Payer test platform: How to ensure compliance, reduce timeto-market and maximize return on investment

Transcription

1 Solution Overview Generating Healthcare Payer Impact Payer test platform: How to ensure compliance, reduce timeto-market and maximize return on investment Healthcare payers today face a perfect storm of business challenges. Increasing cost pressures, healthcare reforms, regulatory mandates, new technologies, empowered customers, and even fraud are causing companies to rapidly upgrade technology capabilities to support much more agile business processes, and Quality Assurance (QA) organizations must match that pace. Genpact s managed QA services enabled by solution accelerators such as Payer Test Platform (PTP) and analytics-driven optimization can reduce cost, improve testing quality, ensure compliance, and slash speed-to-market. DESIGN TRANSFORM RUN

2 Healthcare payers are facing multiple challenges forcing the organizations to contain costs and drive efficiency without sacrificing quality or control. This is necessary to compete in a rapidly evolving healthcare environment. Payers face the following key challenges: 1. Medical loss requirements add to cost pressures Today, these requirements are compelling payers to streamline their administrative costs to just 85% of the payers medical target spent. This puts additional pressure on organizations to reduce overall administrative costs. 2. A rise in consumerism is changing the business scenario Historically, healthcare was a B2B business with employers the key stakeholder. Healthcare reforms have transformed healthcare into a B2C business, which calls for a much more agile response to varied customer needs and preferences. 3. New technologies now dominate Service-oriented architecture, software-asa-service, mobile, big data analytics, and the cloud have changed how IT functions. Payer organizations technology capabilities must evolve. 4. Mandatory regulatory changes are adding complexity ICD-10 and other standardization initiatives are increasing compliance-related spend. Payers are now turning to IT to respond to these challenges. Improving QA testing can improve return on INVESTMENT and increase agility and speed time-to-market while bolstering customer satisfaction. The new healthcare environment has put a spotlight on testing. Efficient testing can ease cost pressures by ensuring applications: Arrive defect-free Are delivered on time Meet ever-changing government regulations Respond rapidly to market pressures Paying claims incorrectly, or worse, causing manual work to process a claim, is not an option when customer satisfaction and per-member-per- month cost are top of mind for every profitable payer. Neither can payers afford delays in making system changes in response to regulatory requirements or rapidly changing market conditions. The Genpact solution Our managed QA services combine process excellence with analytics and technology to provide a complete testing solution for healthcare payers that cover: Requirements traceability Test data and script creation Unit/SIT testing UAT Regression testing Our testing and performance Center of Excellence (CoE) has perfected best practices from our experience providing end-to-end solutions across the software development life-cycle. We are skilled working with different models of software development such as the V-Model, waterfall, spiral, and iterative. We have years of experience working with leading payers and healthcare organizations. Our deep knowledge of payer operations and data has helped evolve specialized analytics applications and technology platforms to address the specific complexities of QA and testing in healthcare payer environments. Proper understanding of requirements, translating them to data requirements, and then using the right data for testing are critical to successfully and quickly execute testing cycles. Analytics is key to determining which data will satisfy the testing requirements. The ability to select data based on production and change it to meet the testing requirements in an effective, efficient, and automated process can save up to 30% of the testing cycle time. GENPACT Solution Overview

3 Genpact s managed QA services leverage technology and analytics-driven optimization with test automation and risk-based testing to do this. This is enabled by solution accelerators such as Genpact s Payer Test Platform (PTP). PTP exponentially amplifies the positive impact of scale, domain expertise, and QA best practices. Genpact s Payer Test Platform Key features Automates regression testing for day-to-day operational and system changes Optimizes utilization of time and effort during regression testing Provides pre-built test scenarios to test for any new change Includes a pre-built test data repository available for claims selection Includes the option to upload requirements in a grid that will be tied to test cases Reduces the effort and time in preparing test data Allows you to add new scenarios Enables you to add new or replicate existing claims data attributes PTP relies on a risk-based testing technique. The software creates test data to meet the requirements of the test case as well as the test environment across members, providers, and services. The IT department can analyze existing production or test data to determine the risk-value needed to drive the test cases. A key feature of PTP is the standard set of regression test cases payers can use to test claims, benefits and providers, and group and member setups out of the box. PTP can reduce cycle time by 20 40% because the platform has already created the requisite test scripts. Having the expertise to know which data to test also decreases cycle time. PTP s workflow management database for ICD-10 reports at the program level. Macros and robots simplify the work stream of the test teams. And it all happens in the cloud. Generates membership (834) based on the claims data available for testing to load in the client s system Replicates subscriber information in the test claims automatically Replicates the provider and various dates of the test claim automatically Generates the test claim s file based on userselected scenarios Contains user-friendly options or file formats to load the test results Compares pre- and post-test results to identify system changes automatically after code deployment Includes a reporting mechanism to generate a report on the discrepancies identified in the pre- and post-test run results Identifies defects efficiently GENPACT Solution Overview

4 We have embedded advanced analytics in the platform. This reimagines the entire testing process because the platform focuses on business outcomes and uses day-to-day experience to continuously learn and improve. Impact Historically, the platform has reduced costs up to 30% and improved testing quality by as much as 80%. The bottom line: PTP reduces cost, improves testing quality, ensures compliance, and slashes IT speedto-market. PTP is exactly what payers need in today s high-tech, competitive landscape. Why Genpact? We have extensive expertise in healthcare payer operations and technology and a history of servicing blue-chip clients including leading blues and national payers. We have expertise in applying intelligent insight and using analytics to make technology smarter, and we know how to redesign processes to better leverage technology. Our proprietary tools deliver efficiency and accuracy that exceed your organization s end goals and expectations. Contact us to discover our complete QA solutions for your organization. Testing Modules Functionality Details Genpact - Payer Test Platform Competitive Alternatives Claims Management Centralized location to add new claims and search existing claims to create the test beds for various testing projects. Repository of ready test data for Healthcare Payer Testing, ICD 9-10 testing and HIPAA 5010 testing. Centralized location to manage, select, edit, delete test claims. Test data upload to create user defined subcategories for specific testing needs. Test data configurator automatically search claims for testing by pre-loading test case based data sets. Test bed creation based on the test cases selected by user. Pre-loaded test claims for regression test cases. Centralized location of all the members to search, add, edit and delete to use into the claims. Upload new test members to mock into existing claims or test bed. Auto generate the membership analytics for selected test bed. Create 834 x12 transaction to enrol new members into test environment. Import claims test beds into membership module for mocking. Centralized location of all the providers to search, add, edit and delete to use into the claims. Auto generated provider analytics for selected test bed. Upload new test Providers to mock into existing claims or test bed. Import claims test beds into provider module for mocking. Mock the service and other dates in the claims based on an active membership in test environment. Mock the dates into existing claims for multiple run for regression testing. Membership Management Provider Management Data Mocking GENPACT Solution Overview

5 Test Case Management Requirement Management Reporting: Claims, Membership, Provider and Test Results Test Execution and Defect Management Preconfigured standard set of 300 regression test cases. Covers business areas such as product, provider, group and membership enrollment, claims and billing. 837 x12 file creation based on test case selection for regression testing. Support regression testing to ensure functional consistency across version upgrade, product enhancement, & changes for compliance in the application. Mapping of claims data with test cases. Centralized location of requirement and test cased to test all process across payer organization. Repository of ready test scenarios for Healthcare Payer Testing, ICD 9-10 testing and HIPAA 5010 testing. Pre-loaded standard set of requirements. Functionality to add, edit, delete, import and export requirements and test cases. Single shared repository to collaborate and share requirements, understand their relationship to tests, and evaluate linked defects. Mapping of requirements and test cases with test data. Multiple templates to provide various analytics reports i.e. claims, membership and provider. Assist user to setup required providers and members for testing. Upload 835 X12 to verify the test result. Automated comparison in between pre and post results for regression testing. Auto generated test claims 837 x12 file to run for testing. Unified functional Testing Performance/Load Testing Test Automation - Script creation using keywords. Automation to run scripts. Dashboard view of requirements, cases, execution statistic and defects Defect reporting and management Business process modeling Storyboard Testing - Visual, story board format to represent test actions. Data Driven Testing - Automatically detect data from spreadsheet to run the test. Test Scripting -provides all recording, editing, and execution capabilities. Automated version control to maintain multiple test sets to enable parallel testing. Support end to end payer life cycle testing.

6 Additional Capabilities Claims Analytics ICD9-10 Up & Down Conversion Smart Data Extraction DRG Shift Analytics/Revenue Neutrality Analyze existing claims data files to identify most used diagnosis and procedure codes as well as high dollar, high volume, high risk, special and critical account s claims. Up Convert ICD-9 claim data into ICD-10 format or down convert ICD-10 claims to ICD-9 format by using a CMS GEMS. Accepts custom maps and support rules based conversion. Perform advance search on data repository to extract and save various types of test data for different projects across the organization. Generates ICD-10 Diagnosis Related Grouping (DRG) category codes from ICD-9 data. Supports reimbursement maps integration to predict the ICD-10 shift in DRG and potential shift in payment of ICD-10 vs ICD-9. Works on 3M DRG Grouper and CMS GEMS. Custom maps can also be imported. Various reports to provide difference in ICD-9 vs ICD-10 DRG, min, max and most like DRG choices. About Genpact Genpact (NYSE: G) stands for generating business impact. We design, transform, and run intelligent business operations including those that are complex and specific to a set of chosen industries. The result is advanced operating models that assist our clients in becoming more competitive by supporting their growth and managing cost, risk, and compliance across a range of functions such as finance and procurement, financial services account servicing, claims management, regulatory affairs, and industrial asset optimization. Our Smart Enterprise Processes (SEP SM ) proprietary framework helps companies reimagine how they operate by integrating effective Systems of Engagement TM, core IT, and Data-to-Action Analytics SM. Our hundreds of long-term clients include more than one-fourth of the Fortune Global 500. We have grown to over 68,000 people in 25 countries, with key management and a corporate office in New York City. Our global critical mass doesn t dilute our flexible and collaborative approach, and our management team still drives client partnerships personally. We believe we are able to generate impact quickly because of our business domain expertise and experience running complex operations, driving our focus on what works and making transformation sustainable. Clients attribute much of our success to our unique history: behind our passion for process and operational excellence is the Lean and Six Sigma heritage of a former General Electric division that has served GE businesses for more than 16 years. For more information, contact healthcare.solutions@genpact.com and visit Follow us on Twitter, Facebook, LinkedIn, and YouTube Copyright Genpact. All Rights Reserved.