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Claims Process Automation Explained

Discovering How Automation Can Help Your Organization with Claims

Claims Process Automation

Processing claims can be expensive, time-consuming, and error-prone for service providers – including those in the healthcare and insurance industry. Intelligent automation (IA) streamlines these processes for better cost savings and faster claim settlement times. By automating repetitive manual work, your organization can dedicate more time to your customers.

In this guide, we’ll learn:

  • How claims process automation works.
  • Examples of claims processes you can automate.
  • What to look for in a claims process automation solution.
  • The benefits of claims automation.

What Is Claims Process Automation?

Claims process automation uses technology to automate the processes involved with any claims – be that in healthcare or in an insurance company.

Most automated claims processing software utilizes technologies such as artificial intelligence (AI), machine learning (ML), and natural language processing (NLP) to collect and analyze structured and non-structured data, processing claims faster and more accurately. In turn, this improves customer satisfaction by lessening wait times and reduces the risk of errors by improving data accuracy and performing regular compliance checks.

What are the steps in claims processing?

Claims Processing Steps

Intelligent automation (IA) deploys digital workers to streamline the healthcare and insurance claims processing workflow along each step.

  1. Reporting the claim: In the initial claims filing process, the policyholder reports a first notice of loss (FNOL) to the insurance firm.
    1. With technology, this claim can be submitted through a mobile app or online.
  2. Assessing the claim: During the claims assessment process, the claim handler reviews the policy to see what’s covered.
    1. This manual review can be automated to detect specific policy language and consult third-party databases to verify the claimant’s identity.
  3. Validating the claim: The insurer gathers additional information, including repair estimates or medical records, to validate the claim.
    1. Automation can pull this data from various sources to help validate the claim faster and more accurately.
  4. Making the decision: The insurer decides if the claim will go through.
    1. Automation’s predefined rules can set payment amounts and coverage, with the option for a human-in-the-loop (HITL) for final checks.
  5. Processing the payment: The insurer initiates payment to the claimant.
    1. You can automate the payment process for accuracy and speed using digital payment methods, ensuring clear transaction records.
  6. Analyzing the data: Once the claims process is complete, the insurer can perform a claims analysis.
    1. Automation tools can help analyze claims data and identify customer behavior patterns – flagging any potential fraud and identifying areas for improvement.

How does claims process automation work?

Claims processes are ripe for automation due to their slow, repetitive tasks, which are prone to error. When you deploy an intelligent digital worker, you’re telling it to take over these tedious tasks.

Digital workers are available 24/7 and work with 100% accuracy. They free your staff to focus on higher-value, complex processes, such as unique case files, potential fraud, and improving customer claims experience.

IA improves communication across systems and departments and provides accurate documentation for better auditability into your processes. This can help with underwriting and fraud investigations. Learn more about IA insurance underwriting use cases to find out how you can improve your organization’s efficiency.

Examples of claims process automation

Claims process automation can be implemented in the following areas.

  • Claims processing: IA allows an insurance provider to easily analyze and consolidate claims data, ensuring insurers have timely access to all relevant information. This means insurers can quickly verify the claim and automatically route the information through the claims department – while updating customers about the progress of their claim. A good example of this is claims management automation in motor insurance.
  • Collecting data: Automation can work across structured and unstructured formats to collate the relevant information at a central point for easier accessibility. Digital workers can also flag incorrect or missing information and immediately notify claims adjusters.
  • Investigating fraud: By bringing data into a centralized system, automation can help identify potentially fraudulent patterns for early detection. IA also reduces human error across manual processes such as data entry and documentation, so insurers always have access to the correct information.
  • Communicating between departments: With IA, insurers can automatically update changes to claim policies and manage cross-departmental communication. Digital workers can also notify insurers when their attention is needed on a specific claim, which reduces the time to service.

Who benefits from claims process automation?

Automation reduces errors and improves the efficiency of claims processing. IA can span across claims operations, including processing, investigation, claims management, and customer service. This is useful for both the healthcare and insurance industry.

Healthcare providers can utilize IA to reduce administrative burdens and improve the patient experience. Specifically, automation use cases for the healthcare industry include:

  • Electronic health records (EHR) integration
  • Data validation
  • Electronic claims submissions
  • Claim status tracking
  • Pre-authorization
  • Real-time eligibility verification

Automation in insurance claims can be used for:

  • Document digitization
  • Data extraction
  • Claims validation
  • Fraud detection
  • Claim routing and tracking
  • Electronic claims submissions

Read more about insurance automation use cases and examples.

What to Look for in a Claims Process Automation Solution

You’ll want a claims process automation solution that works over entire processes, including submission, review, decision, and payout. Depending on your business operations, you’ll likely start small with inefficient individual tasks and move toward end-to-end digital transformation.

Your choice of automation solutions should align with your business objectives and regulatory requirements, but it should also meet your goal to improve the efficiency of claims processing, increase profitability, and offer a more personalized experience to enhance customer engagement.

Here’s what to look for in your workflow automation tools:

  • Integration capabilities. Find tools that seamlessly work across your existing business systems, databases, and software to avoid disruption during implementation. These systems can include HR, accounting, underwriting, etc.
  • Centralized access. Find a claims automation system that connects the various data sources and brings them into one centralized location for easier accessibility.
  • Accurate data management. Use automation solutions that ensure consistency and accuracy.
  • User-friendly interface. Find an IA solution with an intuitive user interface (UI) that will simplify insurer and customer experiences. This will help avoid delays and missed information.
  • Customization. A flexible solution will help you adapt the automation technologies to suit your unique business outcomes.
  • Scalability. Even if you start with simple task automation, look for a scalable automation solution, so you can extend to total workflow automation as your volume of claims increases.
  • Decision support. A robust solution should include automation tools that support decision-making, so your employees have an easier time making timely and informed decisions.
  • Analytics. Comprehensive reporting is crucial in tracking your automation performance, identifying bottlenecks, and helping you continuously improve your claims process workflow.
  • Futureproofing. An ideal automation in claims processing is flexible, scalable, and capable of combining with new or evolving technologies to ensure you stay competitive.

The most important aspect of selecting an automation solution is to assess your business needs and ensure the solution functions in your existing systems. When you start your automation initiative, create a business case of the potential benefits of automation, including improved efficiency, reduced errors, better customer and employee experience, and increased return on investment (ROI).

What technology can you use to automate claims?

What Technology Can Be Used to Automate Claims?

Depending on your business goals, there are various levels of automation in claims processing that can transform how you work. These can include, but aren’t limited to:

  • Robotic process automation (RPA) automates tasks by deploying software robots programmed on predefined rules to mimic human actions and reduce manual processing. In an insurance company, these tasks can be extracting data, filling in forms, moving files, and scheduling meetings. Healthcare providers can use robotic process automation to set appointments, file patient medical records, etc.
  • Artificial intelligence (AI) imitates human thinking to understand and complete complex tasks. It’s often used with other technologies to improve efficiency and broaden the scope of complex claims process automation.
  • Machine learning (ML) is a subset of AI that learns from past models rather than being programmed on predefined rules. ML does a lot of the heavy lifting, as it’s specially designed to work well with large datasets. ML is especially useful for analyzing and detecting fraudulent claims, identifying patterns, and automating decision-making based on historical data.
  • Natural language processing (NLP) is a subset of AI that can read and interpret relevant data with the capability of interpreting human language. This helps simplify data uploads into the claims system and classifies those claims documents for easier accessibility.
  • Optical character recognition (OCR) converts other unstructured documents, such as handwritten texts and images, into machine-readable digital formats that can be automatically processed. With SS&C | Blue Prism® Document Automation, you can turn handwritten documents into decision-ready information immediately.
  • Intelligent document processing (IDP) extracts data from complex, unstructured data where OCR cannot (e.g., a web form). SS&C | Blue Prism® Decipher IDP is our IA solution at scale, where we combine OCR and AI to accurately extract information and remove time-consuming work from your teams.
  • Business process management (BPM) provides a systematic approach to designing, modeling, executing, monitoring, and optimizing an entire claim processing workflow by allowing organizations to implement standardized procedures and business rules for better decision-making and regulation adherence.
  • Cloud-based solutions allow for easy integration with other systems and data storage, with more processing power on demand.
  • Chatbots and virtual assistants can offer automated responses to customer queries about submitted claims and status updates.
  • Intelligent automation (IA), sometimes known as intelligent process automation, streamlines critical business processes by implementing AI and RPA – often including NLP, ML, OCR, and other automation technologies. IA can help in the claims process from document processing, claims adjustments, fraud detection, etc.

In reality, claims process automation can combine all of these technologies. They’re flexible, so you can assess your current business processes and determine your best ROI first.

Benefits of Automating Claims Processing

What Are the Benefits of Claims Process Automation?

Claims processing automation offers a host of benefits, including:

  • Accuracy: IA reduces human errors in the claim handling process, from calculations to data entry and manual review, which helps monitor claims costs and prevents overpayments, underpayments, and processing delays.
  • Efficiency: Automation reduces manual tasks such as data entry for claim forms – both for employees and customers – resulting in faster claim processing times and resolution. Read more about how you can speed up your claims management.
  • Cost savings: Automation reduces operating costs since fewer employees are used on manual tasks. This also reduces errors that lead to costly rework or insurance fraud and allows your employees to focus on higher-value, strategy-driven tasks.
  • Customer service: Faster and more accurate processing improves patient and/or customer satisfaction. IA offers insight with customer journey maps to help you customize their experience. It also gives customers real-time access to claims statuses and automated responses through chatbots that don’t require human interaction. These fast and accurate services will help to improve customer loyalty and keep you relevant in a competitive landscape. Read more about how automated claims management improves customer experience.
  • Risk mitigation: Automation incorporates fraud detection algorithms and ML to identify suspicious claims patterns – also reducing the risk of financial losses by performing regular compliance checks.
  • Document management: Automated systems can organize and store claims data electronically for easier document retrieval and better security – essential to the healthcare and insurance industry.
  • Employee satisfaction: By freeing employees from manual claims processing, they can focus on value-adding activities such as complex claim handling processes, brainstorming new products, or providing better customer satisfaction.
  • Environmental impact: Automation reduces paper-based processes, which can contribute to environmental sustainability and reduce waste.

IA can yield various short- and long-term benefits as it works to optimize your claims management processes.

Key Takeaways

Automating healthcare and insurance claims processing streamlines and accelerates the often costly, time-consuming, and error-prone claims settlement processes. By harnessing technologies such as intelligent automation, organizations can automate tasks across the entire claims lifecycle, from submission to payout, while also reducing fraud and rework.

Claims process automation spurs business growth, allowing your organization to focus on higher-value, complex solutions and positioning you for a competitive future of adaptability and sustainability.

Want to find out how claims processing automation can help you? Contact an SS&C Blue Prism expert today.