Review of approach and roadmap for setting up a centralized claims management service for the largest public health organization in the world

Our client

As the world's largest national provider of primary, acute and social care, this health organization serves more than 60 million people free of charge.
It had recently established a service organization, providing clinical and business support services to its public shareholders.

case 08

Background:

  • Our client established a project to set up a centralized claims management for primary care organizations, also exploring the option of outsourcing the service.
  • Claims management, also known as acute invoice validation, checks activity reports and invoices against what is appropriate from contractual and clinical perspectives. It provides an opportunity to set standards and deliver cost savings.
  • Recently concerns arose about scope, direction and speed of the project. As a result, we have been asked to review the position of the initiative, the approach taken and to recommend a way forward.

Approach:

  • We analyzed the key documentation (e.g. Business Case, Request for Information, Initial Call Off Notice) and interviewed project team members and stakeholders. Objectives, assumptions, options, decision rationales and the chosen approach were reviewed in detail.

Outcome:

  • The case for a centralized claims management service remained strong, however, the expected benefits were unlikely to be realized under current plans.
  • It was suggested to:
    • Explore the option of running the central claims management service internally before committing to a third party solution,
    • Put in place a separate interim solution to achieve short-term benefits,
    • Follow a revised way forward for reviewing the options – and to implement a more effective project governance reflecting the proposed changes.


 

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