Transforming Healthcare Operations with End-to-End Expertise

This article is the first of a four-part series describing how the four business process management (BPM) pillars can optimize operations.

By Sohail Djariri

In the complex and interconnected world of healthcare, operational excellence requires more than discrete expertise; it demands an integrated, end-to-end understanding of both payer and provider domains. From member services and claims processing to clinical reviews and revenue cycle management, organizations that possess this holistic view are uniquely positioned to identify inefficiencies, streamline workflows, and deliver seamless, patient- and member-centric experiences.

Driving Synergistic Savings Across Customer Touchpoints

Analyzing workflow issues end-to-end ― across the healthcare journey from call centers to claims ― can yield valuable insights. Members typically call to ask about their benefits, prior authorizations, and claim status. Next-gen technology, including predictive analytics and process mining, can visualize all the steps, end-to-end, that occur across the member journey. The result: a visual representation of issues that affect all customer touchpoints. Addressing these issues results in measurable outcomes:

• Reduced operational costs: 20%-25% for contact centers and as much as 35-40% for claims.
• Lessened number of touches per claim from ~7 to 1.5 to 2.
• Accelerated issue resolution.
• Improved member and provider satisfaction.

Identifying bottlenecks across all customer touchpoints provides information about how to resolve bottlenecks, prevent them from happening in the future, and elevate the customer experience. Reduced internal handoff, rework, appeals, and calls by 15% ultimately enhances NPS, which leads to better Star Ratings.

End-to-End Utilization Management

Utilization management (UM) also illustrates the importance of end-to-end domain expertise. Sagility’s precision UM method addresses issues such as process missteps due to lack of clinical data integration, inconsistency in data exchange standards, and differing policies among payers. End-to-end domain expertise enables clients to overcome any imprecision, lessening provider burden, which reduces abrasion, enhances member satisfaction, and decreases administrative 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 predict duration and level-of-care needs accurately. These analytics help provide prospective approval for the entire course of treatment.
• Provider scorecard: The provider scorecard yields insights about compliance with process fraud, waste, and abuse requirements, as well as accurate and timely information submission. This process provides an opportunity for a back-end audit, helping to automate 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: Upon identification of key parameters driving utilization needs, a holistic care management program can help members seek only necessary care needs that will maximize outcomes. Addressing social determinants can reduce unnecessary utilization, optimize recovery, and reduce hospital readmission.

To provide this kind of precision focus, healthcare organizations are looking for BPM 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.

Integrating Healthcare End-to-End

Healthcare organizations that integrate end-to-end domain experience are positioned to pull the right levers. End-to-end domain expertise is more than a strategic advantage; it’s a necessity for healthcare organizations aiming to thrive in a value-driven environment. End-to-end visibility streamlines handoffs between departments, reduces rework, and closes gaps across all stages of care and administration. Deep domain expertise can help healthcare organizations bridge functional silos, lessen administrative burdens, and improve outcomes across the entire care continuum.

Read more in our white paper, Fixing the Friction: How Strategic Operations Management Unlocks Healthcare Efficiency at Scale, to explore how the four pillars of Business Process Management (BPM) can reduce operational burden, improve patient outcomes, and drive resilience across the care continuum.