Claim Processing

In many cases auto adjudication leads to pending claims due to lack of information. Typically this information is there on payer systems and applications. As payer systems are built in silos, a single application is not able to connect the dots and retrieve the information to make a valid decision. RPA bots can be trained to gather disconnected information on different applications to make an informed decision. The automated process reduces average transaction times from 12 to 2 minutes. This will also help in increasing the auto adjudication rate to above industry standard of 85%.

Use Case Services Offered

Provider Data management

Payers spend a lot in terms of tracking provider details. Incorrect provider information could impact operational inefficiencies, like low auto-adjudication rates, denied claims, and reprocessing of claims. AI in healthcare can reduce the cost of maintaining provider data and improve overall data integrity.

Provider Credentialing

Provider credentialing and Re- Credentialing is an ongoing task within a Payer network. Payers have to fetch information from providers and then validate the information against third party or government databases. Once validated this information is updated on Payer systems. With OCR (Optical Character Recognition) enabled RPA and IPA (Intelligent Process Automation), process efficiencies can be achieved in these areas.

Member Enrolment

Payers have to process a huge volume of new member enrolments every year especially during the Annual Enrolment Period from Oct to Dec every year. It is a manual process that involves heavy paper work resulting in delays and is error prone. Typically during the AEP payers hire temporary staff to process this paper work. RPA can automate the entire process seamlessly, and bring down the processing errors and incomplete applications; subsequently reducing the turnaround of enrolment cycle times.

Benefit Configuration and Plan Load

Intelligent RPA bots can be used for benefit configuration loads and testing. Multiple systems and multiple groups and policy holders are affected by plan changes and benefit changes to their groups and individual policies. RPA can be used to test the changes and identify failures. RPA can also be used for regression testing for any changes related to benefit and plans. Typically the turnaround time for these changes is high, like 30 days. Implementing RPA solutions can reduce this time with zero errors.

Premium Reconciliation/Demographic changes

Medicare and Medicare advantage plans see a lot of requests coming from CMS for demographic changes like address change. These requests can be processed by intelligent automation using RPA in combination with IVR.
Over the period of a year many policyholders see changes to their income and may change jobs, lose employer funded plans or may even lose jobs. These changes will result in plan change premium changes and or source of premium may change from personal to SSI. Policy holders will also change the method of payment for their premium. These changes also result in missed premiums or overpaid premiums or unapplied premiums. These changes can be captured and processed using intelligent RPA bots which can access multiple sources of data and upload the relevant payer systems.

Contract Load

A large Payer can typically lose up to billion dollars annually due to incorrect contract load resulting in overpaid claims. Timely and accurate Provider Contract loads are necessary to avoid incorrect payments and overpaid claims. Provider contracts and terms of service are renewed every year and can also be renegotiated any time during the contract.
Paper contracts are converted into digital contracts and uploaded on system to facilitate auto adjudication. Typically contracts are paper contracts or excel files are used to capture the change in information.
Intelligent RPA solutions can be used to capture the unstructured data or semi structured data like contract terms, reimbursement methods and pricing from paper contracts and can upload the Payer Systems with zero errors saving time and incorrect payments.

In 2020, as the situation across the world rapidly changed from business as usual to adapting through a pandemic, RPA is already being implemented to accelerate operations in healthcare, helping organizations and professionals deal with the overwhelm caused by CoVid-19.