Challenge
An organization needed to clarify the healthcare claims it was processing for US veterans. The organization received and paid US TRICARE claims, based on contracts with healthcare providers nationwide. Many of the 2,500 contracts were signed decades ago, and there was no efficient way to check the amount due on a claim, or to check a contract’s compliance with today’s TRICARE standards. The contract formats also varied from one provider to another, so there was no single path to convert the unstructured information into standardized data..
The healthcare claim payer needed a way to check payment details and confirm compliance across thousands of unstructured contracts.
Solution
The Grant Thornton team proposed an automated solution to analyze and convert the contracts. First, the team had to turn divergent contracts into a single source of data. “One of the challenges was trying to develop models that were broad enough to capture all of the different language that people used, but that conceptually meant the same thing,” said Grant Thornton Advisory Services Senior Associate Cody Root. “We actually had somebody on our team who had spent time managing TRICARE programs for healthcare organizations prior to joining Grant Thornton,” said Grant Thornton Advisory Services Partner Tony Dinola. “We used DocuSign Insight for the contract intelligence component, and we used our own table extraction capabilities that are built on AWS to automate the analysis required for reading the details within the contracts and doing compares against the TRICARE program,” Dinola said.
Results
The Grant Thornton team completed the automated analysis and conversion to clarify the claim payer’s contract terms with:
- Estimated 12,500-20,000 analysis hours saved, based on 5-8 hours required to analyze each of the 2,500 contracts
- Revenue leakage controlled by giving payment processors quick access to the contracted payment amounts
- Compliance assured by using an automated compare of contract payment terms with US TRICARE requirements
- Contracts identified that were below or above the current compliance requirements
“I think a significant pain point for almost any corporation out there is the ability to actually make sense of unstructured data in their environment,” Dinola said. “The value of information that is contained within legal contracts — whether that be on what we refer to as the buy-side or vendor base contracts, or on the sell-side or customer base contracts — is enormous. But, the time required to do the analysis of unstructured data and compare that to structured transactional data is largely not feasible in today's environment without these types of tools and technologies.”
The healthcare claim payer now has a single source of truth to verify its claim payments and compliance, with automation replacing up to 20,000 hours of contract analysis.
Sound advice
Dinola and Root discussed how Grant Thornton helped clarify the claim payer’s contract data and compliance.
“Commonly the feedback we’re hearing is, one: ‘I never thought this was possible,’ and two: ‘The return on the investment is enormous, because you are giving me a cost-effective solution that’s oftentimes driving 10, 12, 15x of return.”
Listen in as Dinola and Root recount the thinking behind our approach:
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