Client
Expanding Access to Healthcare Across the U.S.
Our client is a leader in providing Medicare, Medicaid, and other healthcare services for the past 17+ years. Operating across 14 states, their services support millions of beneficiaries while facilitating necessary Medicaid Management Information Systems certifications. Their eligibility and enrollment solutions impact 46 states in the U.S., serving 37 million people in government healthcare services.
Challenge
Addressing Complex Needs and Regulatory Demands
The client faced significant challenges in creating a seamless healthcare enrollment and eligibility experience:
- Complex Beneficiary Needs: Medicaid beneficiaries required assistance in selecting managed care plans, primary care physicians (PCPs), and dental plans while navigating intricate eligibility and enrollment processes.
- Diverse Population: The platform needed to support states with populations ranging from 300,000 to 10 million beneficiaries, each with unique requirements and criteria.
- Data Integration: Establishing data security in healthcare with secure, HIPAA-compliant data exchanges between state systems, health plans, and vendors was complex.
- Regulatory Compliance: Managing sensitive data while adhering to state and federal regulations posed significant challenges.
These challenges required a robust, scalable solution capable of supporting millions while ensuring compliance and efficiency.
Solution
A Comprehensive Platform for Enrollment and Claims Modernization
Hexaware developed and implemented a comprehensive Enrollment Broker (EB) platform to effectively meet our client’s specific needs and challenges. We tailored the platform to support state-specific requirements for managed care plan selection and enrollment.
Key Components of the Solution
- Choice Counseling & Enrollment: The platform empowered Medicaid beneficiaries by providing clear and accessible information about managed care options, eligibility, benefits, and disenrollment rights. It ensures a smooth and efficient Medicaid enrollment process for handling requests.
- Automated Eligibility: Leveraging state-specific criteria, the platform matched beneficiaries with appropriate healthcare and dental plans, streamlining the eligibility verification process.
- Streamlined Workflows: The system effectively managed enrollment, including plan selection and communication protocols. It also addressed rejections by offering actionable feedback to users.
- System Integration: The platform enabled robust connections between core eligibility benefits systems and external entities like county systems, CRMs, web portals, data warehouses, health plans, and CMS.
- Claims Modernization: Hexaware led a modernization initiative for the client’s claims administration platform, enhancing eligibility, provider management, and claims management modules. The solution ensured seamless integration, scalability, and agility by constructing a flexible, modern platform built on over 300 modular services.
This future-ready solution significantly enhanced operational efficiency and beneficiary satisfaction.
Benefits
Transformative Outcomes for the Client and Beneficiaries
Hexaware’s Enrollment Broker platform delivered transformative results for both beneficiaries and the client’s operations:
- Enhanced Beneficiary Experience: The platform enabled Medicare beneficiary support, empowering beneficiaries by providing accessible and accurate information and seamlessly guiding them through the plan selection and enrollment process. This ensured that beneficiaries felt informed and supported at every step.
- Operational Efficiency: By automating eligibility assessments and streamlining workflows, the platform significantly reduced manual effort and processing time, improving overall operational efficiency.
- Regulatory Compliance: The platform guartanteed HIPAA-compliant data exchanges and full adherence to state and federal regulations, protecting sensitive beneficiary information and maintaining trust in the system.
- Scalability: Designed with adaptability in mind, the platform accommodated varying state populations and requirements, ensuring long-term sustainability and flexibility for the client’s operations.
These advancements improved beneficiaries’ experiences and optimized clients’ operational capabilities, positioning them for future success in the managed care landscape.
Summary
A Scalable, Future-Ready Platform for Healthcare Services
Hexaware’s solution transformed beneficiary enrollment by placing eligibility systems at its core. It automated eligibility assessments using state-specific criteria, ensuring beneficiaries were matched with suitable healthcare and dental plans. The platform integrated seamlessly with external systems, enabling secure, HIPAA-compliant data exchanges and streamlined workflows. By providing accurate and accessible information, it simplified plan selection and enrollment processes, enhancing the beneficiary experience. The scalable and adaptable platform supported diverse state populations while ensuring compliance with state and federal regulations. Designed to be future-ready, it addressed evolving needs in government healthcare services. This transformation sets a new benchmark for efficiency, accuracy, and accessibility in beneficiary enrollment.
