Resolving grievances and appeals for a leading managed healthcare company
A major U.S. healthcare company, serving 23+ million members, faced challenges managing 650,000 annual appeals from diverse sources, including claim denials and utilization review decisions. Turning to Infosys, a strategic solution was implemented to streamline operations and bolster the workforce, reshaping healthcare appeal handling. Handling 650,000 annual appeals from providers and members, the company grappled with diverse sources, including adverse claim decisions and denials for non-inpatient hospital services. Infosys tackled this by establishing delivery centers in talent-rich cities, reducing onboarding time and introducing a proprietary RPA solution for appeal validation and redirection. The Failure Mode and Effect Analysis approach identified potential process failures, enhancing efficiency in managing the intricate landscape of appeals.
