Case Study

Centene Recovery Platform

Background

American healthcare in a nutshell.

The American healthcare system stands out for its myriad challenges and shortcomings when compared to other developed nations. Struggling with issues of accessibility, affordability, and equity, it lags behind other systems in providing comprehensive care. Despite the high cost, the U.S. ranks last in healthcare quality among developed nations.

To put it bluntly, the American healthcare system is a mess. The complexity of the system is so great that a single person can’t possibly understand the intricacies of the entire process. Even if they could, the for-profit motivation of the industry provides enormous friction in simplifying and bettering the system.

Who is Centene?

Centene Corporation is a multinational healthcare company that provides a range of services to government-sponsored healthcare programs, focusing primarily on underinsured and uninsured individuals. As of writing this, Centene is listed as number 25 on Fortune 500 with 74,000+ employees. It is one of the largest providers of Medicaid and Medicare services in the United States, also offering services through the Health Insurance Marketplace and the TRICARE program for military personnel and their families.

Of the 33 developed nations in the world, the United States sits among them alone as the only predominantly private, for-profit health insurance model. 

The Problem.

When a patient leaves a hospital, the hospital packages all  services provided into a single claim and bills the patient’s insurance. The insurance then reviews the claim, validates the patient is covered for the services received, and calculates how much each service costs. However, the time required validate a claim is longer than the required window for paying the hospital. 

To solve this, insurance companies choose to overpay the hospital so the paitent can continue to recieve care. Once the claim is done being validated, the insurance company will then bill the hospital with how much money should be refunded. 

The American healthcare system today:

Medical Bills Are the #1 Cause of Bankruptcy in the U.S.

1 in 4 Americans have medical debt.

The average ER visit can cost more than a month’s rent.

The healthcare industry spent $568 million on lobbying in 2020.

Over 28 million Americans are uninsured.

Healthcare costs grow about 5.7% each year.

Objectives

#1

Reduce the time of validation, minimize claim errors, and increase the effectiveness of calculating the refund amount.

#2

Decommision Palantir, the software currently used to organize claim processes, communication, and claim analysis

Team Environment

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