June 21, 2021

The healthcare ecosystem aims to have a healthier society by providing accessible and better quality of care with superior member experience at a reduced cost. However, the healthcare industry is challenged by increased cost pressures and shrinking margins, along with the struggles of adapting to rapidly changing regulations, payment reforms of value-based models, and increased consumerism. This is nudging the healthcare industry to continuously accelerate business and technological transformation and be future-ready with respect to people, process, and technology. Moreover, the COVID-19 pandemic has created a greater need for business transformation in healthcare as the existing workforce and technology issues exacerbate the broken and interdependent processes. This is observed even for industry-leading automated-processes like claim processing.

Transforming Healthcare Operations

An individual becomes a part of the healthcare ecosystem when they purchase a product or locate a physician for treatment. The journey continues as they enroll in a plan or schedule an appointment with a primary care physician (PCP). It is the responsibility of the payer and the provider to help the member navigate this journey and tackle the issues at every touchpoint.

The existing inefficiencies in the processes are the biggest hurdles that enterprises must overcome to provide seamless front-end and back-end services. Bringing process standardization and minimizing variations within a process are the first steps towards reducing operational inefficiencies. These inefficiencies intensify further due to multiple legacy applications, fragmented member data with minimal interoperability, lack of skilled resources, and other similar issues. Several plug-and-play solutions introduced by organizations to drive efficiencies often increase the burden on existing IT infrastructure and prevent enterprises from being agile. Having a single platform appears to be an ideal scenario but is not feasible for all organizations.

That is where digital transformation solutions help organizations drive seamless and efficient operations by giving the machine the 'first right of refusal' to augment human capability through automation, analytics, and artificial intelligence (AI). This approach drives exponential business outcomes by enhancing end-to-end customer experience. It can be implemented across the value chain of payers, providers, and pharmacy operations like member onboarding, network management, patient access, claims processing, collections, wellness management, contact center, regulatory reporting, etc.

Holistic Approach to Process Transformation in Healthcare

Healthcare organizations must adopt a holistic approach towards automation for business process transformation. Appropriately selecting the right automation candidate - that has an impact at an organization level - for improving business KPIs and impacting the user journey is the ultimate success for any automation. For example, the high call volumes for claims could be due to incorrectly processed claims by the claim's adjudicator. Instead of enabling

technology solutions like a chatbot for member services, ensuring the claims are correctly processed the first time will help drive efficiencies in the member contact center and achieve the required outcome.

AI in Healthcare - A Paradigm Shift

Apart from traditional Robotic Process Automation (RPA), AI is heavily explored to bring about intelligent automation in healthcare. Besides automating rule-based process steps, these technologies bring a paradigm shift by supporting strategic decisions through machine learning (ML) and deep learning algorithms. It can recognize patterns and help with intelligent insights and predictions that can be effectively leveraged across the healthcare ecosystem like clinical data extraction, radiology image interpretation, understanding the disease progression, treatment outcomes, and care management. It can also help identify patterns in claims denial for Providers or incorrect claim processing by Payers.

Healthcare Analytics - Unlocking the Real Value of Data

Though we bring about automation and AI to transform operations, all the issues cannot be addressed unless there are facts to substantiate the root cause and deliver value. Analyzing the data generated by multiple processes helps strengthen such facts. This data must be collected from siloed operations and viewed holistically not merely for reporting but also to identify waste in the system, enable process standardization, drive automation, and understand the drivers of operational inefficiencies. While data is the universal truth, unless the real value of data is unlocked, it remains incoherent. Hence, a data-driven organization must utilize operational and predictive analytics to transform operations from being reactive to proactive.

Summing Up

The willingness to explore various dimensions of transforming processes and adopting relevant changes faster can lead to exponential and purpose-driven growth of healthcare organizations. Ultimately, this will help healthcare organizations provide exceptional member experience, focus on the greater quality of care, improve margins, remain competitive, and be resilient to unseen challenges like the pandemic.

Shefali Gupta heads the Healthcare Domain Services at TCS. She is responsible for customer relationships, business development and growth, and delivery excellence. With nearly three decades of experience across IT and BPS, Shefali has managed large transformation engagements across multiple industries. She has a rich experience leading large complex programs and driving key initiatives for TCS Healthcare. Shefali holds a Master's degree in Computer Application from Jadavpur University, Kolkata, India.