A healthcare payer groomed his unstructured contracts


Challenge
An organization needed to clarify the health care claims it was handling for US veterans. The organization received and paid US TRICARE claims, based on contracts with health care providers nationwide. Many of the 2,500 contracts were signed decades ago and there was no effective way to verify the amount owed on a claim or verify a contract’s compliance with today’s TRICARE standards. Contract formats also varied from vendor to vendor, so there was no single path to converting unstructured information into standardized data.

The healthcare claims payer needed a way to verify payment details and confirm compliance of thousands of unstructured contracts.

The solution
The solution
The Grant Thornton team offered an automated solution to analyze and convert contracts. First, the team had to transform divergent contracts into a single data source. “One of the challenges was trying to develop models that were broad enough to capture all of the different languages ​​being used, but that conceptually meant the same thing,” said Cody Root, senior partner at Grant Thornton Advisory Services. “We actually had someone 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 Overview of DocuSign for the contract intelligence component, and we used our own table mining capabilities that rely on AWS to automate the analysis required to read details in contracts and make comparisons with the TRICARE program,” Dinola said.

Results
Results

The Grant Thornton team performed the automated analysis and conversion to clarify the terms of the claim payer contract with:

  • Estimated 12,500-20,000 analysis hours saved, based on the 5-8 hours needed to analyze each of the 2,500 contracts
  • Revenue leakage is controlled by giving payment processors quick access to contractual payment amounts
  • Ensured compliance using automated comparison of contract payment terms with US TRICARE requirements
  • Identified contracts that were below or above current compliance requirements

“I think a big issue for almost every business is the ability to make sense of unstructured data in their environment,” Dinola said. “The value of the information contained in legal contracts – whether on what we call basic buyer-side or supplier-side contracts, or on sell-side or customer-side basic contracts – is enormous. But, the time required to carry out the Analyzing unstructured data and comparing it to structured transactional data is largely not feasible in today’s environment without these types of tools and technologies.

The healthcare claims payer now has a single source of truth to verify their 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 contract data and claim payer compliance.

“Typically, the comments we hear are: one: ‘I never thought this was possible’ and two: ‘The ROI is huge because you’re giving me a cost-effective solution that often results in 10, 12 , 15x back.’”
— Tony Dinola, Grant Thornton Advisory Services Partner

Hear Dinola and Root share the thinking behind our approach:

contacts:

Tony Dinola
Tony Dinola
Partner, Advisory Services
J +1 704 632 3492

cody root
cody root
Senior Partner, Advisory Services
J +1 602 474 4922

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