Case Study: Leading Health Insurance Provider strengthens safety, compliance, and fraud control with MetricStream

A Leading Health Insurance Provider Strengthens Safety And Compliance

One of the world’s largest health insurance providers faced mounting regulatory complexity, stronger accountability to stakeholders, and growing risk of fraud and abuse following major U.S. healthcare changes. The company relied on manual, paper-based processes, spreadsheets and siloed applications, which made managing market conduct exams, conflict-of-interest surveys, accreditation and incident response slow, error-prone and hard to standardize across states and business units.

The company selected MetricStream’s workflow-based GRC platform to automate regulatory alert tracking, market-conduct exam management, conflict-of-interest surveys (integrated with PeopleSoft), accreditation workflows, document control and fraud/incident case management. The solution delivered role-based portals, automated notifications, analytics and dashboards, resulting in streamlined compliance processes, proactive regulatory tracking, better data-driven decisions, tighter fraud controls and an enhanced public image with reduced risk of sanctions and fines.