Transforming Health Insurance Systems

When a major health insurer embarked on a strategy to convert its legacy mainframe claims processing to a single, modern, rules-based solution, Envisian was there to help deliver what would become the largest migration by a health insurance company in the world.

This major overhaul would involve more than 120 projects, large and small, and cost around $200M over four years. It would require the design and development of new payment and claims systems, process changes, and integration with a new Government claims platform.  It would send substantial ripples across the whole organisation, and re-define its relationships with external stakeholders, including hospitals and regulators.

Envisian had a wide range of responsibilities and roles throughout the program. We provided program management, project management, change management, architecture, integration, business analysis, technical analysis, testing, release and environment management, b2b, as well as advisory and QA services.

The strategy was to move one claim area at a time, starting with hospital claims, probably the most challenging of the claim areas. From our extensive experience in transformation, we don’t recommend doing everything at once. ‘Chunking down’ gives space to look at governance, stakeholder frameworks, technical alignment, benefits realisation and business impacts/processes.  In particular, it would allow our client to take into account the capacity of the organisation’s culture to absorb change, as well as to review what worked well and what didn’t.

From the beginning our work was driven by targeted business outcomes, which provided a clear and transparent means of tying the cost to deliver with tangible business return, at each stage of the work. In a program of this size, which took some years to complete, it was important to demonstrate investment value early.

We developed the functional requirements (data types, data sources, reporting requirements) in consultation with key stakeholders and built the non-functional capabilities (hardware, software, and integration) in tandem.  We undertook a parallel set of activities to ensure that appropriate governance was in place for the program and that the BI community was engaged and empowered to influence investment priorities (always a challenge in any transformation) as well as data governance.

We refined business requirements, implemented a new organisational structure for service delivery and increased visibility of, and addressed appropriately, all risks, issues and changes.  We tested functionality, developed system application, integration and user acceptance test plans, oversaw conversion/data migration solutions, process maps and documentation and engaged with business process teams.

We forged and embedded a strong customer-focused delivery culture, ensured the successful transition of technology to support teams, engaged new business management and sponsorship and developed strong networks within Private Health Insurance and the broader business.

The professionalism of our team ensured all claim processing solutions were migrated without any major disruptions to key business stakeholders and external parties, including integration of high volume transactions (HICAPS) without major impact or outages.