The Challenge
Our health plan customer needed to quickly comply with a compliance audit requiring detailed information and specific contract data.
The problem? Our customer, like many payers, stored contracts and information across multiple systems and repositories, with a significant portion of contracts governed by outdated processes that had been in place for decades. In order to comply, our customer was prepared to spend time and money on assembling a sizeable contingent labor team to manually review over 600,000+ line items.
When our customer discussed their challenge with us, we knew there was a faster, less expensive way to get the work done. We proposed using automation to unify data, extract key contract elements, and enable compliance and audit teams to review contracts at scale.
The Opportunity
We developed an innovative solution to automate the review and extraction of key contract elements for the audit. The automated audit response tool we built is a reusable solution that will enable future audit efficiencies.
Want to learn how it works? Download our automation workflow overview.
Our Approach
We started by capturing audit requirements with our customer’s business and legal teams while asking the question: Can automation serve this purpose? Our experts assessed their data and tech environment and confirmed that an automation build was the best path forward. From there, our team translated requirements into a solution framework, identifying the contract data flow and processes required for quality review and escalation. With the solution framework defined, the team quickly built an automated solution to help our customer maximize efficiency and scalability.
Key data and automation capabilities were applied to solve for:
- Contract and metadata extraction and consolidation in a data mart with cross references for key audit requirements
- Web systems automation for seamless integration of additional contract and data applications
- Automated processing and data extraction from PDF and image-based contract documents
- End-user processing and review tool to support the manual audit team review contract elements and handle escalated cases
- Submission packaging tool that meets both customer and regulatory requirements, including FOIA (Freedom of Information Act) stamping and file size limitations
We used automation to significantly reduce or eliminate manual work while supporting required human review, correction, and/or escalation. This approach enabled the customers team to quickly and effectively achieve audit goals.
Project Results
In just 3 months, our custom automated solution helped our customer save $2.6M.
Now, their teams are equipped to respond rapidly to future audit demands and improve speed to compliance.
$2.6M
savings from automation
600k+
automated line item audit responses
75%
reduction in anticipated audit response team size
Our approach established a pathway to future audit efficiencies across the organization. At the end of our project, we shared recommendations to further improve audit response time, team efficiency, and data quality. These recommendations cut across technology and data, processes, and workforce. Key future state enablers include contract data and metadata consolidation, enhancements to contracting, audit team operating models, and end-user tooling.
Download our "Audit Automation for Healthcare Payer Overview" for insights across:
- Contracts & Metadata Consolidation
- Contracts Processing & Review
- Regulatory Submission
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