A Unique eBusiness Solution that Saved Millions
Before the Bay Consulting Group’s Dave Johnston arrived on the scene, Ontario’s Workplace Safety and Insurance Board (WSIB) faced being buried under a growing mound of costly and inefficient paper.
“Dave brought us a disciplined methodology for looking at the problem, defining options and reviewing them for the best choice,” says Brock Horseman, WSIB’s chief operating officer. “The results were clearly cost-saving.”
WSIB is the largest payer of work-related health claims in Canada, processing nearly 350,000 claims annually for on-the-job injuries. It deals with some 20,000 health care providers including, among others, physiotherapists, doctors, chiropractors and occupational therapists. Total annual payouts for health claims: more than $400 million.
Reviewing the WSIB situation with Emergis, a leader in the e-commerce field, Dave found that filling out the required paper forms and the various approval levels meant injured—and out-of-pocket—workers and providers had to wait from four weeks to six months before receiving a cheque in the mail. But after WSIB implemented Dave’s and Emergis’s modernized health claims management system, submitting a worker’s claim became as simple as most current employee drug and dental plans where there is either no charge at all or a claim is resolved almost instantly. Simply put, Dave’s BCG contribution helped Emergis develop a unique IT solution that cured WSIB’s paper paralysis.
EMERGIS' SOLUTION AND WSIB'S NEEDSDave Johnston, a Wharton MBA graduate with vast practical experience in developing IT systems, had been working with WSIB on other projects when he joined forces with Emergis on the WSIB Health Claims Management project. Emergis, which specializes in the online processing, adjudication and payment of prescription drug, dental and other health-services claims, has a reputation for effectively connecting payers and providers, helping them achieve greater efficiency throughout their operations. Its products simplify administrative processes, decrease costs, facilitate the highest quality of care and maximize efficiency through the entire claim management process, from capture to submission, from adjudication to payment. Emergis customers include leading Canadian health insurers and the top Canadian banks. All but a handful of Canada’s pharmacies and some two-thirds of its dentists use Emergis systems.
But WSIB was looking to do more than reduce the costs of adjudicating and processing health care providers’ services and invoices. It also wanted to acquire and maintain client information and data that would allow for better case management and quicker resolution of claims.
HANDS-ON FROM VISION TO IMPLEMENTATIONEmergis retained BCG’s Dave as the project executive and overall program leader. “I put together the vision and developed the ‘architecture’ that met WSIB’s needs,” he recalls. Working with a core team of two or three senior Emergis staff, and backup from Bay Consulting as required, Dave worked on the company’s premises for nearly a year in this critical first, visioning stage.
“WSIB needed a system that adjudicates and then automatically authorizes patient treatments and services,” he recalls. “To do this, the system had to reflect WSIB rules and practices and be able to make electronic payments to the providers.”
After WSIB agreed to purchase the specially designed health claim management system, Dave spent another year with Emergis at WSIB in the delivery and implementation stage. The new system became operational in the fall of 2003. “Dave helped us move forward on a rapid and expedited pace,” says Bob Ransom, at the time an assistant vice-president at Emergis. “He helped us maximize revenue opportunities.”
Adds Emergis Account Director Pamela Hooke: “Dave rolled up his sleeves and helped us do the work that needed to be done. And he never lost sight of our final goal and the big picture. He was superb at ensuring that we understood the right approach to take and, more importantly, why it was the right approach.”
Working closely with the client and developing the “architecture” is key to Dave’s problem-solving IT approach. “When I say ‘architecture,’ I mean a business model reflecting operating requirements and commercial needs. It’s a blueprint for business and change.”
SIGNIFICANT GAINS FROM MODERN MANAGMENT AND MODERN ITFor Dave, this architectural blueprint is a pathway to engineering IT change; it guides the development and delivery of integrated IT solutions. “Over the years,” he says, “I’ve learned to meet commercial needs through new ways of doing business enabled by advanced IT. In short, modern IT capabilities coupled with modern management can enable significant bottom-line results.”
WSIB’s Horseman agrees. “Dave helped us achieve significant administrative savings of more than $1 million annually, plus additional efficiencies. And we were able to improve service to our customers, both the injured workers and their employers.”
But Horseman also pays tribute to Dave’s contribution in another way that is not so easily measured. “Dave will be most remembered for his willingness to transfer his knowledge to staff,” he says.
For his part, Hooke says Dave brought this sharing approach to his dealings with Emergis staff. “He was very good at taking the time to educate us and move us in the right direction,” she says.
Reflecting the success of the solution, WSIB and Emergis agreed to extend the contract for an additional six years at the end of the original term.
HIGHLIGHTS OF HCMHighlights of the Emergis Health Care Management System (HCM) Developed with WSIB.
HCM is a rules-based, architected application system and information resource that performs the following functions:
- Automates policies, practices and guidelines using a sophisticated rules engine;
- Captures and edits provider and worker bills (eligibility, accuracy, etc.);
- Creates and captures rehab treatment plans;
- Adjudicates provider’s bills and worker’s expenses;
- Pays those bills by electronic transfer or by mailed cheque;
- Captures the health-care costs against the claim.
- Provider registration and enrolment;
- Bill submission, capture and edit, including e-channel and Electronic Data Interchange;
- Automated adjudication using a sophisticated rules engine that incorporates policies, practices, standards and fee schedules;
- Exceptions management – both centrally and distributed to the case management teams;
- Vocational rehabilitation plan management encompassing Web-based referrals, plans, amendments, bill submission and actuals;
- Predictive payments for recurring expenses;
- Payment and explanation of reimbursement;
- Workflow and messaging;
- Inquiry and search ability for bills and payments; and,
- An extensive integrated database.
- Production Data Centre and e-Solution Infrastructure that includes: secure site, solution and technology infrastructure hosting, operations management and uptime, network management, connectivity and messaging;
- Business operations and services such as: help desk, daily operations management, cash management, management and control, financial management, provider management, provider adoption, billing, and audit and control functions;
- Customer and account management, including Service Level Agreements; and
- Ongoing product and solution enhancements;
- Business and IT consulting services.