Medicare Administrative Contractor increases Prior Authorization Capacity and improves supplier experience.

After completing an optimized Targeted Probe and Education Solution for Durable Medical Equipment. The client selected Digital Blue to optimize, integrate, and automate the medical review process for Medicare parts A, B, and HHH claims.


The Center for Medicare & Medicaid Services (CMS) implemented the medical review program to prevent unwarranted payments and protect the Medicate Trust Fund. Medical reviewers conduct claim analysis using many disparate databases, spreadsheets, and ad hoc templates to drive the process. Through a concurrent project, the client saw the opportunity to streamline all lines of business into one common platform built for handling case and workflow activities. 

About the Client

The client is a Medicare Administrative Contractor (MAC) for the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare. MACs are private healthcare insurers that are awarded jurisdiction based on geographical area to process Medicare Part A, Part B, or Durable Medical Equipment (DME) claims.  The client serves over 24 million Medicare beneficiaries and 100,000 healthcare professionals. MACs compete and recompete for contracts with the CMS.

Solution Highlights

  • A 360° suite combining the best of both worlds in Workflow and Case Management tools
  • A virtual Case Tracker works day and night to find new cases, claims, review decisions, and other documents and quickly logs them as completed events under their associated cases.
    • The tracker lists out who did each task, the type of task, when it was done, and what notes were made into a master log.
  • The tracker creates all data relationships needed on each task to be reportable under multiple structures from the start. 
  • Several user-friendly interfaces allow knowledge workers to manage lists and track collaborative steps.
    • Critical areas like Action Reason Codes, Program Activity types, and Issue Topics are managed directly in the application. New programs and topics appear in process dropdowns instantly as they arise.

Overall Results

Results materialize as a function of technology enhancements delivering on automation and technology-assisted operations and the behavioral change that shapes the workforce’s ramp-up and acceptance of the changes introduced over time.

Key measurable outcomes of these improvements include:

  • Consolidated 12 different systems and tools previously needed into one platform.
  • Simplified reporting, data entry, training, management, and support.
  • 88% automation of the 58 types of events that had previously been logged manually.

Optimize MAC Operations by Partnering with Digital Blue

The Digital Blue team has been optimizing MAC operations since 2006. Our experienced team has helped several MACs make significant, measurable improvements in their business performance. Schedule your exploratory digital transformation call today!