Cox HealthPlans Cuts Complexity of Claims Process in Preparation to Launch ACO Model

17 December 2012 | Dr. Dennis Schmuland, Chief health strategy officer, U.S. Health and Life Sciences, Microsoft
​With increasingly higher hurdles to clear in today’s healthcare environment, payers are seeking new strategies to meet their dual mandate of providing high quality services at a lower cost point without sacrificing profitability. To do so, health plans must cut non-medical costs and reduce complexity in their operations, and as a result, many are investing in new IT solutions to simplify administrative practices and streamline processes to meet the demands of the evolving marketplace.
Cox HealthPlans, based in Springfield, Missouri, is one such insurer that successfully leveraged a modern claims management and administration platform to cut costs and unnecessary complexity in their business. In 2004, Cox embarked on a road show to find a flexible solution to help the company achieve greater efficiencies in serving their nearly 45,000 members. After evaluating a number of products, they put the final decision to a company-wide vote, and employees overwhelmingly selected QNXT, TriZetto’s enterprise application system built using Microsoft .NET framework.
“Employees were familiar and comfortable with the Windows user interface,” said Susan Butts, Director of MIS at Cox HealthPlans. “At the same time, our IT team was thrilled with the flexibility and scalability of the .NET architecture. The state of Missouri, like many other states, has its own set of unique regulations on top of federal regulations, and there wasn’t a software package out there that could address every nuanced requirement. We needed a configurable solution that would allow us to write our own surrounding code. QNXT was an easy decision from an IT perspective.”
One of the main reasons that QNXT offers the flexibility that health plans need to adapt to rapidly changing business demands is that QNXT takes advantage of the Microsoft Connected Health Framework for Health Plans, a collection of vendor-agnostic best practices and guidelines for building service- and standards-based, interoperable e-Health solutions. The Connected Health Framework is a next-generation open architecture platform designed to support direct-to-consumer connections, delivery of actionable information within the context of existing workflow and digital lifestyles, and end-to-end collaboration with healthcare providers and trading partners.
Since going live with the solution in 2006, Cox HealthPlans has seen enormous ROI, including higher levels of customer satisfaction from both members and providers. With added capabilities such as being able to report members’ spend toward their annual deductible and allowing providers to process claims more quickly, customers have responded with positive feedback which is gathered via surveys and directly from Member Services. Cox HealthPlans has also seen a continual increase in the number of new providers and members signing up to use the web portal. Other key benefits include:
  • Increased profitability & cost savings: Using QNXT, Cox has been able to improve their bottom line and grow their revenue. In addition, Cox HealthPlans was able to boost efficiency and reduce staffing and associated costs through attrition by automating a number of processes.
  • Improved auto-adjudication of claims: Based on rules-based architecture, the TriZetto solution allowed Cox to cut additional costs by increasing the auto-adjudication rate from 62 to 94 percent, significantly improving accuracy and reducing the number of customer service calls.
  • Faster training: With an easy-to-use platform, consistent rule editing, wizard steps, and the ability to write consistent policies and procedures, the time spent training users on the claims system has decreased by 50 percent.
  • Reduced time-to-market: Reconfiguration of new products previously took 30 days with the legacy system, more than twice the time it currently takes with the QNXT solution. With the new flexibility provided by the TriZetto software, Cox HealthPlans can now have variations of benefit plans up and running in as little as 10 days.
Over the past six years, Cox HealthPlans has added a number of additional QNXT offerings from TriZetto, including a web portal that serves members, providers and group plan administrators, as well as a QNXT case management module that allows them to analyze claims as they come in. Using this application, Cox HealthPlans is able to monitor member health and offer members suggestions to various in-network health services based on their claims. With so many of the burdensome processes now automated, Cox HealthPlans is turning its attention to building an ACO model. First up on the agenda – work with TriZetto to build an ACO-like bundled-payment system that can facilitate cross-data sharing and connect with providers to identify higher risk populations.
Dr. Dennis Schmuland
Chief health strategy officer, U.S. Health and Life Sciences, Microsoft