Fraud, waste and abuse are problems that plague almost every sector of health care in the United States. Estimates put the annual cost-to-taxpayers in billions of dollars, ranging from as much as 3% to 10% of all health care expenditures.
To address this constant increase in fraud, waste & abuse; as well as meet regulatory compliance requirements, our customer was using an extensive array of applications for tracking, analyzing and reporting the usage of prescription drugs. But despite continuous management of these applications, the company faced several challenges such as:
Reporting was delayed by weeks due to the need for manual work
A loss of $1.5 million after a consolidation project failed to deliver after several months of development efforts
The company is one of the largest providers of health insurance and pharmacy benefits in America, with annual revenues of over $50 billion. As a company of this scale, the company needs to deliver not only good customer experience but also meet stringent regulatory and compliance requirements. This is not an easy goal and the company has to continuously innovate for providing members with a simplified experience to a complicated and confusing benefits system.
With close to a million patients being managed, the (multiple) legacy systems were proving to be highly inadequate – they were not integrated, required substantial manual work that often led to errors. This caused SLAs to be missed and service delays for patients.
The company evaluated several solutions for the development of a Centralized Clinical COE application that addressed all the lacunae of the legacy system and brought in advantages of Cloud & AI technologies. The options evaluated were traditional dev processes as well as existing low-code dev platforms.