In recent discussions with WNS, NelsonHall explored the company's advanced healthcare management solutions. WNS provides evidence-based criteria to guide providers in ordering the most appropriate tests, procedures, and treatments for their members. This approach enhances patient care delivery and outcomes while improving provider relations and reducing healthcare treatment costs.

For example, a regional health plan was experiencing high prior authorization denial rates and provider dissatisfaction. The WNS Consult™ platform led to a demonstrated net direct savings ROI of 4.9, improved provider satisfaction and overall savings, and reduced prior authorization denial rates.

WNS’ model is proactive and focuses on behavior change rather than denial of services. It involves proactive outreach to ordering providers, offering clinical education with in-house clinicians, and modifying treatment plans to suit patients’ needs while reducing denials and abrasions.

It aims to continue to reform clinical guidance and authorization in two ways: a rigorous approach to clinical guideline development, and leveraging smart technology. At the same time, WNS offers a flexible approach to which activities it performs and which are retained in-house.

A Rigorous Approach to Clinical Guideline Development

Clinical knowledge is derived collaboratively and utilizes ~600 clinicians while promoting proactive peer outreach and integration of practicing physicians. This ensures that clinical decision-making includes comprehensive medical knowledge and real-world practice, leading to the efficacy of healthcare plans.

The platform’s clinical guidelines are based on research across:

• Governmental quality and regulatory guidelines
• Specialty society guidelines
• Evidence-based literature.

The governance model uses an independent panel comprising WNS clinicians and subject matter experts who review and update guidelines quarterly across ~400 topics and seven specialties. This process ensures that the evidence-based guidelines reflect the latest medical research and regulatory standards. These guidelines are then translated into detailed business rules that guide the Consult platform’s clinical decision-making process with branching logic, if-then, and ‘re-direct’ (auto-approval) rules.

Streamlining Authorizations with the Consult Platform

The authorization process begins with an order request submitted by the ordering physician through various channels (e.g., phone, fax, web, EHR). It enters the Consult platform and into its regulatory rule engine, which deciphers the requests against business rules and clinical guidelines. If the rule criteria are not met, the request progresses through a three-tier assessment and review before a denial or authorization is granted:

• Tier 1 – Initial assessment conducted
• Tier 2 – Nurse review
• Tier 3 – Peer-to-peer review.

If an order reaches Tier 3, the peer-to-peer review determines the appropriate course of action, which can result in a major procedure change or withdrawal of the order request. At any of the tiers, notifications are sent to the ordering provider and member if authorization is granted. If a request is denied, WNS issues a denial letter and handles all administrative communications, including denial language.

The Consult platform supports EMR connectivity and API-based architecture to provide seamless integration with existing healthcare systems, facilitating real-time data exchange, and improving the responsiveness of healthcare services. The platform has achieved ~80% automation and ~70% portal adoption, demonstrating high efficiency and user engagement.

The application of predictive analytics and AI within Consult allows for more intelligent decision-making and enhances the ability to forecast patient care needs and outcomes more effectively.

Offering a Flexible Service Model

Recognizing the diverse needs of health plans, WNS offers both delegated and non-delegated models, allowing for flexible integration of their services according to the strategic goals of the health plan. These models range from handing over everything from case intake to appeal management to WNS (delegated model) to health plans opting for non-delegated models, keeping certain services in-house (such as medical necessity decision and appeal management).

Looking Ahead: Continuous Improvement and Expansion

The WNS future roadmap includes clinical and non-clinical investments. Clinical expansion includes increased coverage of genetic testing, oncology clinical pathways, and post-acute programs. The non-clinical expansion includes enhancing the platform’s capabilities to include order pattern intelligence, UMaaS, and enhanced member engagement.

WNS’ initiatives will continue to offer improvements in how healthcare services are managed and delivered, leading to better outcomes for all stakeholders.

NelsonHall recently attended the DXC Connect Insurance Executive Forum in Charleston, South Carolina, where the theme was ‘Connecting the world’s largest insurance community to solve challenges and drive value’. DXC focused on:

• Its new product strategy to meet insurers’ transformation and investment needs
• The ability to combine its SaaS solutions with BPS to offer BPaaS services
• AI-based enhancement plans.

New product strategy launch

DXC has adjusted its product strategy to enable its clients to adopt an investment strategy or strategies dependent on their level of need to transform vs. minimize new investment. The key elements are:

• Protect – aims to safeguard organizations’ present investment while improving their existing capabilities, managing systems, and refining their environment for optimal performance. This is suitable for organizations that wish to minimize their investments while modernizing their infrastructure and optimizing their running costs by moving to a consumption-based cloud model
• Extend – access to innovative solutions, leveraging APIs and AI, and ensuring a secure system of records. This is the next step to add new functionality incrementally. Here, DXC stresses the importance of an ecosystem approach, though based on the client retaining their existing core insurance platforms. This involves incorporating these platforms into a wider ecosystem with approaches such as RESTful APIs. The ecosystem then facilitates co-innovation through access to additional point solutions, adding new capability and flexibility to switch functionality in and out
• Transform – for organizations looking for a more fundamental IT modernization. This involves digitalizing with AI and cloud-enabled solutions, making new upgrades to the DXC Assure platform, and operating in a more transformative model.

DXC’s improvement and investment strategy is strongly influenced by its user groups. Over the last year, DXC has made ~466 total enhancements to its P&C solutions, and 49% of these enhancements were community-led.

P&C BPS powered by DXC’s Assure

DXC’s Assure SaaS platform enables insurers to efficiently accelerate expansion capacity to new markets/geographies, with DXC BPS personnel providing access to expertise and support options tailored to the client’s transformation journey. DXC provides support across all 50 U.S. states; it will enhance, run, and maintain platforms and currently supports ~$2.6bn of direct written premiums.

DXC supports all insurance LOBs (e.g., workers comp, flood, commercial, specialty, and personal) and notifications services clearinghouse with ~4k trading partners, 40k endpoints, and robotic enablement.

DXC provided a use case of an insurer receiving 1,000 emails with attached documents and involving manual triaging of e-mail type, classification, and data re-entry, leading to inefficiencies in processes and increased chances of human error. DXC leveraged DXC Assure Submission and applied AI and ML. 95% of submission emails were converted to actionable data within 2 hours of receipt with a ~90% accuracy rate.

AI enhancement to DXC Assure solutions

DXC is making a major push to leverage generative, predictive, and cognitive AI solutions. They have established an AI strategy which focuses on three core areas:

• Customer AI – for improved customer experience, areas of change include a hybrid call center, real-time sentiment analysis, and GenAI knowledge assistants
• Company AI – for operational efficiency, appropriate knowledge management, and improving business outcomes
• Community AI – for a collaborative approach with real-time feedback and easier use of innovation.

AI-based enhancements that will be available in Q2 2024 include:

• DXC Assure Legal – end-to-end litigation management solution leveraging AI to automate processes for guideline compliance. Allows greater visibility and control over legal spend, leading to less time reviewing invoices
• DXC Assure Claims – partnering with AWS, a new omnichannel function that enables claims professionals to initiate texts and calls from the claims system. This addition reduces the time needed to resolve claims and furnishes a thorough audit trail of the interaction
• DXC Assure Submissions – leveraging AI and ML to extract data from semi-structured and structured submission documents. The AI is taught to distinguish critical data points from unnecessary data, reducing processing time and error rates
• DXC Assure Cede – integrating GenAI capabilities to enhance data in real-time as users navigate the system. The platform examines current SOPs, manuals, and documents to offer instantaneous summaries, enhancing productivity and user experience.

Next, DXC is further extending its AI use cases to reinsurance and Australia’s workers’ comp, both areas in which the company is already active.

Conclusions

• DXC is aiming to offer smooth migration paths from on-premise legacy insurance solutions to AI-driven SaaS and BPaaS services
• It is developing ecosystems of complementary solutions that insurers can adopt on a plug-and-play basis via APIs
• While not all GenAI PoCs will be successful and become widely deployable, DXC is making a major push to incorporate generative, predictive and cognitive AI into all its insurance modules.