New Care Management Platform Increases Efficiency, Reduces Cost of UM

Background and Challenge

A Fortune 50 national health benefits provider was using multiple legacy platforms and manual processes to support utilization management (UM), which involves assessing the appropriateness of care before it is authorized and delivered. The legacy platforms were costly to maintain and scale to support the organization’s growing membership of 50 million patients. Increased demand combined with reliance on disparate platforms and manual processes were beginning to intensify already long turnaround times.

Tegria was engaged to help manage the development of a new care management application and then migrate the legacy solutions’ users, operational staff in India and the Philippines, to the new system. The new platform was expected to eliminate or automate manual processes, support evolving demands, and reduce costs.

Solution

Tegria’s multi-pronged approach included implementation and customization of a Customer Relationship Management platform, development of a new care management application tailored to the organization’s specific requirements, and the addition of a clinical decision support tool with real-time integration to the UM applications. Each incremental go-live event included training for business team members and end users.

Tegria experts also led a transition to Agile application development methodologies to ensure clear documentation of business needs and priorities, as well as rapid and steady delivery of new functionality. This new process enabled consistent business feedback on the technical solution during development and design that ultimately increased leadership buy-in and user acceptance.