Overview

The client is a leading healthcare payment company with over 1500 employees. They had an acute need to streamline their claims process for financial optimization.

Challenges

• Automatic processing of healthcare claims submitted in non-standard formats
• Aim was to replace existing 3rd party OCR Bill review system with a new product owned by the client.
• MVP Scope: Train the product on 800+ unique claim formats

Solutions

The MVP included features to upload documents, review & edit the extraction, assign denial reasons to individual line items, export the output, summary view by Rev Code and user access management.

Technology Stack

• Azure Forms Analyzer
• Azure Functions
• Azure Web APIs
• ReactJS Web Application

Key Achievements

• Team Size: 8 (1 PM/BA, 4 Developers, 3 QA)
• Timeline: Ideation to MVP in 9 months
• Metrics: Achieved 85% accuracy at a field-level
• High accuracy with challenging data objects such as tables

Client Overview

A third-party administrator who supported payors with adjudicating out of network claims. The process involved time-sensitive and number-centric scenarios with complex test conditions and heavy test data dependency. The client’s key bottleneck was to edit solution functionality.
 

Industry

Healthcare

Challenges

• Insufficient test coverage and test cycle time to conduct the edit code testing led to high functional defect leakages.  
• Extensive claims test data is needed as a pre-requisite to validate the Edits during every release cycle.  
• Test coverage and test data issues led to quality issues which directly impacted the revenue and dissatisfied customer experience.

Solution

Genzeon took over the QA function from the in-house team and assessed the current QA. We defined a 30-60-90-day plan with the following focus:  

• Prepared the requirement traceability to determine coverage gaps 
• Built test cases to improve the overall test coverage 
• Initiated test automation to build the automated test coverage  
• Reduced the test data generation and cleanup process
• The 14-person onshore QA team was transitioned to an onshore/offshore model 

Benefits

Metrics improved significantly.