions spanning:

  • With the pay-as-you-go model, organizations can better scale and align with needs as the business changes. This is additionally bolstered by metered tech investment and reduction, with system, platform, and solution costs assigned to the “As a Service provider.” BPaaS provides assured tech currency, data security, and scalability — reducing tech investment risk. With this shift from technology and operations spending “As a Service” enables health plans to accelerate growth with a core focus on product development.
  • BPaaS helps centralize siloed operations for consistency across all units and improved process flows and outcomes. The BPaaS partner is uniquely incentivized to drive performance and optimize the resources and service levels—regardless of volume fluctuations.
  • Professionally operated, auditable “As a Service enables stringent compliance that addresses the nuances of regulations and how they can affect business from an end-to-end perspective. These “As a Service” models also provide a lot of efficiency due to the experience BPO organizations bring, which is a core differentiator.

In The Front Office

Exceptional member experience is more important than ever, as supported by a modernized contact center and measured by value-based benchmarks. This experience is integral both for differentiating healthcare organizations and for preventing the loss of valuable customers. Contact Center As a Service (CCaaS) — essentially, the front door of “As a Service” —provides:

  • An optimized consumer or member journey: CCaaS end-to-end journey mapping drives an enhanced experience. These member journeys can be enhanced using the CCaaS model, where all customer touchpoints are integrated, reducing the customer effort for the member.
  • Plug-and-play experience optimization: The CCaaS solution suite comprises a fully integrated, cloud-based platform with bolt-on digital accelerators, including chat and chatbots, text, and speech and data analytics. AI-based omnichannel provides seamless resolution over multiple touchpoints and channels. In addition to channel preference customization, the results are improved efficiencies and a higher rate of touchpoint resolutions for the customer. 
  • Up to 30%  cost savings in tech investment alone: With vendor accountability for bringing forward more robust, latest-and-greatest technology, health plans can also rely on additional predictability of spend and reduce their capital expenditure.

In The Back Office

In the back office, BPaaS delivers critical benefits—reducing administrative burden with access to modern tech and reducing the legacy burden and overall spend, with enhanced speed to market. BPaaS provides seamless integration with artificial intelligence (AI) and machine learning (ML) boosting benefits between claims, provider network operations, and pre-payment integrity checks. In these critical areas, BPaaS delivers:

  • BPaaS seamless integration starts with claims intake, FWA rules, and auto adjudication rules. The result is the delivery of a streamlined processing environment, leading to more lean and efficient operations with significant cost savings. This includes interoperability between internal and external departments. Additionally, there is one-stop accountability from a compliance standpoint.
  • Value-added robust analytics processing leverages the latest AI and ML tech, driving precision in payment accuracy and elimination of claims leakage.
  • Accurate data management and timely payment ensures that provider and member abrasion is minimized – with quality provider data — and faster speed to pay.


With the regulatory landscape and high cost of operation, health plans are critically evaluating their Utilization Management (UM) strategy and performance.  These organizations must focus on high-efficiency, end-to-end workflows that eliminate silos and bottlenecks in critical areas of health service management.  

  • Real-time determinations and faster case turnarounds can reduce up to 40% of operating costs. This can be achieved by leveraging AI-enabled technology like automation, natural language processing, ML, and assistive technology. A well-connected UM workflow bridges critical touchpoints across operations and compliance with seamless service delivery – from intake to clinical and post-service review. One key use case is the high cost of manual prior authorizations — a fulcrum point where faxes and phone calls are inherent processes from which inaccuracies and inefficiencies result in delayed care and provider dissatisfaction. 
  • Improved provider satisfaction can lead to higher NPS scores and Star ratings and better member engagement. Access to multi-channel prior authorization submission processes makes it easy for physician practices to submit prior authorizations over their preferred process at a time that is convenient, minimizing provider abrasion. The ability to obtain real-time decisions makes a world of difference to providers, as they ensure their patients get timely care — ultimately boosting member satisfaction, resulting in higher net promoter scores (NPS) and Star ratings. 
  • Evidence-based care guidelines support appropriate ordering that is clinically indicated, thus ensuring patients get the right care. UM as a Service leverages evidence-based guidelines that support clinically indicated health services, resulting in better care quality, safety and cost savings, with a first-time-right process and more precise clinical decisioning. 
  • The right BPaaS partner brings healthcare domain expertise that bridges gaps across these three areas of Front-Office, Back-Office, and Clinical. Additionally, a considerable advantage will be found with a partner that has end-to-end understandings and capabilities across the entire payer-provider ecosystem.

Article originally published in Healthcare Business Today.
Click here to read the full article

4 ways to win with claims denials

Facing both revenue and expense issues and exasperated by clinician shortages, hospitals are increasingly noting denials in the danger zone.  “Danger zone” translation: Denials are increasingly higher than 10%, costing significant dollars in lost or delayed reimbursements—as well as more overhead for rework and resubmitting claims. A recent Crowe RCA benchmarking analysis provided the industry-wide numbers: Claims denials rose to 11% of all claims last year, up nearly 8% from 2021. 

Winning with denials means focus on both administrative and clinical denials. On an average, clinical denials account for 45-50% of the total denials.  Not included in this number are payer post-pay audit payment takebacks.  Payers get a second chance at these denials, often two and three years post payment, but there is no second chance for a provider once service is rendered.  

Across both denials types, many outside experts bring a good mix of experience and capabilities across four critical areas of denials overturn: root-cause analysis, audits, analytics, and the right resources.

Root-cause analysis
Today, data on denials by every way it can be sliced—payer, revenue source, type—are available or can be built with limited investments.  Revenue cycle management (RCM) issues and inefficiencies have many root causes, and it is critical to track these to avoid revenue loss.  A stringent review of root cause analytics shows that the major sources of revenue savings are:

  • It’s key to fix staffing shortages in critical areas of system and process integration.  Pressure on provider revenue cycle and other administrative teams to reduce costs, like labor, across all non-clinical areas of work have led to key controls and critical resources being let go. The experts, typically the middle management or consultants, required to bring together payer knowledge, clinicians, process, and technology are not available or have competing priorities.
  • Implementing AI solutions to monitor service quality and coding will help keep pace with the increased AL based scrutiny by payers.
  • There is a need for accelerated monitoring medical necessity requirements of payers, brought about due to the change in forms of reimbursement such as telehealth, remote monitoring, implants, and mainstream adoption of experimental procedures.

Successful auditing includes a strong foundation of clinical SMEs and a robust audit sampling solution, such as querying the 835 denial reasons against medical records and appeal letters. This will result in detailed focused audit samples that enable robust coaching and feedback mechanisms to the nurses that are preparing the appeal letters. Additionally, quarterly clinical quality rounds and reviews by MDs and specialists will facilitate accurate documentation of clinical criteria that reflect medical necessity in the appeal letters.
A scalable and holistic denial management approach keeps the patient in the center of the denial and looks for relevant and accurate information across consultants and episodes of care.

Similar to clinical audits, periodic reviews of the each non-clinical step involved in overturning a denials is essential.  Perhaps not the entire process but several processes controls can be automated.  Untimely filing write offs can be limited if worklists are automated based on appeal filing limits.  Often this information can also be used by contracting.  Some payers have a 30-day filing limit but a three-year timeline on payer post payment audits. Data on denial reversals, lag times, and medium of claim submissions can be made readily available based off information on PA systems. 

Once there is clear understanding of the predictive nature of the denial trends, common findings can be applied into a predictable matrix based on historical trends. Then, AI-led querying of unstructured data and robust statistical methodology will allow propensity models to be deployed for managing efficient operations.
Also critical are payer processing rules, whether Milliman or Interqual, LCDs or NCDs and integrating automated controls. While case complexities impact the effectiveness of controls, providers continue to write off large amounts for authorization and medical necessity on recurring and other therapy services.  For example, it is possible for an automated control to be developed reminding a registrar that Ocrevus needs to be re-authorized or analytics to highlight non-typical variations in service coding from one month to another that could potentially impact payment.

The right resources
The cost of managing clinical denials operations is constrained due to the high cost of recruiting high-demand nurses and clinical teams. Highly cost-effective operations, without compromising on quality, leverage decoupling of the workflow between offshore clinicians and onshore SMEs and specialists.
With a routinized governance process with review of clinical acumen across specialties, supported by audits, multi-shore teams will achieve significant learning curve optimization. With conducting of Inter-rater reliability tests between the onshore and offshore teams, there is consistency in the quality of the appeal letters and establishing medical necessity.

The industry trend has been to skinny down on non-clinician staffing to control cost.  But successful denials overturn, ultimately, means finding the right Denials Team balance of clinical support and revenue cycle expertise. Often a clinician’s time is spent filing in appeal forms and uploading documents on portals—tasks that a non-clinician can perform and/or can be automated should be routed to non-clinical staff.   A revenue cycle management team that integrates the clinician, patient and payer, irrespective of location, is typically the most effective.

3 Payment Integrity Imperatives in Post-Pandemic Healthcare

Even pre-COVID-19, claims fraud, waste, and abuse (FWA) was a top-of-the-agenda issue for health plans aiming to evolve both care quality and consumer experience expectations. But the pandemic has surely raised the stakes for a need for a whole new payment integrity (PI) architecture, including complete process re-engineering and AI, automation, and analytics enablement. Health plans are grappling with compounding operational challenges — from aberrant services related to COVID-19 diagnoses to service shifts, uncontrolled telehealth expansion and, of course, labor shortages.

How can payers precisely address payment integrity needs while also strategizing healthy fiscal futures?

Here we provide three factors of the heightened PI pressures, with guidance on how PI solution experts can help.

1. Volume fluctuations and resource challenges

Complications affecting accurate forecasting of utilization and payments include excessive COVID-19 diagnosis, extended visit durations and increased visits for therapies, and early refills and disbursement of excess prescribed quantities for pharmacy and durable medical equipment (DME).

In addition to the existing legacy wastage and abuse issues within claims processes, there is now a greater need for specialized processes within payment integrity.

The return-to-normal volumes predicted for quarter three rested mostly on coronavirus utilization — with varying results across payers. There was COVID-19-related higher medical loss ratio increase for some payers — with some payers experiencing deferred care but often not at predicted levels. While other payers had higher than expected deferred care, there were also plans showing continued declines in enrollment.

The unpredictability across payments and bills resulted in operational challenges only heightened by the labor shortage. Health plans are challenged with multiple effects of this shortage — on top of enrollment declines, there are struggles with remote work, resource reallocation to support critical COVID-19 initiatives, and the resulting recruitment and retention of billing staff.

All of this amounts to operational disorder to effect more billing inaccuracies and payment errors. In addition to agility and flexing to meet seasonal shifts, another challenge lies in putting data to use to identify the aberrant providers, erroneous claims, and incorrect payments.


Elevated people, process, and technology payment integrity expertise is needed to help design a program that will be able to handle these fluctuations and resource challenges allowing organizations to step up the audit accuracy focus — with rules and query writing for a prepay focus.

The right experts leverage a pre- to post-pay approach for a proactive and preventive strategy to exponentially drive down inaccuracies and overpayments for improved recoup for payers over time. These experts can provide top-notch analytics tools and techniques that are combined with automation, machine learning, custom configuration, and manual review and intervention to analyze the claims data. The right experts deliver a brain-bot combination as they also bring the human ingenuity via skilled, experienced payment integrity specialists. Finally, the right payment integrity expertise requires robust internal business analytics solutions that depend on knowledgeable resources across IT, PI, and the SIU to maximize actionable findings.

2. Expansive state and federal regulation changes coupled with demand for transparency

The pandemic has brought swift changes in regulations and policies to ensure access to patient care. Health plans have been burdened with more and more administrative lift as well as increased regulations focused on greater transparency in billing processes — beyond the already tall order for modern-day member care and experience focus. Now these plans have to keep in step with federal government regulations while also enforcing individual states’ mandates regarding “non-essential” claims processes and review of COVID-19 related claims.

Among the many pandemic payment fallouts, this scenario is played out daily — a patient with coronavirus symptoms undergoes not just the COVID-19 test but possibly other tests to rule out respiratory problems. Confusion around payment, services, and improper coding are just a few of the factors that can then result in a surprise bill. This bill starts a long and expensive journey to correct coding and payment — at a significant loss to all parties: patient, provider, and payer. This surprise bill is today a key focus of the NSA relating to how providers and payers will communicate with individuals on hospital billing of payers and will also make the reconciliation process more complicated.

Ultimately, new government regulation, COVID-19 requirements, exceptions, and payment-related complexities have only intensified payment integrity challenges.


These experts can provide the deep domain and current understanding of regulations and rules, augmented by the requisite highly trained claims and coding expertise to optimize operations for payers. Payment integrity solution providers also have the required stringent attention to drive improved accuracy of information between provider and payer to ensure that there isn’t a post-pay audit issue associated with the par/nonpar provider in relation to new regulations around billing processes.

3. Rapid increase of telehealth billing and inaccuracies

Early in the pandemic, telehealth utilization surged as consumers and providers sought ways to safely access and deliver healthcare. At the core of COVID-19 disruption are emerging services and new medical coding and billing procedures — with telehealth at the top of the list. A significant number of health plans expanded coverage for telemedicine and telehealth services related to behavioral health, specialist visits, and primary care so people could receive care while remaining safe at home.

In April 2020, research showed that overall telehealth utilization for office visits and outpatient care was 78 times higher than in February 2020.

In addition to the patient/member-centric benefits of access to providers, telehealth also brings potential coding and payment aberrations. Case in point, there is the risk of coding of e-visit or virtual check-in claims to higher-level telehealth visits, as well as up-coding of evaluation and management (E&M) services to a higher level of service than actually rendered. Undoubtedly, the addition of telehealth will surely drive an increase to stats like yesterday’s citation of 80% of medical bills with errors, per Medical Billing Advocates of America research.


Health plans are experiencing a clear need for highly trained coding resources that can meet CMS timelines and unforeseen resource demand. The right payment integrity experts will bring rightshoring of cost-effective resources that are highly trained AHIMAs or AAPC-certified coders. This labor pool can further scale quickly and complete projects of any size with the maximum level of accuracy following a proven quality assurance process.

In conclusion

As expert problem solvers, payment integrity solution providers have the best exposure to the understanding of the nuances of the COVID-19 impact, including the regulations and how they can affect business from an end-to-end perspective.

The global reach of some of these service providers allows for rightshoring models that ensure that compliance standards are met while still providing cost and operational optimization, with the implementation of new tools, such as analytics, AI, and automation.

The healthcare industry presents a complex lifecycle of stakeholders with financial impacts and experience expectations — and payers must answer to all of them. These parties are all influencers of market position, image and, ultimately, success. With the right payment integrity approach and finely tuned focus, payers will find the exceptional service execution require to thrive in today’s environment.

Building a Successful Data Culture in the Post-Pandemic Healthcare Reality

Postponement of nonessential surgical procedures early in the coronavirus pandemic not only disrupted surgical care at U.S. hospitals, but also took away a large portion of hospitals’ total income, according to two recent studies. The University of Pennsylvania and Children’s Hospital of Philadelphia findings were presented at the virtual American College of Surgeons (ACS) Clinical Congress 2021. Nationwide, hospitals lost $1.53 billion from missed elective pediatric procedures alone, during the first three months of the pandemic — March to May in 2020. Thus, involvement of RCM BPO expertise is critical to fast-track revenue collections and enable providers to do what they do best: provide safe and effective care to patients.

Challenges in data science deployments

A machine-learning (ML) system is not just code; it is the combination of code, data, parameters, and training environment. Today, most healthcare organizations are looking at the potential of using AI/ML in helping achieving business outcomes and, despite significant investments, data science fails to make the desired impact. Key reasons include:

  • Data science literacy at senior levels — Often, data science models do not survive the proof-of-concept (POC) stage, and they are sidelined due to a lack of fundamental data literacy at senior levels of the organization.
  • Data findings conflict with intended course of action — At times, if data findings conflict with intended course of action usually derived based on past experience and gut feel, that could jeopardize the adoption of data science recommendations.
  • Data availability, quality, and preparation issues — Collection of the required data is a challenging task. Data exists in both structured and unstructured format and is stored in various places with unique security and privacy issues. Data cleaning is a primary task before any form of analysis. Unstructured data or unformatted data, which may take most of the time for data cleaning, can be a reason for losing motivation. Insufficient data that is available for the analysis can also be a factor for failed AI/ML projects.
  • Traditional RCM metrics are usually “lag indicators” — The primary KPIs by which practices measure revenue cycle performance are largely retrospective in nature: net collections, days in A/R, denial rates, and cost to collect, to name a few.
  • Availability of skill-set — There is a profound lack of deep technical expertise and business acumen by data scientists in areas other than data science. You rarely find a data scientist who can take a step further to understand how a java backend application works and exchanges data. Strong business acumen (i.e., understanding of the provider RCM) is also critical to developing successful data science POCs.
  • Analysis — Paralysis, challenges in building a compelling data story — There is a tendency to pick a large scope for deploying analytics and getting lost in the details. A lack of a clear data story telling leads to a vague explanation of analysis and recommendations. This delays / hampers the adoption of data culture in the organization.

Building a data culture

To arrive at the right business decisions, it’s critical that you start with the right business questions. Some pointers that could help build a successful data culture are as follows:

  1. Investing in data literacy across the organization. Specialized training should be offered just in time.
  2. Data-driven culture building. It starts at the very top. Include data in the decision-making process. Get in the habit of explaining analytical choices.
  3. Fix basic data-access issues quickly.
  4. Choose metrics with care. Move from retrospective to real-time reporting and action.
  5. Build a data science center of excellence (CoE). Invest in building a team with deep business acumen and data science skill sets.
  6. Make proofs of concept simple and robust, not fancy and brittle. Be willing to trade flexibility for consistency — at least in the short term.

Recent wins in data science deployments

Sagility has been able to build successful ML models to determine propensity of claim resolution and payments and optimize resolution efforts by identifying patterns of claims that could result in non-cash resolution. As a result of the deployment of Propensity-to-Pay Analytics Model, the Sagility team has delivered these breakthrough results for one leading national health system and longstanding client partner, for which Sagility manages multiple service lines, including Physician, Credit Balances, Payment Posting, and Day 1 A/R.

  • Sagility helped the client save $.4 million, for a 15% increase in the cash collections on claims within 90 days from the date of placement.
  • The client had benchmarked cash collections 0 – 90 days from the claim placement date at 25%. Sagility is now operating at 28.5%, which is well above the benchmark.

Looking ahead

The potential for big data analytics / data science is huge in the future. Machine learning can also process the information much faster with its accelerated learning and advanced capabilities. Based on this, the time required for solving complex problems is significantly reduced. However, data is most useful when everyone has the ability to explore it, both individually and collaboratively, with other team members. The democratization of data and collaborative analytics are the future of business intelligence.

5 Provider Coding Myths, Debunked

Over the past 18 months, healthcare providers have grappled with historic cost and care challenges. The COVID-19 pandemic has increasingly forced providers to assess new areas of transformation to unlock operational value and cost efficiencies. Unique trials call for alternative solutions, and health systems are taking a new look at cost and process-challenged areas like coding, which has been an area often operationally underestimated and rife with misconceptions. Here we dispel some common myths by presenting facts about how effective coding can not only help providers survive the current market but start thriving with proactive denials prevention and insights.

1. MYTH: There is no labor shortage..

FACT: There is a labor shortage of skilled coding specialists. Especially in light of the pandemic, businesses across industries are facing critical labor challenges. According to the Bureau of Labor Statistics, since February 2020, as the pandemic took hold in the United States, healthcare employment is down by 542,000 positions. And even before the pandemic, the BLS predicted a surging need for coders, with job growth of 15%. This supply-and-demand scenario is bolstered by the rise of telemedicine, new codes, multiple guideline updates from CMS and AMA with respect to COVID-19 and telemedicine, and a changing service delivery that increases the need for coding expertise. The shortage of workers is driving providers to take a fresh look at business process outsourcers (BPOs), which can provide healthcare coding expertise at a fraction of the cost of onshore workers.

2. MYTH: Offshore coders do not understand US regulations.

FACT: Coding specialists don’t need to be trained in the US. Today’s BPOs can provide well-trained and skilled offshore resources.  Sagility, for example, has established a Coding Academy to develop a robust talent pool. The Coding Academy is a world-class coding academy that creates industry ready certified coders who can significantly and immediately add value. Our experienced certified coders are well versed in ICD-10-CM, CPT/HCPCS, National Correct Coding Initiatives, Local Coverage Determinations, National Coverage Determinations and other CMS and payer specific guidelines. Adept at both payer and provider specific coding requirements (diagnostic, procedural and DRG coding), insurance and government regulatory requirements, team members have seeded expertise under SME guidance and cross-trained for related specialties. These team members form the core of a multi-shore capability.

3. MYTH: Outsourcing does not reduce costs.

FACT: The cost of outsourcing is significantly lower than insourcing. BPO coding expertise can represent up to 40-50% discount for first-time outsourcers.domain expertise and clinical specialization to address areas like coding-related denials, which can comprise 30-40% of overall denials. Two-thirds of these denials are not reworked by providers because they do not have time, resources, or skillset to understand and resolve denials. Couple that with an efficient coding and billing process, and a provider can work proactively to prevent nearly 90% of their denials. This lifecycle focus is an area in which coding expertise can deliver, especially those with ecosystem knowledge and multispecialty payer and provider coding delivery. These partners train coding talent from a mindset of dual perspectives—and payer understanding means a more proactive approach for providers with more coding value delivery.

4. MYTH: Coders do not have process expertise or co-create value.

FACT: Coding operations are optimized with innovation and operational excellence. Design thinking, cocreation, and process reengineering are key advantages of BPO, which come equipped with singular process and technology expertise. As innovation hubs that specialize in transformation every day, BPOs can boost coding and clinical expertise with the innovation firepower of automation and analytics skills, domain expertise, and regulatory compliance. For example, solutions such as intelligent analytics enable service vendors to help hospitals stay ahead of the curve to predict potential denials that flag for additional reviews before a claim is sent out to prevent denials. These solutions are supported by customized dashboards to describe top denial reasons, top denied procedures, modifiers, and diagnoses. Finally, with centralization of these coding resources, changes in systems, regular coding updates to stay current and compliant can be implemented quickly and efficiently.

5. MYTH: Coders are not specialized.

FACT: Certified coders are specialized by coding area. Coders gain expertise in specific specialties that are not easily interchangeable. For example, an office coder may not be an expert in coding surgery or anesthesia and vice versa. Similarly, coders are not necessarily experts in resolving denials. Managing a coding denial requires experience and knowledge beyond coding. It is hard for a provider to find a coder meeting their specialty requirement which may result in revenue loss or upcoding resulting in non-compliance against coding regulations. For example, clinical denial-trained coders know how to resolve denials.

The BPOs that can best solve for today’s coding challenges have extensive ecosystem experience working for both providers and payers, giving us a unique exposure to understand both worlds. Our training and best practice sharing are designed to enhance our coders on both teams to prevent denials happening in the first place. By rightshoring the work, our clients can immediately save 40-50%, which goes beyond the cost of labor – finding the right skillset, overhead to work on preventable denials, cost to manage operations, quality, and infrastructure. Through our technology-enabled coding solution, we can reduce coding denials by 50% and will stay you fully compliant with federal regulations.

Health Plan Guidance: 3 Essentials for No-Surprises Act Compliance

In recent years, the healthcare industry has increasingly been paying attention to the error rates in health plan directories. Undependable directories create poor member experience by impacting access to care. The Consolidated Appropriations Act COVID-19 relief bill, signed into law on December 27, 2020, requires health plans and healthcare providers to work in tandem, so that members are informed and protected.  This law, under the No Surprises Act, an interim final rule recently passed, mandates that health organizations ensure provider directories are current and accurate. Currently this Act targets an effective date of January 1, 2022, with health plans required to verify provider contract status and updates every 90 days. Health plans and organizations that do not comply face penalties and both member and provider abrasion.

As Provider Network Operations is increasingly at the fulcrum of both health plan operations and optimized consumer experience, here is how operations experts such as business process outsourcers (BPOs) can efficiently and effectively address the three aims of No Surprises:

1. Health plans need to update provider directories and respond quickly to consumers.

The No Surprises legislation requires health plans to update their database within 48 hours of receiving demographic change requests from a provider.

How BPOs Can Help: The right operations partner can provide the people, process, and technology expertise to update directories with speed and quality.This enables real-time provider demographic updates. This output can be either shared through an automated nightly batch run that updates the plan’s database directly or as an output file in any desired format. Additionally, dashboards can provide visibility and ensure compliance as well as access to data that can help drive process refinement specific to the experiences (such as, if a provider prefers phone outreach or responds to phone outreach, but does not respond to email outreach, processes can be refined based on the data we have collected based on the experiences to reduce provider abrasion). These insights go a long way toward both No Surprises compliance and the enhanced Star ratings and reduced provider abrasion that support optimized experience.

2. Regular verification of provider contract status and updates is required at least once every 90 days.

How BPOs Can Help: Provider Data Verification and Collection modules can help to conduct planned outreach campaigns to collect provider data. This data collection and verification activity can be performed outside of clients’ core systems and the application can provide cleaned output files in most industry-standard formats.

The verification aspect of network management is complex, as all providers and provider groups have different communication preferences. The right BPO partner will have customized applications, as well as multimodal outreach processes that use three different communication channels:

  • Phone
  • Email with link to online self-service portal
  • Fax

Another network management challenge is reaching out to providers without adding to their workload. Traditionally, most provider verification campaigns for updated directory information are run by fax or phone. While provider outreach can be supported via fax, phone, or email depending on what works best for a particular office, the ideal option is directing providers to an online pre-populated form. Providers can easily update their information without having to deal with pesky manual forms or spend more time over phone, and health plans receive updates quickly and efficiently.

3. Healthcare providers must communicate information more frequently to health plans to verify accurate directory information.

How BPOs Can HelpToday’s providers must respond to a constant flow of requests that taxes resources and adds to cost. Network management experts can provide tools via customized auto-reminders to the contact person at practices, alerting them that it is time to attest demographic information pertaining to their providers.

All of these No Surprises mandates are on the horizon—along with the requisite additional oversight and compliance. On the bright side, today’s healthcare organizations can seize the moment and accelerate their drive toward a more B2C healthcare experience. And BPOs have the required core solutions to get them there faster—with critical No Surprises compliance and also the solutions to meet of the ever-raised bar of optimized provider experience, accurate provider data/directory, and improved and more cost-effective processes. When accurate information is made available on consumer directories, millions of members are empowered to make the choices that are best for them and their families.

The Human Side of Healthcare Analytics

Capturing a consumer’s emotional response to a service or sales experience is increasingly vital to their interaction with a brand. The pandemic has made this fact increasingly clear, with both healthcare payer and provider operations accelerating digital delivery of member/patient experience. Emotional analytics and innovation to enhance healthcare interactions, using digital emotional signaling, are a means for brands to acquire and retain consumers. That is because healthcare interactions support that merges digital solutions with empathetic analytics can play an essential role to measure the moods, attitudes, and emotions that garner brand preference and loyalty.

A recent study by Tempkin Group showed when individuals have a positive emotional association with a specific brand, they are 8.4 times more likely to trust the company, 7.1 times more likely to purchase more and 6.6 times more likely to forgive a company’s mistake. Although sales figures, surveys, social media posts, and ratings may help inform brands about customer views, they do not provide the finer, granular insights regarding what goes unsaid. And existing conventional measures cannot intercept brand bias since they focus on measuring the probability of specific customer reactions while the customer is already having a biased outlook towards the brand.

As healthcare organizations continue to focus on improved operations and real-time insights that drive customer satisfaction, frontline resources are becoming increasingly dependent on data to improve the customer experience. But driving real time insights is less and less achievable, as current systems are disparate—across technology, locations, and resources—and they do not achieve a unified or real-time interaction insight. Additionally, real-time feedback is increasingly difficult —with the proliferation of channels adding to the siloing of reporting data. As this shift continues, operations are searching for more ways to provide instant impacts to the programs that they manage. Healthcare organizations need real-time tools that provide immediate insights into the condition of their interactions and the program overall.

Today’s analytics solutions solve for three key customer experience truths for healthcare consumers:

  • Today’s digital-led customer care must meet the needs of Generation “C”, the “connected” customer demographic that spans generations. These consumers make purchasing decisions based on brand reputation and a more personalized experience. A strong digital toolkit of home-grown assets containing Interaction Analytics; AI-Powered Data Capture; and Intelligent Automation will elevate and customize engagement to earn and retain these buyers.
  • Even in the face of all the digital, people still make decisions based on emotion. Consumers form an opinion about a brand even before they have shared any real-life experience with them. Any conversation or dialogue with that brand either counters or reinforces those subconscious thoughts regarding the brand. This bias is based on how the customer feels as he or she is experiencing issue resolution or any other service support.
  • Healthcare organizations, now more than ever, require extreme efficiency and speed, reduced costs, improved CSAT, quality and Star ratings.

How do you solve for these truths? Healthcare organizations are understanding the need to step up yesterday’s analytics products with a next-gen approach that builds on what is available today. Analytics partners set themselves apart with domain expertise, custom-fit solutions, tech agnostic solutions that are customizable to client needs, innovation and value maximization to leverage proven methodologies and best practices. Sagility brings analytics to drive next-level empathetic experience, with results such as the interaction analytics we recently deployed for a leading healthcare payer. This solution resulted in a nearly 80 NPS score for the client’s Medicare member base—significantly beating the industry standard of 27 . With a combination of tools and strategy, experts can bring these experience solutions to meet demand with next-level ROI to engage and retain members while also delivering both essential insights and operational savings.

Three Ways Healthcare Engagement Models Differ from Other Industries

First published on May 23, 2018, by Austin Ridgeway, Director, Sagility; refreshed on June 1, 2021

Over the past couple of years, there has been a lot of industry buzz about what retail can teach healthcare about engagement strategies. Now it’s time to walk the talk, with many watching and learning from disruptors.

Healthcare has, undoubtedly, made B2C strides toward 24/7 optimized experience—from nurse triage to customer relationship management (CRM) and analytical population health management (PHM) data collection. Both payers and providers are more proactively tracking member and patient interactions to build intelligence for future interactions. Data collected is building on previous elements, fostering a holistic portrait of healthcare consumers, creating the foundation for predictive intent, and providing a more effortless experience.

Leaning heavily on these new strategies, healthcare is catching up to retail’s disruptors—from digital convenience to personalization. It’s important to remember, however, that the road to engagement is not an easy one for healthcare. The Uberification of healthcare metaphor notwithstanding, retail-to-healthcare engagement comparison is far from an apples-to-apples scenario.

There are key differences between other industries and healthcare organizations, which have to navigate distinct market complexities.

1. More stringent compliance

When it comes to protecting member/patient/customer, and partner data, as well as storing it as securely, healthcare carries a much heavier risk and burden than most other industries. The cost of attaining and maintaining regulatory compliance is high, in terms of costs and resources.

At the top of the list for healthcare is the heavyweight Health Insurance Portability and Accountability Act (HIPAA), which changes daily with the onset of telemedicine and wearable devices that store protected health information (PHI).

Undeniably, the healthcare compliance list is long, and a moving target. With all of the state and federally driven mandates, payers and providers know that even the smallest mistake can result in sanctions by the government, resulting in high costs, oversight, and extensive auditing. So, while functionally, other industries focus on certification and compliance, healthcare has to abide by a broader pool of more stringent regulations.

How BPOs can help: Credible healthcare business process outsourcing (BPO) organizations with reach and a diverse client base not only have a practical comprehension of the broader federal regulations but also benefit from the granular knowledge of state-driven certification requirements and understand the implications of conforming to these regulations.

As expert problem solvers, they have the best exposure to the understanding of the nuances of regulations and how they can affect business from an end-to-end perspective. The global reach of these service providers allows for rightshoring models that ensure that compliance standards are met while still providing cost and operational optimization, with the implementation of new tools such as robotic process automation (RPA).

2. Multiple customers

If the “customer is always right,” then who is the customer in healthcare? Ask any supplier, and they may question whether they serve physicians, patients, hospitals, or insurers.

Healthcare payers and providers have many users and influencers across all operations. Payers aim to engage and satisfy members, providers, and potentially other stakeholders such as third-party administrators. Providers answer to patients, payers, and other parties who have a stake in their success.

Unlike retail, the healthcare industry presents a complex lifecycle of stakeholders with financial impacts. These parties are all influencers of market position, image and, ultimately, success.

How BPOs can help: BPOs can help to address these market challenges, as the right partner will have holistic healthcare lifecycle management expertise that builds long-term relationships to engage and offer exceptional service execution to members, patients, and other relevant stakeholders.

Outsourcing partners typically have a capability set that expands across numerous functional areas within payer and provider organizations. BPOs with a consultative approach will provide the abilities to manage the expectations of all relevant influencers, from voice to back-office operations. This understanding of upstream and downstream impacts will also assist with driving efficiencies and cost-saving opportunities.

Ultimately, as a virtual extension of healthcare client operations, a good partner will carry the customer-centric solution thinking that has led other industries to healthcare interactions success.

3. Internal silo-ization of these orgs

Keeping in mind the bureaucratic and complex nature of healthcare processes, there can be organizational silo-ization that occurs within operational business units. Take, for example, internal decision-making for a health plan’s provider engagement, which could roll up to another leader than the one who owns member engagement. In this classic example, there can be disconnects, causing higher costs and other operational inefficiencies.

How BPOs can help: Considerable advantage will be found with a BPO partner that has end-to-end understandings and capabilities across the entire healthcare ecosystem. These service providers, like Sagility, are experts at centralizing operations to ensure consistency across all operating units and offer exceptional experience and improved outcomes.

Ultimately, to navigate these unique industry challenges and finally deliver the customer experience found in other buying scenarios, healthcare will increasingly look to the essential accelerators.

Data analytics, RPA, AI, and machine learning are key enablers to healthcare transformation—from the way physicians are educated and practice care to how payers support care delivery. With proven success deploying these innovations, along with customer care learnings from more mature industries, BPOs can help healthcare clients to pave the way to truly improved customer, member, and patient experience.

Preventing and Appealing Clinical Denials with Analytics, Automation, and AI

U.S. hospitals lose $262 billion due to denied claims each year, representing roughly 10% of the total claims paid.

Unraveling the root cause of denials costs an average of $118 for each hospital claim, with 60% to 80% of those denials typically recoverable on appeal. For an average hospital submitting 200,000 claims annually, that represents over $2M in potential rework. Hospitals typically lose 2-3% of net patient revenue from claim denials.

The reasons that insurers give for clinical denials vary widely, but commonly include “prior authorization missing,” “not medically necessary,” “experimental or investigational,” “length of stay,” and “treat in a lower level of care setting.” What is not commonly understood is how the reasons relate to the clinical root cause, what medical documentation is required to support the service, and how the payer’s clinical policies relate to the denial decision.

Facing the need to solve for denials from multiple payers with varied clinical policies, hospitals have traditionally hired nurses and other medical professionals to manually review cases, navigate systems, and liaise with departments to investigate and appeal denied claims. Hospitals frequently run into resource limitations with this conventional approach. Today, maybe 20% of clinical denials can be appealed with this method.

Successful clinical denial resolution requires a clinical skillset to research the root cause and to address the patient’s medical situation and appropriate payer criteria in an appeal. Applying modern technology — such as analytics, automation, and artificial intelligence (AI) — can help to increase the number of clinical denials investigated, boost appeal effectiveness by addressing true payer clinical policy root cause, and recover much-needed revenue.


Definition and context: Analytics is a mechanism for extracting meaningful insights from an organization’s existing data for better business decision making. Data are extracted from many source systems; cleansed, integrated and stored in a data lake; enriched and synthesized with the latest AI and analytics tools; and then rendered in reporting dashboards for decision-makers.

Potential analytics applications for clinical denials:

  • Indicate the propensity to overturn denials based on payer, denial error, procedure code, and diagnosis.
  • Identify trends in clinical documentation integrity by service and common payer clinical criteria.
  • Identify potentially uncollectible codes through prior appeal trends.


Definition and context: Robotic process automation (RPA) uses existing end-user software interfaces and enterprise applications to automate processes to reduce effort and bring in process efficiency. Full and hybrid/blended (with human intervention) automation approaches are possible. Automation leads to better capacity handling, faster processing, fewer errors, reduced penalties, better compliance, and cost optimization.

Potential automation applications for clinical denials:

  • Appeal templates for faster and accurate processing.
  • Automated prior authorization workflows to negate denials for missing authorizations (up to 10% of ACA plan claim denials relate to prior authorization).
  • Image recognition to facilitate automated routing and standard appeal follow-up on common clinical denials.
  • Clinical data integrity through automation using common denial sources from patient and provider data.

Artificial intelligence

Definition and context: While RPA has helped to automate rules-based, structured data and processes, cognitive automation is the process of identifying and processing unstructured and semi-structured data. Cognitive automation brings much needed artificial intelligence into rule-based RPA. Cognitive elements such as machine learning (ML) and natural language processing (NLP) can make sense of data that appears to lack patterns. AI goes one step further than RPA by enabling machines to execute subjective processes requiring decision making.

Potential AI applications for clinical denials:

  • Verify required medical documentation for frequently denied services and flag tagged portions for clinical review.
  • Digitize the request process for commonly required medical records when a patient’s file is missing outside physician records or other specialist encounters to support denied service.
  • Provide a summary (for a clinician) of the patient’s associated medical condition related to applicable payer clinical criteria.
  • Generate appeal letters based on medical records for clinician review for common conditions and denied services.

In clinical denials, a technology-led approach increases the number of appeals that the hospital is able to address, revenue collected, and effective clinician allocation. Analytics, automation, and AI can improve root-cause analysis based on underlying payer clinical criteria while both refocusing and minimizing processing tasks for staff.

Up to 90% of denied claims are preventable. Rework is preventable. With the help of technology, medical professionals can optimize research, decrease overall denials with key prevention strategies for medical documentation and billing, and reduce time spent on uncollectible accounts.

Get more ideas on how to use analytics, automation, and AI for revenue cycle management in our “Accelerating claims reimbursement with Sagility clinical denials advanced recovery” case study and our “Recover lost revenue: Leverage AI to automate your revenue cycle” whitepaper, which offer insights on how to use technology to maximize provider revenue.  

For Better RCM, Prioritize People and Track with Technology

Across the healthcare industry, health information mismanagement is causing a loss of millions of dollars each year. Inefficient use of staff resources and systems, or the failure to invest at all, reduces a healthcare provider’s already thin margins. Provider finance leaders are struggling to address the financial impact of post-pay audits, denials, and processing appeals, while revenue cycle departments are inundated with backlogs of denials on previously paid claims, distracting them from standard claim resolution processes.

Proper revenue cycle management (RCM) involves careful documentation of the entire patient journey, from pre-registering through payment collection. The solution for streamlined, successful RCM requires hiring for the right skill sets and leveraging the right tools to track and analyze patient and member data—and healthcare organizations must prioritize this challenge.

Seek out these associate attributes

Because each detail of a person’s path of care must be recorded accurately, the ideal candidate for this type of work is meticulous and adheres to the many and varied processes that payers provide. Timeliness is essential, as is proactive self-motivation to ensure each step is completed. An ability to communicate effectively with multiple people and departments, along with knowledge of medical terminology, are essential skills.

Perhaps the most desirable skill is familiarity with or the aptitude to quickly grasp the tools and software used to perform data collection, analysis, and reporting. Although technology-enabled RCM services are widely available today, many organizations are running on antiquated systems that fail to integrate with more modern options, which contributes to inefficient operations and additional lost revenue.

Track it all with the right tools

Once captured by a proficient employee, patient and member data can be handed over to artificial intelligence (AI)-based systems. Machine learning (ML) and Natural Language Processing (NLP) help reveal insights from the information gathered, and predictive analytics can provide recommendations based on patterns detected.

Although critical, patient and member data isn’t the only information to track. The work performed by employees and the tasks themselves must also be monitored. With good data and analytics in place, key performance indicators can be reviewed and improved upon regularly.

A recent article in Becker’s Hospital Review states, “By effectively tracking your issues, you can improve your revenue cycle by prioritizing the issues with the largest impact on fiscal management, revenue cycle processes and workflows and ensure personnel are held accountable to meet target dates and goals.”

A huge source of revenue leakage is due to post-pay recoupment, according to Belinda Cridge, Director of Client Services at Sagility. Although the contracting and revenue cycle management functions previously worked in silos, she says, “Contracting now proactively reaches out to the billing and follow-up folks to check on issues related to post-pay audits while they go into new contract negotiations.”

Cridge adds that although there’s no way to estimate or predict the number of upcoming recoupments, proactive tracking is important. “Set up your system to be able to track recoupment and to track audits,” she advises.

Sagility Director of Client Relations Matthew Betts agrees. “You definitely need a tool to track and monitor the information, and you also need resources who know how to use that information to prevent denial kickbacks, manage the audits, and provide upward feedback with leadership.” Information needs to be incorporated into your denial reduction initiatives in a timely fashion to prevent further revenue leakage in future audits.

At Sagility, we’re known for both our service capabilities and analytical expertise.

Member Experience: Never a Better Time for Digital Enablement

Health plans are all too familiar with the challenges of member experience—that perfect storm of call/processing volume surge, staffing challenges, and critical moment-of-truth engagement pressures. And the stakes are even higher for 2021, according to JD Power research.  The organization’s fourth annual study found that member satisfaction averages dropped from 712 on a 1,000-point scale in 2009 to 701 in 2020. J.D. Power and Associates measures health plan satisfaction of 133 health plans in 17 U.S. regions in seven areas: coverage and benefits, provider choice, information and communication, claims processing, statements, customer service, and approval process.

To be successful, today’s digital-led member engagement must meet the needs of Generation “C” – the “connected” customer demographic that spans generations. These consumers make purchasing decisions based on brand reputation and a more personalized experience. A strong digital toolkit, containing interaction analytics; AI-powered data capture; and automation, will elevate and customize engagement to earn and retain these buyers. It may be counterintuitive, but digital enablers such as analytics, AI-powered intake, and bots can deliver a more empathetic, customized member enrollment experience—one that earns and retains customers for life.


Interaction Analytics solutions offer key advantages along all consumer journey touchpoints, delivering essential ROI with voice of consumer insights related to preferences and experience enhancements to drive higher CSAT and NPS. Contact centers have a goldmine of customer feedback.Insights can be built from speech data that is a valuable information source of customer sentiment and intent. The data tells the unbiased story here – to avoid missed opportunities or misalignment of feedback. The proactive insights built at the crucial open enrollment phase are actionable by helping health plans to tailor their product development to consumer choice across key member demographics.

Case example: As a value-added service, Sagility engaged with a leading health insurer client to implement VOC analytics. Our solution was deployed to transcribe and analyze millions of interactions. We conducted a deep-dive analysis on negative customer feedback into how claims settlements are made and the customers’ lack of awareness of the benefits provided by new insurance products, especially in the Open Enrollment season. The results included:

  • Better correlation between NPS/CSAT rating and call types, driving a solid 33%​ NPS and CSAT improvement.
  • A more streamlined and frictionless claims settlement process along with more frequent and clearly defined communication to all customers regarding insurance products and their benefits.
  • A trend analysis of member demographics by geography, resulting in better provider network relations.

AI-powered data capture

Today’s cutting-edge machine learning, optical character recognition (OCR), and intelligent character recognition (ICR) for cognitive intake have elevated the document management process once considered highly burdensome for payers. The open enrollment process is a touchpoint ideally suited to intelligent data capture. Open enrollment is a highly paper-intensive process that presents an excellent opportunity for improvement. With the inherent paperwork and processing, AI-powered innovation provides tremendous opportunity for workflow enhancements to minimize subjectivity of structured/unstructured data—for faster turnaround and cost savings.

Case Example: Sagility created an intelligent machine learning solution to help improve a client’s Star rating—a measure directly linked to member experience. The team addressed the entire workflow with a cognitive content processing solution leveraging an image analytics engine to process the source. The solution featured a natural language processing (NLP) engine to analyze key words and context. For one process, this as-a-service solution drove Star ratings improvement of the MA plan by an 8% weighted average. For member experience, this data capture closes the loop, addressing member resolutions via AI for quick, accurate decision making—those functions on which Star ratings are established. With better ratings, step one of the member experience journey—plan selection—is enhanced.


By bringing greater automation to the open enrollment process, organizations can decrease their labor requirements while realizing a greater return on investment. Bots can streamline the repetitive and time-consuming steps of the open enrollment process for crucial desktop efficiencies that significantly impact customer experience. This “straight-through processing” is the smartest path of least resistance, with a bot-brain approach to address seasonal challenges with intelligence.

Case Example: For a leading health plan, Sagility looked at a process of manual data entry for member details in the enrollment system, starting from intake applications over different formats. For Specialty enrollment, as per this process, the client was converting XML into PDF applications, which were manually indexed and given to resources for entry. Before Sagility’s involvement, there were 12 screens to be filled manually, with requirements of more than 99% accuracy for data entry. For Medical enrollment, applications were coming from brokers with multiple instances of missed information and multiple data entry provisions. Sagility leveraged blended RPA solutions to take Specialty and Medical queues live. For Specialty, we helped drive an increase from 25 to 40 apps daily, reducing costs by 40%. For Medical, we reduced costs by 30%, decreasing the time taken to complete one application by five hours. With these processes, the Sagility achieved $400,000 in annual savings for the client.

The above case examples are proof points to support the fact that BPO partners bring a unique solution mix to address open enrollment: automation and analytics as-a-service capabilities, seasonal talent scale and agility, and right-shoring cost savings. The right BPOs are ideally suited to accommodate needs like open enrollment on the principles of lean operations, and also co-creation, design thinking, and globalization. Beyond cost-cutting, good BPOs implement meaningful changes that help eliminate silos and align objectives in order to achieve true operational and engagement impact.

Seamless Customer Experience Begins with Enhanced Direct Enrollment

This year’s open enrollment period takes place from November 1 through December 15, when consumers can select or renew an individual exchange plan either on or off marketplace. For the millions who purchase these plans, the experience can be cumbersome and frustrating as they struggle to make complex decisions based on balancing competing interests of cost, quality, and access.

Because creating a frictionless shopping experience for customers (and especially repeat customers) should be a critical objective for health plans, the federal government has enabled a key technical enhancement to the marketplaces called enhanced direct enrollment (EDE). EDE changes the game for how consumers purchase insurance, and smart companies will optimize the upside available from EDE for their customers.

What is enhanced direct enrollment (EDE)?

When the healthcare exchanges first launched, individuals shopping for plans on a health plan’s website were unable to complete a transaction for coverage without being redirected to HealthCare.gov to first verify their eligibility. This led to confusion as customers were suddenly presented with new slates of options after having initially made a buying decision. In many cases, shoppers had to start over, or they closed out of the process in frustration. Many either never went back or went straight to HealthCare.gov when they felt ready to shop again.

EDE enables health plans and web brokers to connect directly to the Federally Facilitated Marketplace (FFM). Individual customers can complete the entire purchase process and experience without ever having to leave a health plan’s web environment. Plan research, eligibility determinations, subsidy applications, pricing, and enrollment initiation can all be completed in one unified shopping experience. In addition, once enrolled, individuals will also be able to access all CMS notices within the same application.

How does EDE improve the customer experience?

For someone looking to buy an individual health insurance plan for the first time, confusion is likely to be the defining emotional state. A research and purchase experience that includes multiple handoffs or disconnects will compound the frustration and anxiety. Plus, the underlying products—which everyone needs but hopes to never use—provide little inherent excitement or satisfaction.

Health plans spend a great deal of money in customer acquisition every year before the open enrollment period. If they don’t leverage EDE, these health plans risk “leakage” every time a hard-found potential customer is redirected to a federal site that is also prominently displaying competing products. Instead of finishing a purchase on the health plan’s website, they may start clicking around the government website and find dozens of additional options to entice them. In many cases, they may end up purchasing from another plan. This is marketing and advertising spend wasted. By leveraging EDE, the individual stays on the health plan website without having to go elsewhere to finish the process.

For health plans, the EDE functionality is not just another widget or fancy add-on; it’s a key component that offers seamless integration into existing enrollment products and workflows designed to improve the customer experience for both current and prospective members. The Centers for Medicare & Medicaid Services (CMS) has designated a small number of firms as licensed EDE entities, and health plan providers must choose a partner that has done the legwork, development, and testing to ensure their products and processes meet CMS standards.

Precision Utilization Management: Meeting Patients Where They Are

Providers view prior authorization as a manual, burdensome, and laborious process, mostly because of process missteps such as lack of clinical data integration, inconsistency in data exchange standards, and differing policies among payers. According to a recent American Medical Association survey, handling the surging prior authorization requests translates into a “high” or “extremely high” burden for 75% of physician respondents. And 90% of surveyed physicians reported that the PA process delays patient access to necessary care. An important front-line negative impact of this time-consuming and often ineffective process is that patients feel the brunt of the delays and are disgruntled due to the endless appeals before receiving the needed care.

The rapid maturity in cognitive automation and predictive analytics supported by robust data sources presents an opportunity for payers to evolve traditional utilization management (UM) processes into an intelligent authorization process. What about taking a surgeon’s scalpel to the process, with a more targeted, precision UM? This more precise UM is a proactive data-driven program that uses the power of predictive analytics to provide a prospective view into the downstream needs of the patient, thereby reducing unnecessary repetition of authorization—every step of the way.

The precision UM method not only reduces burden on providers but leads to reduced provider abrasion, enhanced member satisfaction, and decreased administrative resources and costs in managing the authorization process.

Four critical elements of precision UM meet the patients where they are in their care journey:

  • Precision analytics: Member analytics looks at member behavior, historical data on compliance with preventive/recommended treatment, comorbidities, and lifestyle factors to accurately predict duration and level-of-care needs. These analytics help provide a prospective approval for the entire course of treatment. For example, a request for varicose vein ablation can be automated through predictive analytics if the historical claims and clinical data show a patient’s lack of improvement with conservative compression therapy and abnormal lab-based venous varicosity. Other lifestyle factors—such as comorbidities or a ground-floor versus an upstairs bedroom—also factor into what additional services (physical therapy or home health) need to be authorized.
  • Provider scorecard: The provider scorecard comprises analytics based on compliance to process fraud, waste, and abuse, as well as outcome measures such as accurate and timely information submission. This provides the ability to audit on the back end for continued gold-card status across UM needs and can help drive dynamic changes to the automated authorizations for stringent cost and quality outcomes.
  • Intelligent automation of authorizations against clinical guidelines: Using machine learning tools enabled by natural language processing functionality, this innovation can reduce review time by 30-40% and optimize the approval to denial ratio by 20%.
  • Care management and care coaching to holistically address the member for better lifecycle outcomes: Upon identification of key parameters driving utilization needs, a holistic care transition and care management program can help members seek only necessary and targeted care needs that will maximize outcomes. Addressing social determinants such as two-story housing when the member has a walker or lack of transport to attend outpatient therapy can reduce unnecessary utilization, optimize recovery timelines, and reduce readmission to hospitalization.

To provide the precision focus above, healthcare organizations are looking for BPO partners with end to-end-expertise and clinical resources to scale support with intelligent tools and workflows to reduce cost and improve the effectiveness of UM programs. These BPOs have the analytics to deliver superior insights with client data, including deep dives to determine root causes of inaccuracies and process inefficiencies. Adoption of precision UM, electronic requests, and interoperable data exchange can significantly improve the payer provider collaboration. Additionally, providers should also consider clinical data audit using NLP solutions, which would increase the accuracy of documentation required for the UM processes.

Rather than expending time and resources to hire or train internal personnel, a skilled BPO organization can bring knowledge and skills in these areas to an organization immediately, with limited lead time. Ultimately, the goal is to develop a partnership that brings precision-UM-focused talent, best practices, and resources to the table.

Bridging Provider-Payer Gaps with Today’s Technology

Across the world, today’s healthcare organizations are sharing one critical challenge: the rising costs associated with improvement in quality care. The underlying mandate is that all stakeholders must keep a sharp focus on making healthcare more effective, efficient, and affordable. To meet this new demand, both payers and providers have made adjustments to service delivery—and technology is increasingly playing a pivotal role.

How can payers and providers leverage technology to better collaborate? In a word: data. The amount of data attached to every patient has grown exponentially—and all of it is gathered, integrated, and interpreted according to compliance guidelines and processes that can vary widely between payers and providers. Additionally, the data sets held by payers and providers can be significantly different. For example, payers possess data on claims, financial analytics, and risk models. Providers have administrative and clinical data that includes case histories and outcomes. Providers need to leverage health plan data in order to move from episodic care to delivering outcomes-based care across the care continuum. Payers need access to patient information in order to work with providers to establish appropriate care plans for their members. In the past, both stakeholders have attempted to bridge these data gaps through costly and time-consuming manual processes. The good news is that today’s more advanced analytics leverage data and improve collaboration of payers and providers—for enhanced experience and decreased costs.

Next-gen capabilities

While the healthcare industry has mastered data collection, the challenge is making it actionable. According to research, about 80% of healthcare data is unstructured, making it extremely difficult to apply against business or clinical challenges, including population health management, countering fraud, waste and abuse and other administrative and financial transactions. And even the 20% of structured data presents enormous challenges in a value-based care world—with different data sets kept by payers and providers. Emerging cognitive capabilities increasingly address issues of unstructured data. And implementation of advanced analytics techniques and usage of new visualization tools provide the ability to pull information from disparate data warehouses while keeping data quality measures in place to make the data ready for analytics, with uniform and up-to-date information available across the organization.

Another area of data mining evolution is today’s predictive analytics models, which lean heavily on data and machine learning algorithms to project the likelihood of future outcomes. These predictive analytics can be used to predict more accurate payment and identify intake weaknesses and care to improve both healthcare delivery and patient experience. These models can generate recommendations based on patterns identified in the information gathered, thus allowing the organization to deliver services more efficiently. Additionally, artificial intelligence (AI)-based systems can reduce administrative burden by providing cognitive decision-making capabilities previously dependent on human effort.

Whether on the front end of patient treatment or downstream, at propensity-to-pay, these advanced capabilities bring many advantages, including:

• Poor communication and inaccurate data contribute to provider abrasion. Today’s CRMs, as a goldmine of patient, physician, and health plan data, serve as a common ground for both providers and payers—a source of accurate information that plays a major role in a more streamlined, efficient payment process.

• The preauthorization required to approve a procedure usually consumes significant time and effort for payers and physicians. The advantage of machine learning and natural language processing enables today’s enhanced image processing to dramatically reduce the number of incorrect approvals and decrease incorrect denials. This preserves high-tier resources and avoids costly redundancy of claims reprocessing.

• A more predictive, proactive analytics approach can reduce new medical record requests by singling out process breakdowns to identify error rates for each provider.

• Predictive data can find and address key inefficiencies in the operational management of healthcare business operations.

Today’s BPO organizations are applying innovation to the modern challenges facing healthcare, including data management and integration and predictive analytics. BPOs not only have claims data from provider groups, but also, payers. Armed with this intelligence, providers can positively affect a patient’s health outcomes, through PHM processes that also bend the cost curve.

BPOs can also bring the strategy and best practices gleaned from years of capturing, processing, transforming healthcare data from all states of the process–from pre-authorization and claims submission to customer care insights. By choosing the right BPO partner, healthcare organizations can align with tools and expertise to reduce abrasion and better navigate the changing ecosystem, while positioning themselves and their consumers for optimized engagement and outcomes.

4 Ways that Healthcare Systems can Manage Denied Claims

Provider healthcare technology has progressed rapidly to advance clinical care. Despite the leaps forward in provider technology, innovation has been comparatively slow for most providers’ financial processes.

Smarter management of insurance accounts receivable (A/R) is an area urgently needing renewed focus to augment healthcare’s drive towards improved cash as well as stringent cost control.

Left unattended, insurance A/R indicators show that, in some instances, gross charges denied by payers have doubled to 15 – 20% of all claims submitted, with the potential for 40 – 60% of those denials recoverable on appeal. Recoveries like that should be incentive enough to find ways to move forward quickly with new processes and new technologies to manage these denied claims.

Revenue cycle management (RCM) issues and inefficiencies have many root causes, from weak clerical skills to outdated or abused technology.

It’s a fact that some health systems have complex, poorly integrated and often outdated technology. Many legacy accounting and patient billing systems are 10 – 25 years old and not capable of meeting the needs of a rapidly changing healthcare reimbursement environment. It is quite possible that a junior revenue cycle professional may be working in a billing system that is older than they are.

Many of today’s revenue cycle organizations are reluctant to adopt disruptive processes and technologies, simply from a natural inclination toward protecting the system’s assets.

A recent Black Book CFO survey stated that few provider organizations are widely engaging in hospital financial automation. Only 20% of the 1,600 hospital and health system CFOs surveyed said even a small part of their organization’s financial and revenue cycle operations were fully digitized or automated. Amazingly, those who digitized more of their financial process said the ROI was substantial.


Healthcare organizations can significantly improve what they capture from payers (known as their contractual payment ratio), as well as accelerate recoveries by focusing on these four key areas:

  1. Invest in your front office. Recruit, onboard, and train your best people to optimize operations. At the front of the house, capture good information and give your patients a clear view of their financial obligations; this will pay big dividends in patient satisfaction.
  2. Ensure accurate coding and supplemental clinical documentation supported by optimized processes and technologies. The latest hospital coding compliance technology will help to identify and correct processes that lead to claim denials. Robust coding processes and contract compliance automation systems help hospitals to get ahead of coding and medical necessity denials, with the added benefit of educating coders, financial analysts, and providers on how to submit clean claims the first time.
  3. Maintain a fast focus on denials. Today’s payment variance reporting can identify underpayment and overpayment trends for analysis with broad-reaching, sustainable return. Highly effective tools, such as chargemaster assessment tools and concurrent charge integrity tools, are not currently being widely used. Prevention is key but, at the same time, addressing denied claims within 24 hours of receipt is critical to optimizing appeals success
  4. Understand the difference between denials and rejections and know what workflows must happen for each. Rejections can cause a great deal of wasted effort. It may help to think of rejections as the end of the story, with payment a lost hope unless the account is reworked from the beginning. Denials, on the other hand, are an opportunity to identify the probability of payment whether the payer’s request is for authorization, coding, or additional information. Denials need immediate response from a trained group who can quickly:
  • Define the needs raised by the payer
  • Address shortfalls according to payer protocols
  • Prepare root-cause analytics to address internal issues and errors made by technologists, technicians, and physicians in the revenue cycle’s process


Once the areas above are addressed, healthcare organizations can focus on scalability, optimizing the quality of data reporting to payers and regulators, and navigating the reimbursement structure of covered charges, provider liabilities, and growing out-of-pocket expenses for their patient-consumers.

The answer is a team approach to denials management: Determine the sources of the health system’s denied claims and address them head-on.

Claims denials will never fall to 0%. However, health systems find benefits from being equipped with trained and motivated staff, aggressive processes, and innovation necessary to recoup the dollars denied by payers and thereby contribute to the organization’s financial sustainability.

Healthcare Customer Engagement: Charting an Empathetic Experience

Imagine this scenario: You are in the hospital after an emergency appendectomy, and you have a simple but urgent question about payment of this (just-delivered) health service. Your physical and mental stress is a load made only heavier with that pending insurance coverage conversation. You are in no mood to struggle with an exasperating app or digital exchange. You want a straightforward, reassuring dialogue—one delivered with good, old-fashioned empathy.

From the other perspective, the bar has just been raised for your engagement team. The right customer service agent has to deliver on several levels: as an empathetic advocate who can listen, relate, and also resolve the issue at hand. Simply put: With all of the renewed—digital and otherwise—efforts towards optimized healthcare interactions, healthcare customer service remains highly challenging.

The recent COVID-19 surge has exposed healthcare interactions teams to an all-new type of issue, one which no bot or digital channel has ever dealt with, to date. What’s needed is a fresh approach to empathy-based engagement as part of healthcare customer experience.

Now is the time for healthcare to learn a few lessons from technology-retail elites like Apple, which is actually renowned for its very untech-like empathy focus. Apple aims for Geniuses to walk a mile in someone else’s shoes and to recognize the emotions their customers feel and change those, to make them feel better. The Apple manual advises the “Three Fs: Feel, Felt, and Found.” This means connecting, relating from personal experience, and consoling with issue resolution. Healthcare would do well to borrow from this model and reduce friction points for more effortless, empathetic problem solving.

Ultimately, there is still a strong foundation for every contact in healthcare—charting of a basic blueprint for compassionate issue resolution. An optimized experience, delivered by an agent empowered to deliver empathetic customer satisfaction, should comprise this flow:

Step 1. Empathy begins with active listening. From the first word spoken by the customer, the agent needs to be focused 100% on the communication at hand. This point in the conversation is critical as an opening to bond and win immediate customer trust. Agents shouldn’t make notes while listening; unless they listen properly, they cannot react to the situation of the customer. Reduce any miscommunication with follow-up questions.

Step 2. Acknowledge the customer with member/patient name and personalize the communication with a concierge touch to earn trust and loyalty. By using unified desktop and disparate systems, today’s agent can pre-emptively acknowledge the issue at hand without spending time on a longer intake. There are also opportunities to track prior visits to eliminate abrasion with unnecessary restating by the member/patient.

Step 3. Show understanding and calm. The adage is that you never truly know what a person is going through. But with healthcare, that goes out the window. Because one thing has been made clear with healthcare customer calls, and that’s that the member/patient’s life is, in fact, being affected by a health issue. Empathy at this stage might mean a reassuring tone with, “I understand this is difficult. I’m here to help.” Do not interrupt the customer, instead show attentiveness.

Step 4. Demonstrate intent to resolve the issue, with the understanding that it won’t necessarily be the case that everything is within our control. At this stage, it’s key to let members/patients know that empathetic customer care means trying your level best to help, with the understanding that some conditions or procedures simply may not be covered. Aim for  authentic communication, with an added personal touch and thank you or expression of gratitude for patience.

Having been on the front lines of delivering healthcare customer service, we’ve seen how clients have evolved their metrics focus—from quality, first-call resolution, and call center CSAT to NPS.

One emphasis that has remained the same is empathy, as the leading attribute in every single interaction that drives all of these metrics. And while empathy is required for all customer service, in healthcare, even more so, the mission is to address critical, personal impact related to health, finance, and the often raw emotions at the core. Helping customers resolve their issues is a delicate balance of all three of these things.

That’s what makes healthcare customer service as uniquely fulfilling as it is challenging.

Social Determinants of Health: Insights from our Experts

Recent reports show that up to 80% of payers are integrating social determinants of health (SDOH) into their member programs. To address this market focus, Sagility recently sponsored a webinar on Best Practices in Addressing Social Determinants of Health Issues Impacting Highest-Need Populations with AHIP. This well-attended event deserved a follow-up session as there were so many great questions from the attendees. On January 15, Sagility shared more essential SDOH thought leadership from our experts Mary Jane Konstantin, SVP and Head of Business, Sagility Population Health Management Solutions, and Tara Page-Haddock, Strategic Product Manager, Sagility Population Health Management Solutions.

Mary Jane kicked off the session with an overview of SDOH, including the importance of focus on the individual level. We level set attendee focus with a poll, “Which best describes how my organization approaches social determinants?” In sum, 32% of our attendee organizations aim to “Address social barriers, with no formal program,” while 27% do, in fact, have a program to address barriers at the patient level. A front-line focus of “Programs to address social issues within my community” was the response for 23% of our attendees, with 18% “Routinely assessing for social barriers at the patient level.”

We polled the audience on “Does your program have a systematic approach for face-to-face outreach,” and 59% of attending organizations do not have this approach. This assessment enabled Mary Jane to elaborate on the value of connecting face-to-face with SDoH outreach. She shared the team members—from peer counselors to community health workers, who can make a significant impact on outcomes with a targeted approach.

Following the webinar, our thought leaders answered some pressing questions:

Question: Can you talk about how a resource list does play a role in SDoH programs?

Mary Jane: In our experience, it’s important to make sure that there is some ongoing effort to update the resource list and make sure it’s still active. I think through issues like housing, we can help with not only housing grants, but also paying for utilities. You need to know what’s available in the local community.

I do want to stress that just giving someone a referral generally isn’t enough. You’ve got to make sure that the member stays well connected with the resource. So as you’re thinking through your outreach, make sure that you’ve made some accommodations for those kinds of services. Tara, anything to add on this topic?

Tara: I will add that it’s key to consider the cultural centers and the retirement centers and the social networking that exists within the member’s community. Our work is often detective work, as we search for the availability of often previously unknown resources.

Question: Can you talk about how you can help with SDoH transportation issues?

Tara: Today, there are a lot of partnerships with Lyft and Uber happening in the communities, and it’s really been really neat to see. I worked with a member in a past program who had a walker, and she walked to the bus and grocery store. She needed the bus to get to the pharmacy and her appointments. Her issue presented with the fact that she couldn’t get to the bus and she couldn’t get a ride to those appointments.  Add to that the fact that her walker wheels were only covered every three months for replacements. This is a good case of a transportation issue. It was about getting her durable medical equipment approved outside of the normal parameters, because her usage of her equipment was so much greater than the average individual who had a walker. This is how transportation can be a key element in understanding.

This can be one of the easiest things to solve for—it’s essential to look at access to transportation and what those benefits are. In healthcare, we often assume members are reading their benefits, yet sometimes it’s just about acknowledging that they have the benefits and helping the member access them.

I don’t think we’re saying that transportation is always the key to improve clinical outcomes. But I believe that when transportation presents as a barrier to care and accessing lifestyle life needs, there’s an opportunity there to make that Improvement.

Lifestyles, locations, and surroundings can all have an impact on an individual’s health. Focusing Social Determinants of Health on the individual level leads to reductions in cost of care through driving engagement, outcomes, and results.