TriZetto Group fights health care fraud and abuse with
i-Sight investigation software

TriZetto Group

TriZetto Group Snapshot

The TriZetto Group, Inc. has implemented i-Sight investigation Software to improve its ability to track, manage and analyze investigations of insurance fraud and abuse in the healthcare industry.

“The i-Sight software solves a number of important problems for us,” explains James McCall, Vice President of TriZetto’s Fraud, Waste and Abuse division. “The i-Sight investigation software solution is easy to use, it saves time, it allows our investigators to work more efficiently, and it significantly improves the accuracy of our case records. I’m absolutely ecstatic about this software.”

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The Challenge

TriZetto’s Fraud, Waste and Abuse division needed a robust, flexible system to track and manage investigations of healthcare insurance fraud and abuse. In the past, investigators maintained case histories in a series of Microsoft Excel spreadsheets, but records were difficult to maintain and ensure consistency of data.

Managers and staff found it difficult and time-consuming to keep track of investigations and prepare reports for clients and senior management. Information relating to different aspects of the investigations was contained in separate files, so there was no easy way to analyze cases by type or duration of investigation, geographic location, dollar value, etc. Clients did not have immediate access to information related to investigations

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TriZetto Group


The Solution
  • The division replaced its existing system with i-Sight investigation software, the world’s most customizable software for logging, tracking, processing and analyzing essential case information
  • Instead of wading through cumbersome spreadsheets, investigators now enter case information quickly and conveniently via i-Sight’s easy-to-use web-based interface
  • All case information is stored securely in one central database, so it is easy to analyze cases and monitor performance across the division
  • Clients can log in and immediately see how their investigations are progressing
Results
  • i-Sight investigation software saves time and money by enabling investigators to work more efficiently
  • Case records are more accurate and up-to-date, leading to better decisions
  • Enhanced reporting leads to higher client satisfaction

Case Study


Headquartered in Newport Beach, CA, The TriZetto Group, Inc. (NASDAQ: TZIX) is a leading information technology and services company focused on the healthcare industry. With its technology touching nearly half of the U.S. insured population, the company provides premier information technology solutions that enhance its customers’ revenue growth, increase their administrative efficiency and improve the cost and quality of care for their members. TriZetto’s customers include national and regional health insurance plans, as well as benefits administrators that provide transaction services to self-insured employer groups.


The Challenge

According to the General Accounting Office, approximately one-tenth of all U.S. spending on healthcare is lost to fraudulent insurance claims and other forms of abuse. TriZetto’s Fraud, Waste and Abuse division provides healthcare insurers with a comprehensive suite of anti-fraud services, including prospective and retrospective investigations of fraudulent claims, proactive data mining and analytics, development of enterprise-wide anti-fraud controls, and recovery of overpayments through demand, negotiated settlements, civil litigation and support for criminal prosecution.

“The process we were using may have worked when the division was started, but now that we have grown, we need to take the next step in development.”
To meet the needs of their clients and achieve superior results, the investigators who work in the division require the ability to log, track process, and analyze accurate case information. In the past, these various records were maintained in a series of Microsoft Excel spreadsheets. Over the years, however, that system proved increasingly unwieldy and incapable to keeping pace with the growing number of clients and investigations. “The process we were using may have worked when the division was started, but now that we have grown, we need to take the next step in development.” says McCall, who assumed responsibility for the division in June 2007. For one thing, two people — an investigator and his or her manager, for example — could not be working on the same document at the same time. Worse still, the old system was difficult to ensure consistent entries were made by every investigator, or accidental errors could overwrite previous entries. These challenges made the data difficult to analyze. “In Excel, one little spelling mistake or a blank space can throw things completely out of whack when you try to sort, or filter the data,” McCall says.

He adds: “When I arrived here, I asked for a report showing the number of open cases by client, by investigator and by type of investigation. The effort necessary to obtain an accurate report was quite manual and included external validation steps to ensure accuracy. I thought to myself, ‘If we are going to optimize our service, and measure performance accurately, this is an area that needs to be developed.’”

As he examined the division’s records in greater detail, as expected, McCall discovered that the limitations of Excel for tracking this type of data were manifesting. Not only did that make it difficult for him to track and monitor investigations, it also meant that the investigation process itself was not as efficient as they could be. As a important consideration for McCall is the growth of the division, he thought, “If case efficiency could be impacted in one case for one client, what could the impact be for 50 cases for 50 clients? The whole would become greater than the parts. I realized that managing information represented a very significant operational enhancement opportunity for us, and for our clients.

The Solution
“It’s nice not to have to worry about managing the system — we can simply go ahead and use it.”
McCall immediately launched a search for a more robust, reliable and flexible case management system. After reviewing several options, he chose i-Sight investigation software, the world’s most customizable software for logging, tracking, processing and analyzing essential case information. “I could tell right away that i-Sight was the solution we needed to improve our workflow and manage our caseload more effectively,” McCall recalls. “I had built case management systems internally in some of my previous positions so I had a very good idea of the features I wanted. The nice thing about i-Sight was that everything was already there. The designers really did a great job of anticipating our needs.”

From McCall’s standpoint, one of the most attractive features of i-Sight is that it is a hosted software product. As a result, there is no need to purchase, configure and administer the software locally; instead, the entire solution is managed remotely by an expert team at i-Sight. To access the system, McCall and his investigators require only a standard web browser. “The fact that the system is remotely hosted is a big positive for me because if something goes wrong, it’s someone else’s responsibility. All I have to do is get myself to a computer with web access and everything is there. It’s nice not to have to worry about managing the system — we can simply go ahead and use it.”

An added benefit is that McCall and his team can log into the system from any location — whether they are in the office or on the road. And rather than preparing detailed reports, printing them out and sending them to the division’s clients, the clients themselves can now easily log in and see at a glance the number of investigations that are underway, and how each of those cases is progressing. “That’s a big plus for us because it significantly improves our ability to communicate with our clients,” McCall says. “In the past someone might have phoned us to inquire about a case, and the investigator would have to pull out the information, organize it and get back to the client. Now the client can just go into the i-Sight system 24/7 and all of the information is there in real-time.”

Not only is the data easier to access, the level of detail is much richer, too. Once a new case is created, the i-Sight system guides users step-by-step through a series of drop-down entry fields that have been customized to conform to TriZetto’s existing workflow while ensuring accuracy and efficiency. Entering a new case takes only a few minutes and requires little or no specialized training. From that point on, automatic reminders and alerts help to ensure that case records are always kept up-to-date and that individual investigations are not neglected or overlooked. “We haven’t finalized all the rules,” McCall says, “but for example an investigator might have 10 days to complete certain steps after a client sends us a new case, and if the information hasn’t been entered by that point he would receive an automatic alert. After 15 days, he and I would both get an alert. The idea is to ensure that we continue to meet or exceed the standard of excellence our clients have come to know. I am highly confident that this technology provides us a platform to exceed.”

“This is a quantum leap forward in operational efficiency and client service”
According to McCall, one of the key advantages of i-Sight compared to the previous, spreadsheet-based system is that it will now be much easier for him to track performance — “not just at the level of the individual investigator, but also in terms of financial performance and how much money we are saving for our clients.”

“With our old tracking system, it was difficult to pull information out in an efficient manner and make it available in a form that was consistent, yet customizable to the clients needs” McCall notes. “And not just for the benefit of our clients, but for people in our own organization. For instance, I’m asked for reports pretty regularly by my superiors. So now, instead of us having to dig around for the information in multiple spreadsheets, my superiors can go into i-Sight at any time and immediately get what they need by running one of the custom reports I have set up for them.”

With i-Sight, McCall adds, everyone wins. “Our investigations proceed more efficiently, our clients get better information, our senior management is better informed and I and my staff have more time to devote to operational responsibilities.”

How will i-Sight affect his division’s performance? McCall doesn’t mince words. “This is a quantum leap forward in operational efficiency and client service, the two underpinnings of a service organization’s ability to be best in class”

“With i-Sight, our investigations proceed more efficiently, our clients get better information, our senior management is better informed and I and my staff have more time to devote to operational responsibilities.”

James McCall, Vice President of TriZetto’s Fraud, Waste and Abuse Division