Health Plan Transforms Claims Management with Centralized Data Solution

The Challenge

The health plan struggled with managing its claims data effectively, resulting in hundreds of millions of dollars in unreconciled claims. The situation worsened as providers, frustrated by payment delays, repeatedly resubmitted their claims. This led to a flood of duplicate claims, further complicating the process and requiring extensive manual intervention to resolve.

Key issues included:

• Fragmented systems with data spread across more than 20 disparate systems
• High administrative costs due to manual reconciliation efforts
• Strained provider relationships resulting from payment delays
• Lack of real-time visibility into claims status
• Difficulty in identifying fraud, waste, and abuse

These challenges impacted both financial performance and provider relationships, highlighting the need for a unified data management approach.

The Solution

To address these challenges, the health plan partnered with Gaine to implement the Coperor Health Data Management Platform (HDMP). Gaine's solution provided a centralized platform to integrate, cleanse, and standardize claims data from across the organization. Key capabilities included:

• Seamless integration with existing claims management systems and healthcare applications
• Real-time data processing and analytics
• Automated workflows for claims reconciliation
• Provider collaboration tools for enhanced communication
• Advanced analytics and reporting tools to unlock data insights
• Anomaly detection capabilities to identify fraud, waste, and abuse

Conclusion

By embracing Gaine's Coperor HDMP, the health plan was able to take control of its claims data, optimize its claims management process, and drive better decision-making across the organization. This centralized data management approach positioned the health plan for future success in an increasingly complex healthcare landscape.

Quantifiable Benefits

The implementation of Gaine's Coperor HDMP led to several significant benefits:

• Recovery of $300 million in previously unreconciled claims
• Reduced administrative costs through automation and streamlined processes
• Improved provider relationships due to timely payments and enhanced communication
• Enhanced operational efficiency and accuracy
• Better compliance and reduced risk

Future Opportunities

• Expand the use of Gaine's platform to other areas of the organization
• Implement advanced analytics and AI to further optimize claims processing
• Leverage Gaine's solution to support value-based care initiatives
• Utilize Coperor's data quality tools to ensure ongoing data accuracy