Company: Unitedhealthcare Provider Service Operations
Company Description: Unitedhealthcare Provider Service Operations (UHC PSO) is business area within Unitedhealthcare. With over 6,000 global employees, we provide best in class multi- channel service to our nation’s healthcare providers. This includes answering questions, resolving issues, and processing medical claim settlements. In 2022, PSO was the recipient of an industry award for Top Global Contact Center.
Nomination Category: Customer Service & Call Center Awards Achievement Categories
Nomination Sub Category: Best Use of Customer Insight
 Nomination Title: Provider Resolution Center
- Which will you submit for your nomination in this category, a video of up to five (5) minutes, explaining the nominated achievement since July 1, 2022, OR written answers to the questions? (Choose one):
Written answers to the questions
- If you are submitting a video of up to five (5) minutes in length, provide the URL of the video here, OR attach it to your entry via the "Add Attachments, Videos, or Links to This Entry" link above, through which you may also upload a copy of your video. If you are submitting written answers to the questions for this category, provide them in the spaces below.
- Briefly describe the nominated organization: its history and past performance (up to 200 words):
Total 200 words used.
The Provider Resolution Center is the nerve center for all provider issues and was established December 2023. While most of the work is reactive, meaning someone needs brings forth their concern, we developed the Provider Resolution Center Detection Team to shift the thought process forward using the following approach:
Dashboards and Monitoring Tools: developed dashboards that track key performance indicators related to service delivery such as contact rates, authorizations, reconsiderations, and appeals.
Abrasions and Distress Indicators: implemented tools to detect different levels of customer satisfaction or service delivery problems identified through customer feedback support tickets or anomaly in service metrics.
Root Cause Analysis: use data to identify root causes of identified issues and develop corrective measures. Translate the insights gained from the data into strategic changes that address systemic issues rather than just symptoms to improve overall customer satisfaction and efficiency.
Insights and Alerts: generate actionable insights from the data and create alerts to notify relevant teams about emerging issues before an impact to the customer. Analyze impact of alerts to help in refining the alert systems and improving the quality of root cause analysis.
By utilizing such comprehensive approach, this process fosters a proactive rather than reactive service framework.
- Outline the nominated achievement since July 1 2022 that you wish to bring to the judges' attention (up to 250 words):
Total 235 words used.
We noticed a trend with out-of-network processing for urgent care providers for various commercial members. We used our analytic tools and intuitions to discover that for that particular provider type, the out of network processing rate was higher than other provider types, which seemed suspicious that a large number of members would seek urgent care with higher out-of-pocket costs in such large numbers.
After reviewing a sample, it was discovered that the many urgent care records had duplicate records in our system that were non-participating.When claims were billed, the system was choosing the non-participating record, despite having a participating record on file due to system configuration errors. We further extrapolated the signal to find that there were a significant number of urgent care claims processing the same way. After reviewing these records, almost all of them required some type of maintenance to fix.
Each record was reviewed, and updates were facilitated, and we kicked off claim projects for each provider impacted without the provider even knowing there was an issue! We put money back in the provider’s hands without requiring them to facilitate an outreach or contact to us. The issue was monitored after completion to ensure the issue did not reoccur.
Each issue that is solved is treated as a learning opportunity to become more proactive. The insights from each issue is then leveraged into future dashboards, signals, alerts, and other identification mechanisms
- Reference any attachments of supporting materials throughout this nomination and how they provide evidence of the claims you have made in this nomination (up to 250 words):
- Explain why the achievement you have highlighted is unique or significant. If possible compare the achievement to the performance of other players in your industry and/or to the organization's past performance (up to 250 words):
Total 63 words used.
Through these efforts, 3,674 claims were adjusted to pay out $343,187 to providers without any outreach required to get payment. This is a change in the model of reactive resolution. The detection team is now using signals for non-participating urgent care records to find additional scenarios that fit the same criteria for review. This reduces the administrative burden for the providers.
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