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Medical Claims Outsourcer Gets a Process-Management Boost

Gtess tapps BPM vendor Fuego to help it revamp existing applications and launch new services.

Dallas-based healthcare payment outsourcer Gtess has offered medical claims automation solutions for years, but behind the scenes, processes still involved manual work steps. What's more, the company's automated workflows were proprietary and hard-coded, so they were hard to change and expensive to maintain.

Enter business process management technology, with its ability to model and code processes once but then flexibly change, simulate, optimize and spawn new processes as needed with minimal coding and IT support. In December, Gtess tapped BPM vendor Fuego, also of Dallas, to help it revamp existing applications and launch new services.

In an all-too-common scenario, Gtess was making do with manual intervention between silos of automation. "People were checking batches and moving things into the next step in the process," says company CTO John Olson. "With BPM, we've added intelligence and automation from beginning to end, so instead of monitoring and moving work around all the way through the process, our analysts are now just managing the queues."

The upgrade has cut manual intervention by an average of 35 percent, which has helped Gtess ramp up process volumes without adding staff. BPM has also helped bring processes right back to customers. Replacing a manual exception queue for rejected claims, Gtess now offers a G-Queue through its Claims Gateway portal that lets customer claims adjusters review and revise claims with corrected payment codes. Rules are a crucial element of that application because they control which claims are rejected and approved.

"We have a sophisticated, proprietary rules application, and Fuego moves claims into and out of that application," says Olsen. "We're looking at whether we need to acquire a rules engine to see if we can put more capabilities in the hands of the customer." Such a move would give Gtess more of the same speed and flexibility with rules that it has gained on processes.

Gtess' first BPM deployment took three months, and a relaunch of the company's Provider and Membership AllMatch service took four months. The latter of which matches the names of medical care providers against databases maintained by payer customers. The Fuego-powered process uses pattern-matching technology to automatically update reference dictionaries, and match rates have increased 30 percent as a result. Gtess says BPM has helped the company save as much as $2.55 on each claim, and 95 percent of claim data is now converted without human interaction.

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