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Blog | Mar 29, 2023

Intelligent Automation for Payer Health Insurance Claims

healthcare insurance claims automation
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Anyone working in the healthcare industry, or those relying on prescription medication, are probably familiar with how slow and often inefficient health insurance claims processing can be. With manual data entry and delays caused by error-prone work and inefficient bottlenecks, more healthcare organizations are looking to intelligent automation (IA) solutions, including robotic process automation (RPA), to improve end-to-end processes.

The healthcare industry is facing challenges with claims processing: from manual repetitive tasks and inefficient legacy software to missed deadlines, denied claims, and mistakes. But with SS&C Blue Prism’s IA and RPA solutions, healthcare providers can build complex, scalable, end-to-end claims process automation, integrated with existing systems to avoid disruption.

Challenges to Healthcare Payer Organizations

Currently, healthcare payer organizations are struggling to keep up with the vast amount of claims processing overwhelming their people. They need better ways of creating and filling claims by automatically extracting data from internal and external systems, adding the relevant medical codes, retrieving prior authorization and validation, and finally, submitting the claims and sending them to the payer to receive payouts.

Ultimately, payers are looking for better reliability, cost-savings, patient and employee satisfaction, and better overall workflow.

Manual processing

Payer organizations handle thousands of medical claim processing daily, and the majority still rely on manual processes to pull prescriptions off the line and physically key data into their systems. Those claims come in various formats, many of which are handwritten.

Then, even when authorizations are processed before the patient picks up their prescription, there are often problems with processing the payments. There are numerous examples where payments are years late due to broken adjudication processes, causing detrimental cash flow issues for pharmacies.

Prior authorization

Many pharmacies are waiting for prior authorizations before they dispense medication, while some payers refuse authorizations for more expensive medications, opting for different—or cheaper—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, thereby creating more work for pay centers.

Claims adjudication backlogs

The healthcare industry is grappling with a backlog of claims adjudication processing. Payers are unable to keep up with the soaring number of claims, and their approach to prior authorizations is only compounding what was already a major weak point in their process workflow. And now, many providers prescribing medications are required to renew their credentialing capabilities, further entrenching the claims adjudication progress.

It's clear the payer-pharmacy claims adjudication process is broken and the healthcare ecosystem—payers, providers, pharmacies, and patients—are all suffering because of it. Implementing IA solutions such as RPA can help clear delays, streamline processes, ensure compliance and accuracy, and keep revenue cycles flowing seamlessly.

Optimizing healthcare revenue cycle performance with intelligent automation
Optimizing healthcare revenue cycle performance with intelligent automation

RPA in 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.

Intelligent automation (IA) is a cognitive AI-based technology with digital workers at the frontline combining RPA, business process management (BPM), process and task mining, and machine learning (ML) to transform operational efficiency. SS&C Blue Prism’s RPA provides a secure and scalable digital workforce, blending employees with systems to optimize workflows across the organization.

Benefits of RPA in healthcare

In the healthcare industry specifically, RPA bots can perform claims management by scanning claim statuses and updating the organization’s revenue cycle management (RCM) system to reflect that gathered data. The results are efficiency gains and better consistency of information. Plus, RPA 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. This speeds up authorizations and payments and eliminates human-made errors, meaning better cost-savings and huge improvements in employee satisfaction and patient experience.

Digital workers in healthcare claims management

Digital workers operate 24/7, carrying out monotonous tasks like data entry with far greater speed and accuracy than their human counterparts, and determining optimal pathways for processes across the healthcare revenue cycle.

As authorizations and claims enter the payer organization, digital workers can capture key data and input it into systems in real time. 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.

From there, digital workers can automatically sift through payer checks and balances to determine whether a prescribed medication is medically necessary and appropriate. If data is missing, the digital worker triggers a request for this information. 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).

Example of RPA in prior authorizations

SS&C Blue Prism worked with a large payer organization to automate their entire pharmacy claims adjudication process, from faxing to point of service and payment adjudication. In deploying our digital workers, our client reduced the average time for medication prior authorizations from six to 10 business days to only four to five hours.

Digital workers accurately read payment requests and medication approvals are now rendered within fifteen minutes. Overall, this saved the business more than 10,000 hours of employee time per month, translating into significant cost reduction.

Implementing RPA into healthcare claims management can drastically improve patient quality of life, helping them get the life-impacting prescriptions they need. But RPA also helps healthcare providers. Doctors are paid sooner, easing payment backlogs and ensuring money flowthrough in the healthcare system, and patient appointment scheduling and form filling is streamlined so employees are freed from tedious tasks.

Health Insurance Claims Automation

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

Consider why a healthcare insurance company might need intelligent automation: RPA bots can sift through historical and real-time data to learn, recognize patterns, and provide reliable insights. Some insurance providers even use these bots to make routine business decisions.

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

Automation Potential for Payers

IA deployment has been relatively slow within payer organizations, where healthcare providers have embraced digital workers across front- and back-office functions. Increasingly, however, 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 to tackle their biggest operational pain points. Just as importantly, organizations need to ensure they’re deploying the right technologies in the right spaces.

Mistakes payers should avoid

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. 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.

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.

That’s why payers need to implement intelligent automation: enterprise-wide, scalable, and secure, so their automations are integrated with additional AI capabilities like optical character recognition (OCR) and intelligent document processing (IDP).

Scaling your processes

Intelligent automation has the potential to completely transform the healthcare industry for payers, from insurance claims to billing. It streamlines workflows, freeing employees to focus on patient-oriented tasks, and saves time and money for the organization overall.

Using RPA bots to run time-consuming, repetitive tasks and simplify inefficient or legacy software, there will be fewer errors and denied claims. Plus, IA solutions can help healthcare providers build more complex and scalable processes end-to-end so they can integrate into new and existing systems without disruption.

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

Optimizing healthcare revenue cycle performance with intelligent automation
Optimizing healthcare revenue cycle performance with intelligent automation

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