What you’ll get from this blog:

• Facing the challenges of analyzing claims data manually
• How automated claims management can free up resources and time
• How to streamline the entire process from when someone submits a claim to when it’s approved
• Real-world case studies of SS&C Blue Prism healthcare customers who found success with automation
• The benefits of strategically automated claims processing

Improve Results for Health and Insurance Providers

Anyone working in the healthcare industry, or those relying on prescription medication, are probably familiar with how slow and inefficient health insurance claims processing can be. Manual claims processing full of data entry and delays have made more healthcare organizations look to technology for solutions.

What Technology Can Help Improve Claims Processing?

Intelligent automation (IA) automates work end-to-end through a combination of technologies, including robotic process automation (RPA), artificial intelligence (AI) and business process management (BPM).

IA can improve efficiency and enable a better patient experience by streamlining the claims processing workflow. Say goodbye to manual repetitive tasks, inefficient legacy software, missed deadlines, denied claims and mistakes.

What solution do you suggest?

With the SS&C | Blue Prism® Enterprise AI platform, healthcare providers can build complex, scalable, end-to-end claims process automation, integrated with their existing systems to avoid disruption.

Challenges to Healthcare Payer Organizations Processing Claims

Currently, healthcare payer organizations are struggling to keep up with the vast amount of claims processing overwhelming their people.

Manually	With Automation
Creating and filing claims by keying in data.	Automatically extracting data from internal and external systems.
Manually checking health plans for insurance coverage.	Scanning through patient data to identify insurance coverage.
Pull prescriptions off the line and physically key data into systems – often in handwritten format.	Move data automatically between systems without requiring human intervention.
Adding relevant medical codes by hand.	Automatically attributing the correct codes to the correct places.
Calling and waiting on hold for prior authorization and validation.	Autonomously retrieving prior authorization and validation.
Submitting claims and sending them to the payer to receive payouts, often with delays.	Sending out claims as soon as they’re available and notifying the correct people.

Late payments

Payer organizations handle thousands of medical claims processing daily, and the majority still rely on manual processes – causing major delays. There are numerous examples where payments are years late due to broken adjudication processes, causing detrimental cash flow issues for pharmacies.

Waiting for prior authorization

Many pharmacies wait for prior authorizations before dispensing medication, while some payers refuse authorizations for more expensive medications, opting for different — or cheaper — medication.

Delays in medication

If a patient is required to change their medication, this can negatively affect their quality of life, also leaving them frustrated and dissatisfied. Those patients who decide to pay out of pocket to avoid delays in receiving their medication, assuming they can afford to, must make paper claim submissions for reimbursements — creating more work for pay centers.

Claims adjudication backlogs

Payers are unable to keep up with the soaring number of claims, and their approach to prior authorizations compounds what was already a major weak point in their process workflow. Now, many providers prescribing medications are required to renew their credentialing capabilities, further entrenching the claims adjudicate on progress.

Implementing automation solutions such as IA can help clear delays, streamline processes, ensure compliance and accuracy, and keep revenue cycles flowing seamlessly.

Real-Work Case Studies of Automated Healthcare Claims Processing

So, we know payers need to speed up the pharmacy claims adjudication process to keep revenue cycles flowing across the industry. And they need to ensure patients are getting the necessary medication easily and on time.

That’s where IA and RPA come in. With digital workers (also called enterprise AI agents) at the frontline combining RPA, BPM, process and task mining, AI, machine learning (ML), etc., you can transform operational efficiency. 

Reducing claims processing times

Select Health processes claims 95% faster with SS&C | Blue Prism® Chorus BPM. They reduced their processing time from 60 days to just 3 days, saving costs where their organization no longer needs to pay for delayed claims.

Top Benefits of IA/RPA in Healthcare Claims Processing

Efficient claims management

An AI agent (once called an RPA bot) can analyze claims data and check claim statuses, then update the organization’s revenue cycle management (RCM) system to reflect that gathered data, ensuring consistent information every time.

Relieving manual tasks

Automation relieves employees from repetitive tasks where their time could otherwise be spent on patient-focused work.

With IA, payers can optimize prior authorization and electronic claims processing, dramatically reducing the number of time-consuming manual tasks for employees, such as data keying.

Better experiences

Speeding up authorizations and payments and eliminating human-made errors improves customer satisfaction, boosts employee morale and ensures a better patient experience.

Digital workers:

• Operate 24/7
• Carry out monotonous tasks
• Perform accurately and consistently
• Work faster than a human
• Determine optimal pathways

How Does Automated Claims Processing Work Step-by-Step?

1. As authorizations and claims enter the payer organization, digital workers can capture key data and input it into systems in real time.
2. Where claims are submitted in a structured electronic format, they’re sent to a scanning mechanism while paper-based claims are converted into a digital format.
3. From there, digital workers can automatically sift through payer checks and balances to determine whether a prescribed medication is medically necessary and appropriate.
4. If data is missing, the digital worker triggers a request for this information.
5. Once all the information is gathered, the digital worker can deem the necessity of the prescription and pull the contracted price of the medication based on the provider’s National Provider Identifier (NPI).

Why Does a Health Insurance Company Need Automation?

Healthcare automation has the potential to revolutionize the healthcare payment industry, transforming and improving end-to-end processes for everyone involved.

Consider why health insurance companies might need intelligent automation. Digital workers can sift through historical and real-time data to learn, recognize patterns, and provide reliable insights. Some insurance providers even use these digital assistants to make routine business decisions.

Automation Potential Gains and Pitfalls for Payers

More payer organizations are recognizing the opportunity for using automation to clear claims processing backlogs and streamline processes across the revenue cycle.

IA gives payers:

• A scalable and intelligent pool of resources
• Digital workers to tackle their biggest operational pain points

Using disparate or unfit tools

Since automation is still rather new to the market, many payers make the mistake of tossing together free or open-source tools that are simply not fit for their purposes.

Rushing to deploy without a strategy

These organizations rush to implement their processes and divert employees to other tasks, then find these automation tools can’t cope with the change and complexity in fluid API environments.

Lacking the resources to monitor and adjust solutions

When these tools inevitably fail to keep up, the entire process automation breaks down, bringing everything to a grinding halt until the process can be rewritten to accommodate application changes.

Organizations are stuck with their staff now deployed elsewhere; meanwhile, the influx of healthcare claims continues until another massive backlog piles up.

The Benefits of Automating Insurance Claims Management

Integrating IA into your insurance system simplifies processes by placing them in an AI environment where information is processed quickly and securely. This automation environment provides various advantages to the health insurance claims management system:

• Processes are freed from human error and lapse times
• Third-party claims can be submitted through a standard process
• Regulatory compliance verification reports are generated automatically
• Decisions are more consistent and reliable
• Digital workers perform repetitive tasks rapidly and without error
• Cost and time savings are realized
• Workflow is optimized thanks to automating most claims decisions, leaving employees to focus on irregular claims or outliers

Improve Healthcare Claims Processing for Good

Intelligent automation has the potential to completely transform the healthcare industry for payers, from insurance claims to medical billing processes.

• Streamline workflows
• Free employees for patient-centric care
• Save time and money
• Reduce time-consuming repetitive tasks
• Simplify inefficient or legacy software
• Reduce errors and denied claims
• Build more complex, scalable processes end-to-end
• Integrate into new and existing systems without disruption

Overall, automation promises outstanding results when deployed correctly, and with SS&C Blue Prism Enterprise AI, we’ll help you get your digital workers up and running quickly and built for the long-term.