A comprehensive health insurer, renowned for its diverse array of health plans encompassing managed care and traditional indemnity insurance, has recently adopted the Sigmify GRC-based QA Audit solution. With an extensive network of healthcare providers, including hundreds of area hospitals and thousands of physicians and healthcare professionals, this insurer sought a solution that could cater to its multifaceted needs, demonstrating Sigmify’s adaptability and versatility as a platform.
Operating across 80 lines of business and managing over 50+ programs, each generating thousands of transactions monthly, the company’s operations team meticulously oversees various aspects such as claims processing, call center operations, enrollment procedures, billing, broker commissions, appeals handling, provider data management, and credentialing processes, among others.
To ensure the quality and compliance of these programs, quality auditors are tasked with auditing their execution. Sigmify’s GRC solution seamlessly supports the QA program, facilitating tasks from generating universes and sample selection to case assignment and workflow management, right through to communicating audit results effectively.
Key components of the QA Audit solution include:
Setup:
- Workstreams: Enables defining workflow steps, determining paths based on conditions, and selecting appropriate checklists for each workflow.
- Roles & Responsibilities: Establishes a matrix of roles (e.g., manager, supervisor, quality auditor, lead auditor) and associated tasks, ensuring proper assignment of roles to tasks and granting corresponding access rights.
- Import Files: Critical for data integrity, this feature allows setting file types, defining import activities, and establishing distribution rules within workflows to ensure accuracy of audit data.
Operations:
- Audit Flow: Cases are uploaded for quality auditors, distributed according to predefined rules, and audited using assigned checklists.
- ATA (Audit the Auditor): Cases audited by quality auditors undergo inspection by lead auditors using distinct checklists to ensure accuracy.
Dashboard:
- Provides insightful reports such as accuracy, productivity, inventory, volume, and QA statistics, facilitating informed decision-making and performance monitoring.
By consolidating multiple tools into a single solution, the QA Audit solution enables the insurer to streamline operations, manage diverse programs effectively, and establish a unified data warehouse to meet future analytical needs.
The biggest win for the company has been the ability for them to define their own workstreams and QA Audit templates.
