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Intro to RPA in Managed Health Care Claims Processing

Programing intricate processes that are required to automate complicated, dynamic claims in a mainframe claims processing platform is too slow and expensive.  Since most of the decisions necessary to automate a MHC claim are rules based, use structured data, and relate to relatively stable processes, RPA’s non-code invasive nature makes the SDLC process unnecessary, which greatly enhances the speed RPA developers can create claim bots, far less expensively than any other automation method.

As the automation rate goes up, the claims that are left to automate are increasingly not rules base, use unstructured data, and have more fluid processes.  Cognitive based technologies become increasingly necessary to deal with non-rules based decisions, unstructured data, and dynamic integration with claim processing teams.  A Center of Excellence (COE) can facilitate and standardize, governed RPA program at scale to other parts of the MHC’s operation.  Beyond the COE, the most mature enterprise MHC RPA programs will evolve operations into an Intelligent Operation made up of hybrid bot/human teams under the same management governed by a COE.  This is the pinnacle of automation augmentation!

RPA can add 10% to a MHC mainframe claim platform’s adjudication rate.  The MHC claim adjudication rate is the percentage of claims that do not require human intervention to apply contract benefits for either a payment or denial of a medical claim.  On average, claims can cost over $4 each to manually finalize and far more to correct retrospectively via adjustment.  For large MHCs, even one percent of claim automation represents millions in claim costs saved per year.  For medium sized MHCs, hundreds of thousands can be saved for each additional percent of claims that are automated.  This is one of the reasons why RPA has been used in MHC claim processing and related function like adjustments for ten years or more.

In 2015 a Fortune 100 MHC automated over 13 million claims with RPA saving conservatively $30 million dollars on a one-million-dollar budget.  This MHC’s manual processing is significantly outsourced.  If these claims where processed with onshore processors, the saving would be over $50 million.   This does not even include adjustments, related correspondence automated, increased quality, and reduced customer abrasion savings.

Contact Matt Gallo at matt.gallo@automatework.com for our white paper on RPA in MHC Claims Processing.