Healthcare payer
meets RPA

Error release automation

This healthcare insurer found that one to two thousand claims were being stopped each daily for a simple error code associated with missing or incorrect data. These claims had to be worked manually to correct or supplied the claim data from other systems. Although these claims were only around three to four percent of the total, they had a big impact on the claim group because it caused constant bottlenecks.

 

The RPA solution was robots with automation scripts based on the same business rules used by the claims group to manually corrected the errors. Both the manual and the automation solutions were imperfect - the claim was still pending and still being touched for resolution. However, robots removed 25 FTEs from this manual process, which the customer considered significant saving, and bottlenecks of two and three-day durations were reduced to same-day resolution.

 

Minor edits automation

Another payer had a claims platform that held claims for minor front-end edits, such as noncompliant national provider IDs, age, address, etc. This meant anywhere from five hundred to fifteen hundred claims daily required manual processing by the claims team: processing which involved going out to several screens in the claims system to find the information needed to make the edit changes.

 

Now, the claims are pulled into work queues based on their hold codes and robots programmed to automate specific edit changes are assigned to the queues. The robots navigate to the claims system screens; collect the data needed to edit the claim; make the edit changes and resubmit the edited claim back into the claims systems.

 

Manually processing the edit changes took ten to fifteen minutes, whereas robots can do the tasks in one to two minutes or less. The RPA solution completely removed the claims team from this edit work, replacing approximately ten to twelve FTEs with robots. It also provided the ability to handle sudden increases in claims volume with more robots, instead of reassigning claims agents to low-value work.

 

Complex claim adjudication

A healthcare insurer was looking for a more efficient way to process coordination of benefit claims. The adjudication rules for those claims are complicated. Typically, the insured are covered by their health plans and their spouses’ plans. This means the insured’s COB provisions must be understood and their benefits coordinated between plans—in such a way that everything is covered and payment does not exceed the total claim. Not a job for a robot.

 

However, the claims agent must look up information in many documents to properly process this claim: at a minimum, the attached explanation of benefits (EOB); the summary of benefits (SOB); and the benefits grid. Plus, any other attachments to the claim file.

 

The RPA solution put these claims in a work queue for robots to assemble all the necessary documents, then placed everything in the claims agent’s folder. Taking this assembly work away from the agents and allowing them to focus exclusively on adjudication decisions, shifted about two hours a day from low-level documentation tasks to high-value claims processing work—for each agent.