Streamlined Banking and Healthcare UX with Scalable Solutions
Overview
Acadia is a new desktop platform designed to serve as a comprehensive user interface for claims operational management and configurations within the ENAC ecosystem. It acts as a crucial front-end for various claims and financial data stores, specifically addressing the complexities of manual fallout queues for both claims and accounting, as well as streamlining the management of refunds and overpayments. Built to leverage common themes and frameworks from existing PEAK applications, Acadia aims to provide a consistent, efficient, and intuitive experience for internal claims operations and accounting teams.
Problem
Client faced several significant challenges in managing complex claims and financial transactions
- Inefficient Manual Fallout Handling: Certain edge cases and fallout scenarios caused claims to be routed out of automated flows into manual queues. The existing process lacked a centralized, intuitive user interface for operations team members to investigate, track, and resolve these claims according to standard operating procedures (SOPs).
- Lack of Visibility and Control: Operations teams struggled with real-time visibility into critical claim details such as reason codes, the exact point where a claim got stuck (e.g., ENAE, Care wall, Denali), the date it entered the queue, and its LPI (Late Payment Interest) clock status. This hindered timely intervention and efficient workflow management.
- Ambiguity in Case Prioritization: There was no clear visual distinction between "informational only" cases (which required no action but needed acknowledgement) and actionable cases, leading to potential confusion and wasted effort.
- Cumbersome Refund and Overpayment Processes: Managing refunds received from providers and processing overpayments involved fragmented, often manual, workflows. This included difficulties in tracking newly received refund data, associating check images with claims, searching for matching claims, and tracking if refunds had already been sent out. The overpayment process lacked a streamlined digital workflow for approvals and reconciliation.
- Compliance and Audit Concerns: Tracking claim failure status at every step for SOX controls was challenging without a dedicated, integrated system.
Solution
Acadia was developed to provide a robust, user-centric solution to complex problems, focusing on clarity, efficiency, and comprehensive workflow management.
Centralized Claims Fallout Queue Management
- Intuitive UI:
A dedicated user interface immediately alerts claims operations team members to new work assignments. - Detailed Claim View:
Users can see all claim details, including Claim ID, Reason Code, Reason for Fallout, Origin of the blockage Date Entered Queue, and LPI clock status. - Workflow Functionality:
The UI incorporates clear workflow steps, enabling users to assign claims, track their status ("New," "Assigned," "In Progress," "Manager Review Needed," "In Quality Assurance," "Completed"), send claims back to the automated path, or escalate them for manager review. - Information Only Handling:
Visually distinct markers allow users to quickly identify informational cases. These cases can be "acknowledged" to move them into history without requiring manual work, while still providing access to error messages and production support contact information. - Denali Calculation Preview:
For claims where rates are updated in the manual fallout queue, the UI provides a preview of the Denali calculation changes.
Refunds and Overpayments Management
- Electronic Mail Room Integration: A dedicated queue allows users to view newly received refund data and associated check images from the electronic mailroom.
- Matching and Association: Robust search and filter capabilities (by Claim ID, Member ID, Provider TIN, Provider NPI, or a combination) facilitate matching refunds to claims. Once matched, the system clearly flags the claim as refunded and associates the check image.
- Overpayment Workflow: The platform supports a comprehensive overpayment process, including reviewing digital mail, downloading images, searching for indicated claims, creating overpayment requests, managing approvals, and tracking the status of refund recovery efforts.
- Comprehensive Data Display: Acadia displays detailed claim, overpayment, and refund information, including differential breakdowns and claim services.
Visibility and Control
- Dashboard Views: Customizable dashboards provide individual users and managers with a comprehensive overview of key data, reports, and KPIs, including real-time metrics on claim statuses and LPI clock proximity.
- Consistent Design: By leveraging existing PEAK application themes, Acadia ensures a familiar and consistent user experience across the ENAC suite.
- API-Driven Data Access: All data is accessed via APIs, ensuring real-time information and scalability.