From pilot program to 120% productivity, scaling smarter PBM support with proactive partnership.

The background.

Harnessing AI and automation to streamline patients’ insurance approvals for medication, this innovative healthtech platform experienced fast growth. The dynamic company required a support partner that could scale quickly, maintain airtight compliance, and improve outcomes across its pharmacy benefit verification workflow. In particular, the client required support with a critical aspect of their process: confirming drug coverage for patients.

After working with a secondary BPO on a different line of business, the company sought a truly collaborative partner that could grow into a co-parent to their operations. Referred by a mutual technology partner, the client selected Transcom. Our initial focus was on calling Pharmacy Benefit Managers (PBMs) to confirm patient eligibility, drug coverage, prior authorization requirements, and financial responsibility, all without engaging patients directly.

The solution.

To not only execute but elevate this crucial process, Transcom’s team took end-to-end ownership of benefit verification, successfully and directly liaising with PBMs with zero patient involvement. Scaling swiftly and with precision, we implemented a specialized recruitment process, sourcing healthcare-savvy agents with top-tier communication skills. By aligning hiring criteria with our client’s unique demands of the workflow, we were able to reduce training time, accelerate performance, and build immediate credibility with key stakeholders.

When a major PBM questioned the legitimacy of incoming calls and withheld coverage confirmations, Transcom immediately took initiative, incorporating drug-specific medical codes into our verification process to eliminate doubt and improve closure rates dramatically. Additionally, as task volume began to fluctuate, our team identified a threat to escalation metrics due to low sample sizes. We flagged the issue with the client, clarified the operational impact, and adjusted reporting expectations to ensure fair and accurate KPI measurement. Through every step, Transcom showed up as a nimble strategic partner, offering proactive solutions and adapting quickly to keep operations running smoothly.

The results.

Transcom’s strategic and proactive approach delivered substantial results across the board reflected in refined, accurate KPIs. Following the implementation of our medical code solution, closure rates improved from 90% to as high as 120%, representing direct patient convenience gains central to the healthtech’s services. As a result of our expert agents, thorough training, and cutting-edge tools, call quality consistently exceeded the 90% target, averaging over 95% every month. By streamlining the PBM liaison process, we also drove the escalation rate down by more than 50%.

These impressive results have paved the way for a growing partnership. While ramping down work with the prior BPO partner, the healthtech is preparing to ramp up its collaboration with Transcom, introducing 30-40 agents as it entrusts our team with more roles. This successful collaboration is a testament to Transcom’s ability to streamline critical operations, autonomously solve complex challenges, and consistently deliver high-quality results.