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 NEEDS
Dave 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 IMPLEMENTATION
Emergis 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 IT
For 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.
On a current note (October 2006), reflecting the success of the
solutions, WSIB and Emergis have agreed to extend the contract for an
additional six years.
-----------------------------------------------------------------------------------------
ABOUT DAVE JOHNSTON
Dave succeeded in the Emergis-WSIB
project because he has three decades experience in e-commerce and
consulting, across several industries particularly in the insurance,
health-care and communications fields. A Toronto native, Dave has a
B.Com. from the University of Toronto. After graduation, he went to
work with IBM Canada for some 18 months before moving to Philadelphia
and getting his MBA at Wharton. Touche Ross hired him out of school and
he worked in New York City as a management consultant for five years.
During this time, Dave planned and developed IT systems for clients
such as McGraw Hill, ITT, Bloomingdales and the State of New Jersey.
Dave then returned to Canada to become Director of IT at Gulf Canada
and, subsequently, IT Vice-President at Cole’s, the bookstore chain. He
joined Bay Consulting Group in 1993. In addition to WSIB and Emergis,
clients have included Bank of Montreal, Rogers Communications, Coles
Books, Gulf Oil, The Woodbridge Group and the Manitoba Telephone
System.
-----------------------------------------------------------------------------------------
HIGHLIGHTS OF HCM
Highlights 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.
There are over 40 key business
process subsystems that comprise the HCM including:
- 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.
As well, the HCM solution, as an
outsourced business process, also provides the following services to
WSIB:
- 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;
- Ongoing product and solution
enhancements;
- Business and IT consulting
services.
