Reducing Fraud and Improving Customer Experience

Reducing Fraud and Improving Customer Experience

Business Driver

A prominent health services company asked Trexin to create a strategy to address an industry-wide Payer challenge for which there is currently no straightforward solution: Identity resolution for healthcare providers (i.e., individuals). Healthcare professionals have a wide variety of roles, oftentimes work in multiple locations sometimes for different organizations, and frequently provide services related to varying health insurance contracts. As technology digitally transforms healthcare and more business transactions are conducted online or outright automated, these “body, building, business” complexities, combined with data quality issues, complicate provider identity resolution and create an environment susceptible to fraudulent activity and resistant to customized digital experiences. Although there have been some industry-wide advances, such as the establishment of a National Provider ID for physicians, there remains a large group of personnel who do not have a national type ID who are either being reimbursed for care services (e.g., physical therapists, Meals on Wheels staff) or are in an administrative role related to reimbursements.

Approach

Trexin’s approach to this 9-week timeboxed engagement was to deploy a highly skilled cross-functional team with expertise in healthcare technology architecture, data, analytics, cybersecurity, systems implementation, and project management to consider all aspects of the problem. After documenting the current-state architecture, the team designed a new provider identity data model to define providers more completely and extensively than has been done in the past. This was followed by an analysis of current and anticipated digital interaction methods, leading to the creation of key provider personas and use cases. The team then incorporated all the current-state assessments, future-state designs, and gap analyses into a comprehensive strategy and solution design.

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