Kidney disease affects nearly 40 million American adults – that’s one in seven of us. Treatment involves life-saving dialysis, a kidney transplant or both. Because of the severity of the condition and the large number of Americans affected, Medicare offers an End-Stage Renal Disease (ESRD) entitlement benefit. The IVR handled 90% of incoming calls, but only 20% of the calls related to ESRD, so we knew we had the opportunity to improve the system.
Within the Centers for Medicare and Medicaid Services (CMS), the Benefits Coordination and Recovery Center (BCRC) is responsible for the collection, management, and reporting of insurance coverage information, including information related to the ESRD entitlement benefit. At GDIT teams are working within the BCRC to ensure Medicare beneficiaries with the ESRD entitlement can access the care and coverage they need.
Challenge: Complex Cases, Critical Coverage Concerns
The BCRC maintains a call center designed to answer questions and share information about the ESRD entitlement benefit. Calls to the BCRC often involve complex questions about specific cases and patient care. Customer service representatives handling these calls must be well versed in not only the mechanisms of the ESRD entitlement and Medicare coverage rules, but in the intricacies of kidney disease treatment itself. Calls come into the BCRC from patients, caregivers, healthcare providers and dialysis centers, and are often longer, require more sophisticated expertise and are harder to triage using existing automation tools.
Approach: Leverage Program Expertise to Optimize an Intelligent Virtual Assistant
While GDIT has been working with the BCRC on this program since 2018, several team members have more than 20 years of experience with the ESRD entitlement benefit. This expertise enabled us to build an interactive voice response (IVR) system that could provide general information, route calls appropriately, and answer high-level questions. The IVR was responsible for handling 90% of incoming calls, with 20% of the calls related to ESRD, but we knew we could improve it.
So, our team members began optimizing its performance and enhancing its capabilities. We built in additional rules-based logic to pinpoint entitlement start-dates. We identified major events – a transplant or the start of in-home dialysis – and aligned it with care notes. We ensured the IVR could appropriately determine when certain certifications were required or, as importantly, not required. We merged datasets to more easily align prior enrollments and streamline reenrollment activity. The team revisited the IVR’s language models and made improvements there as well.
Impact: Cost Savings, Higher Satisfaction Scores, Improved Patient Outcomes
As a result of this work, today the IVR handles roughly 1,500 ESRD calls per month – up from 300-350 calls per month. That’s a four-fold increase that requires two fewer customer service representatives, which for this program are cost-intensive resources. This work means faster time to resolution for callers, better internal routing of calls, more satisfied users, faster benefits to patients and better health outcomes for these patients.
Given the importance of the ERSD entitlement and the number of Medicare beneficiaries affected, this work takes on major significance for our team. Applying technical know-how with program experience to envision the art of the possible is enabling us to help the customer meet the mission in a really powerful way. This is one of many GDIT programs where our role as a systems integrator transcends information technology and transforms technology into making a meaningful difference for customers and the men and women they serve.
Learn more about our healthcare portfolio and the capabilities we bring to bear.