Case Studies
Large Northwest Health Plan
Key Issues and Challenges
This Seattle-based health plan is a $2.5 billion health insurance payer in the Pacific Northwest. The independent Blue Cross and Blue Shield Association licensee faced claims payment accuracy issues that were severely impacting its profits. While it was painfully aware of the problem, management was frustrated by the inability to track, identify, process, and recover overpayments.
Solution
Targeting accountability, control, and overpayment issues head-on, Calypso developed new processes that would identify and prevent claims overpayment problems. This comprehensive solution improved upon previous "band-aid" repairs, enabling management to create a trail of accountability on all claims. In addition, Calypso utilized the Compass recovery management system to recover overpayments and provide management reports with consolidated data on the reasons for overpayments. This was a vast improvement over the existing recovery and organization methods. Calypso also implemented our discovery technologies to detect overpayments. Calypso became a vital part of the operation, while leaving "ownership" of the data with the client.
Results
Calypso helped the client recover over $200 million in the past five years, with significant increases each year.
Large East Coast Health Plan
Key Issues and Challenges
In recent years, this $5.5 billion East Coast healthcare insurance company had grown into a large organization with nine decentralized recovery programs. Management wanted to replace manual overpayment tracking processes and automate reports on consolidated savings and recoveries. Several major systems projects were underway and management wanted to understand the primary causes of their claim errors so they could determine their ROI for system enhancements.
Solution
Calypso was given six months to make significant improvements to the company's operational efficiency. Working alongside the client's operations team, Calypso:
- Improved existing processes
- Implemented its recovery management software to create efficiencies in data capture and trending
- Utilized its discovery technology to detect overpayments in multiple claims systems
This collaborative approach made it possible for Calypso to effectively implement change and improvement while enabling the client's team to take ownership of the new processes. The implementation was completed on time.
Results
- The client increased its recovery rate by over 50% in less than six months after implementation
- The client has recovered over $132 million since July 2001 when they implemented Calypso's processes and software
- Manual tracking processes have been replaced and paper chasing has been eliminated
- The provider contracting department reports improved provider satisfaction and a significant decrease in provider phone calls