EXL resources increase quality, reduce appeals and grievances, for top health insurer

Challenge

When one of America’s leading health insurance organizations decided to streamline its utilization management (UM) appeals and grievances (A&G) intake process to improve patient services and control cost, it turned to EXL for help. The insurer required a rapid influx of expert staff to support forecasted increases in Medicare A&G volume starting in December 2024 and beyond. To meet the demand and allow time for ramp up, they contracted for 10 EXL offshore resources in August. The goal was twofold: improve efficiency to avoid missed turnaround times that could result in non-compliance, and eliminate or correct administrative errors that could lead to denied claims.

“The team did a really good job completing all the cases daily, with almost zero errors. Thanks for doing such a great job.” – UM Team Leader, Large Health Insurance Client

Solution

EXL collaborated closely with the client to understand and clarify the mission goals and determine which internal operations would be affected in the process; process training started in August. By October, the first 10 resources were nested and ramped up going into November. By December, three more resources were added to address appeals, with another entering process training on grievances in January.

Concurrently, EXL established real-time monitoring and support to reduce average hold times (AHT). Queue rotations were practiced regularly to enhance product mastery. Product knowledge tests were conducted monthly, along with pre-shift huddles to update team members.

Outcomes

EXL’s practiced approach to training and onboarding kept the client’s implementation timelines intact. Since day one, training attendance has remained at 100%.

Now, as appeals come in via fax, voicemail, and email, the EXL team creates new cases and assigns them to onshore analysts for review. The added bandwidth offers the client flexibility to target staff where capacity is needed most.

Stakeholders praised the outcome, identifying opportunities to expand operations beyond Medicare and intake going forward. Added benefits include:

AHT for all 14 queues down from 902 seconds to 456 seconds since project launch.
98.91% overall QA score from November to January.
Zero attrition from September to January.
Appeals cases where either medical reasons or administrative oversights led to denial are now effectively being contested or re-evaluated.

To learn more about EXL’s insurance domain expertise and capabilities, please visit EXLservice.com.