Case Study

on

Claims Reporting
overburdening Regional
Payor Employees

Submitted by -
Anurag Dwivedi
Background
XYZ, established in 1933
Offers high quality health insurance at a
competitive price
Consumer-focused health care in a US state.
Fully taxed, not-for-profit company
Four major operations centres and a head
office
It has two departments
Reporting : The Reporting department
works on creating Claims reports for
Client Managers
Analytics : This department works on very
specific reporting needs of the client
managers.
Problem Statement
Reporting department of XYZ, a health
insurer has been overburdened with
reporting requests from client managers
Action
XYZ has reached out to PwC to devise an
offshore model to help them with Reporting
work (Standard Report, Complex Report and
Ad Hoc Requests)
Task
PWC to design an Offshore-Onshore
Operating Model for the success of this
project and formulate report request
management process, team performance
metrics and PHI privacy and standards
Suggest market growth areas for XYZ and
recommend a roadmap
2
Team Structure
Offshore Team Analyst Senior Analyst Consultant Senior Consultant TOTAL
(Offshore) (Offshore) (Offshore) (Offshore)
No. of resources 9 6 13 10 38

Onsite Team Manager Senior Consultant TOTAL

(Onshore) (Onshore)
Manager No. of resources 1 2 3
(Onshore)

Assumptions
Senior • Avg time of 1.5hr taken to complete 1 complex report
Consultant • These ad hoc reports were earlier rerouted to analytics/other teams but now
(Onshore) will be handled by PwC team
• Avg 20 Ad hoc reports have been considered of which 10 were handled by
Analytics team and 10 by other teams
Senior • 60% of reporting assigned to analytics team are simple and can be handled by
Senior Analyst
Consultant Analyst
(Offshore)
(Offshore) • 40% of reporting assigned to analytics team is complex and requires Senior
Analyst
• Standard report + 60% of Ad hoc report assigned to other team are simple and
Consultant Analyst can be handled by Consultant
(Offshore) (Offshore) • Complex report + 40% of Ad hoc report assigned to other team are complex and
require Senior Consultant
3
Costing Analysis
Cost Resource Rate Resource Fees Hrs required No of No of No of man- Resource Resource Fees
($/hr) ($/hr) in this project resource resources hours Rate ($) ($)
Manager
(Onshore) 80 175 16 1 1 16 1280 2800
Senior Consultant 60 150 16 1 2 32 1920 4800
(Onshore)
Analyst
(Offshore) 15 90 336 8.4 9 360 5400 32400
Senior Analyst 25 100 224 5.6 6 240 6000 24000
(Offshore)
Consultant
(Offshore) 35 110 505 12.6 13 520 18200 57200
Senior Consultant
(Offshore) 45 135 395 9.9 10 400 18000 54000

Weekly TOTAL 41 1568 50,800 1,75,200

Annual TOTAL 26,41,600 91,10,400

Margin of 42% is obtained considering additional expense equal to Resource Rate expenses
Costing Analysis
4
Offshore-Onshore Operating Model
Designation Role

Manager (Onshore) Collaborates with different business teams of XYZ to understand the requirement and coordinate for smooth
functioning of the business

Senior Consultant Verify data collection is complete and coordinate for more information. Syndicate with manager to understand
(Onshore) the business requirement and review reports for quality assessment.

Senior Consultant Work on complex report requests and Ad Hoc reports which were rerouted to other teams and are complex in
(Offshore) nature

Consultant (Offshore) Work on standard report requests and Ad Hoc reports which were rerouted to other teams and are simple in
nature

Senior Analyst (Offshore) Work on Ad Hoc reports which were rerouted to specifically analytics team and are complex in nature

Analyst (Offshore) Work on Ad Hoc reports which were rerouted to specifically analytics team and are complex in nature

Considering Quality, Volume of reports, leave schedules and unforeseen circumstances team size is at 38 Offshore and 3 Onsite members

5
Report Request Management Process
Request submission Request Fulfilment Tracking

Report Request

Review and
Approval required? N
Submission
Y

Business Pending more

PWC Verification
approval information

Assign reports
Repository and
Status Tracker
Fulfil Request

6
Report Request Management Process
Request submission
• Report Request process to be submitted by the Client managers as and when the request is received by XYZ from its
clients (Organization) through online portal.
• Report request to be approved by the Engagement leaders if required

Request Fulfilment
• PWC onsite team to verify the request received and ask for any additional information required based on the details
submitted by XYZ
• Reports are assigned by the onsite team and updated in the Repository and Status Tracker accessible to Offshore
team.
• Request is fulfilled by the assigned team member who further updates the Repository and Status Tracker for final
review and submission.

Tracking
• Completed reports submitted by the team members are then reviewed by the Senior team/Manager before
submission to XYZ. This layer of check helps in Quality management
• The tracker will contain information like report request, Assigned date, Report status, Reviewer Name, Reviewer
comments, Approvals

7
Team Performance Metrics

First time
Team
Percentage of
Metrics
Number of Number of
Active Utilization
resolution delayed improvement customer Staff Count
requests Rate
rate reports initiatives complaints

Individual Metrics
Average Error
Completed request Pending requests Error count Utilization Rate
resolution time

8
Privacy of PHI data requirements
• Business Need To Be HIPAA-Compliant (https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html)
• Team that has access to PHI must ensure the technical, physical and administrative safeguards are in place and adhered to, that
they comply with the Privacy Rule in order to protect the integrity of PHI

Technical Safeguards Physical Safeguards Administrative Safeguards

• Implement a means of access • Facility access controls must be • Conducting risk assessments
control implemented • Introducing a risk management
• Introduce a mechanism to • Policies for the use/positioning of policy
authenticate ePHI workstations • Training employees to be secure
• Implement tools for encryption and • Policies and procedures for mobile • Developing a contingency plan
decryption devices • Testing of contingency plan
• Introduce activity logs and audit • Inventory of hardware • Restricting third-party access
controls • Reporting security incidents
• Facilitate automatic log-off of PCs
and devices

9
Insurance Plan Data
Recommendations for market growth
areas for XYZ
Market Share
60.00%
Enrollment Market 50.00%
California; 13.68%
40.00%

30.00%

20.00%
New York; 7.50%
10.00%

0.00%
California New York Texas Florida Illinois Pennsylvania
Texas,
7.02%

High potential markets where XYZ still has a low market share
Florida, should be focussed for business growth.
6.14%

Illinois, California
5.10%
New York
As per the analysis XYZ should start
Pennsylvania; 4.12% Texas
with focus on five markets
Florida
Pennsylvania 11
Segments and Roadmap for XYZ
Segments
High Medium Low Enrollment
171261907
New York Rhode Island Utah
California Delaware North Carolina 180000000
160000000
Pennsylvania Nevada Wisconsin 140000000
Washington Arizona Oregon 120000000 74281190
Kansas Texas Arkansas 100000000 60382287
Michigan Maine Louisiana 80000000
60000000
Missouri Vermont Montana
40000000
Indiana Massachusetts New Mexico 20000000
Illinois Colorado Ohio 0
Mutual company Private Public
South Dakota Maryland
West Virginia New Hampshire
Florida Puerto Rico
Oklahoma Hawaii
Alabama District Columbia Private companies are doing well. Turnaround strategy is
Virginia required for Public and Mutual Company in the High Segment
Tennessee market specially where XYZ has a market share less than 30%.
Idaho
Nebraska
Wyoming
12
Thank You