A large, national health insurer

A growing business with new challenges

Already a top 25 insurance company with over 6 million members, this group was looking to grow their government business and streamline operations, experimenting with new models and expanding to new states. A forward-looking leadership team knew that in order to make things work at scale, they needed to fully automate their claims reimbursement process.

A more modern payment system

For a long time, they’d been making payments using pricing and editing data gathered from the federal register, but were having issues keeping their data in sync. People at the company were also struggling with a slow and expensive system configuration process: each time a change needed to be made to operationalize a new payment quirk, the IT team had to be called in for what sometimes could be weeks worth of work. And most urgently, their legacy claims system was not set up to handle the complexities of innovative new government programs, limiting their opportunities.

Working with operations and IT leaders across their business, we set a multi-stage plan to transition payment operations to Burgess’ systems.  Initial success and an excellent experience on their Medicare Advantage business, led to the decision to expand our relationship to include other Federal Services, Dual-Eligibles, and Medicaid in multiple states.

Better processes, better relationships

Our payment automation, modeling, and auditing tools have become an indispensable resource for more than 1,000 people throughout their organization — people across claims operations, configuration, provider relations, medical economics and management.

Their system today is able to handle even the most complex situations, matching negotiated reimbursement terms exactly, and using custom payment formulas and fee schedules. Accuracy and automation across lines of business continues to increase each year.  By 2016, the organization was using Burgess’ tools to process 800,000 – 1,000,000 claims per month.

Over the course of our 16+ year relationship, this business has been able to not only reduce operational overhead by multiple millions each year, but also increase first-pass payment accuracy, minimizing risk and improving their relationships with providers across the country.