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Client Overview

Students in the state of California are provided healthcare by their schools. In turn, schools are eligible to receive reimbursement for costs incurred, from the government. To do this, a formal claim needs to be submitted, by filing necessary paperwork as instructed.

Nearly half of all claims made were rejected due to improper or incomplete filing. This is because the government’s medical claim process features strict criteria, especially when it comes to filling out forms.

While errors during manual input by school administrators were common, a lack of information from healthcare providers also led to incomplete forms.

Rejected claims caused schools to incur the costs instead. Students also felt discouraged to obtain free healthcare, because of a possible claim rejection.

Requirements

A medical claim system that reduced the margin of error was of priority. In turn, this would increase the approval rate of claims made to the government.

Ease of use was also important, so that school administrators can reduce the time spent on doing repetitive tasks such as data entry and verification.

Solution

A web application was developed by EFutures, to solve the problems of the existing medical claim process.

Objectives were met by modularizing the web application into the following:

1. Administrator – The main access point for school administrators to file for claims.
2. OptiClaim – For inputting all information pertaining to medical treatments undergone by students.
3. OptiReport – A report generation tool, to assist in the decision-making process.
4. File Processor – Enables bulk data import, thereby eliminating the manual entry of vast amounts of information.
5. OptiLearn – A learning hub which that offers help and support on using the web application.

 

Outcomes & Benefits

Digitizing the medical claim system was highly successful, especially since the approval rate of claims significantly increased.

The solution developed by EFutures featured advantages across varying stakeholder groups – from our client to the schools that implemented it.

The product owner (our client) benefited by:

– Automating the medical claim system to increase overall efficiency while reducing costs.

– Reducing labour-intensive staff by 75%, thanks to automated workflows.

 The schools (as our client’s end customers) benefited by:

– Substantially increasing the approval rates of medical claims.

– Eliminating the need to manually enter vast amounts of data, either via Service Entry or Bulk Service Upload.

– Lower service charges.

– Improved customer support through a self-service portal, live chat as well as a dedicated relationship manager.

– Improved overall student health and well-being.