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Virtusa: Innovating Process Improvement in Healthcare


A conversation with Alok Mandal, Vice President, Healthcare Consulting, and Shankar Ram Swaminathan, Vice President, Healthcare Solutions, Virtusa


What was the core problem or set of problems or situation that your team was looking to solve with your solution?


Alok Mandal: In Healthcare Payer Industry there are multiple people, process and compliance implications. The problem we are discussing today on how do we manage Appeals and Grievances (A&G) effectively. We had done multiple successful implementations in the past, and our Appeals & Grievances solution has been asset to accelerate the journey for payer organizations. We observed missing workflows and connectivities among systems, be that in the form of intake or as part of data enrichments. Another aspect of the situa- tion was the need to create dynamic dashboard and metrics that businesses could look at to make smart decisions. Based on our past ten-plus years of experience, we felt that actionable reporting is an area to look at. Additionally, the question that is in front of us is how


can we create timely resolutions to the problems? Once efficient workflow is implemented, the problem becomes how one can operate on time. This has repercussions directly on CMS star ratings related to the Medicare and Medicaid lines of business for health plans. Statistically about 20 percent of the time, appeals reach a second level. This means that the member or provider was unhappy with a particular claim and the associated appeal decisioning and resolution. Can we optimize that to a more optimal value with the right decisioning and documentation? That’s where we found an opportunity to introduce AI to read the data, to read the characteristics of a particular claim, and to make a recommendation.


It sounds as though one of the challenges in the compliance area is that everything was exception- based, and you needed an algorithm in order to move the process forward more quickly and efficiently?


Alok Mandal: Absolutely, and the challenges get amplified with increasing intake channels. We have someone calling in versus mailing in or faxing; how can we standardize the channels together? We have an NLP-based algorithm that helps us to sweep all the intake into a centralized,


seamless way of taking it forward. So yes, a more systemic, algorithmic way of handling those decisions. Shankar R Swaminathan: From my perspective, all the


payers we deal with see great value in this solution. Part of the CMS rating impacts the payers and the health of the plan member/patient at the review time.


Healthcare has been so fragmented and balkanized; one of the things that you’ve achieved here is pattern detection and categorization for faster, smoother processing. Is that correct? Is that what sets you apart from the competition?


Shankar R Swaminathan: Yes, those are the two critical features of the solution that differentiate us. Most of the time, people triage appeals or grievances, trying to figure out whether the clinical review is there and what the subjective biases might be.


How is the landscape going to evolve forward in the next few years?


Alok Mandal: We started the Appeals & Grievances asset build-out almost three years back, laying our product out into an orchestration of each step of the process as workflow. The second generation was to introduce NLP and AI into it. We have a patient-centered model that’s patented. And we’ve broken it down based on what we see in the industry to attack it from a business-value per- spective. And we continue to add value to the solution. We’re making it more interconnected in terms of process, for example, introducing blockchains around information involving particular members, based on plan details and historical EHR data around the patient. Shankar R Swaminathan: The main thing is around


an interconnected healthcare ecosystem; that’s where healthcare is moving toward. I see this as a solution that will become a digital ecosystem for members, provid- ers, and plans together. They will see a near-real-time resolution of these appeals and grievances. That’s where the industry is going, and this will be a digital ecosystem solution for the healthcare industry.


www.virtusa.com


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