Claims Processing

Boost claims processing with RPA. Automate data validation, claims verification, and document handling to reduce errors, delays, and costs while enhancing compliance and customer satisfaction.

Optimising Compliance Reporting with Robotic Process Automation (RPA)

The term is a bit ambiguous because “Compliance Reporting” can mean “a company’s adherence to regulatory compliance and the monitoring thereof” or “reporting on the compilation, verification and submission of documentation according to a required standard or requirement.” Fortunately, in the world of RPA, this makes no difference. It will help you with both!

Robotic Process Automation (RPA) is crucial for improving compliance reporting and providing efficiency and accuracy, which are essential for data-driven organisations. This technology optimises compliance processes by tackling several key challenges:

  • Data Entry Discrepancies: Data entry and report generation are prone to typos, misclassification, and calculation errors. These inaccuracies can lead to non-compliance, fines, or other penalties.
  • Time-Consuming Processes: Gathering data and creating reports manually is labour-intensive and time-consuming, causing delays in meeting compliance deadlines and reducing overall organisational efficiency.
  • Inconsistent and Delayed Reporting: Manual processes can lead to inconsistencies in report formats and data representation across different periods, complicating trend analysis and issue identification.
  • Difficulty in Maintaining Audit Trails: Tracking changes and maintaining comprehensive audit trails can be challenging without automated methods, leading to oversights and difficulties during audits.
  • Lack of Real-Time Monitoring: Manual reporting typically provides static snapshots of data, limiting the ability to monitor compliance in real-time and potentially missing opportunities to address issues promptly.
  • Risk Mitigation: Monitoring, identifying and tracking discrepancies or non-compliant activities is often tedious, laborious, and difficult to maintain consistency with when defined according to pre-determined standards.
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Even for reporting in general, RPA workflows are capable of collecting data from multiple sources, performing calculations, and formatting the outputs. Subsequent reporting information, according to predefined templates and where interaction is needed at specific points, alerts the relevant parties that their attention is required.

How Robotic Process Automation functions with Processing Claims

Robotic Process Automation (RPA) automates routine and rule-based tasks in claims processing, such as verifying claims, extracting data, and processing documents. The technology simulates human interactions with various systems and databases to expedite claims handling.

In the claims processing workstream, RPA automates activities like data validation, claims verification, and updating client records. Task bots interact with multiple systems to process claims efficiently, following predefined rules and procedures. This automation reduces the need for manual intervention, streamlining the overall process.

Benefits of using RPA for Claims Processing

  • Efficient Claims Verification
    Automation modernises claim verification by automating data validation, policy checking, and fraud detection tasks. An RPA bot swiftly analyses claims data, cross-references it with policy details, and even identifies potential fraud indicators, allowing claims professionals to focus on complex cases.
  • Automated Documentation Handling
    Proficient document management is fundamental for expediting claim processing. Process Automation facilitates document processing by extracting pertinent information, systematically organising claim files, and verifying complete documentation, reducing processing duration and augmenting document precision.
  • Enhanced Communication Processes
    Managing “open” communications between the divisions and the client during the claims process demands precision, consistency and timeliness. RPA can automate response and status communications by sending status updates to claimants, notifying relevant stakeholders, and generating response templates.
  • Streamlined Claims Adjudication
    RPA streamlines claim adjudication by automating the assessment of claims against policy terms, calculating settlements, and generating adjudication reports. An RPA bot efficiently handles routine claims, allowing claims professionals to focus on more complex cases requiring human judgment.
  • Optimised Fraud Detection
    Since Fraud Detection is a critical consideration in claims processing, RPA, combined with AI and machine learning, can automate aspects of claims processing to analyse claims data against predefined fraud indicators proactively, flag suspicious patterns, and even initiate investigations.
  • Automated Payment Processing
    RPA can be enabled to interact with financial systems to automate payment processing by calculating settlements, generating payment instructions, and ensuring timely disbursement. This accelerates the claims settlement process and minimises errors in payment calculations.
  • Efficient Claims Review Processes
    Conducting reviews for denied or disputed claims involves meticulous scrutiny. By automating the initial assessment steps, such as collecting review-related data, scheduling review meetings and generating comprehensive review reports, RPA can ensure a standardised and efficient claims review process.
  • Customer Satisfaction Surveys
    RPA automates the distribution and analysis of customer satisfaction surveys, providing claims professionals with valuable insights into claimants’ experiences and sentiments.

Transforming Claims Processing: RPA in Action

We reflect on some examples that show the impact of RPA on claims processing through real-world scenarios.

Case Study 1: RPA Enhance Efficiency in Electronic Health Records and Patient Care

A healthcare consultancy firm specialising in Electronic Health Records (EHR) solutions uses Robotic Process Automation (RPA) to streamline manual processes in hospitals and healthcare systems for their customers. With decades of experience implementing EHR platforms, the consultancy utilised Fortra Automate RPA to connect disparate systems and automate high-volume tasks such as claims processing, billing, and appointment scheduling.

For a healthcare entity, the consultant integrated the EHR system with a third-party vendor for patient reimbursement, previously a labour-intensive process involving up to 300 daily updates and thousands of monthly updates. Automate was used to create a bot that seamlessly monitors, ingests, and processes files, updating patient records and making necessary changes in an hour—compared to the four-plus hours required using manual inputs. The process is now entirely autonomous and error-free.

Other projects using Automate include automating medical maintenance processes and report delivery in health systems. These projects supported employees with bots that executed tasks such as updating medical records and notifying referring physicians.

Full case study can be found here

Case Study 2: Streamlining Claims Processing with RPA in large Healthcare provider

A large not-for-profit healthcare organisation faced challenges with claims processing due to the complexity and volume of claims from its seven medical facilities and outpatient centres. Each facility generates hundreds of in-patient and out-patient claim files daily, but its claims management system, ePREMIS, can only handle one file per type daily.

Previously, the Patient Financial Services (PFS) department handled claims manually, which was time-consuming and prone to errors and delays. When claims did not match the summary report, personnel had to spend significant time identifying unprocessed claims.

To streamline the process, the organisation turned to RPA process automation software. The organisation automated daily transfers of hundreds of claim files to an FTP server, where the bot joined inpatient and outpatient files and transferred them securely to ePREMIS. The bots also facilitated auditing by comparing processed claims with a summary report and generating audit reports for PFS personnel to identify missing claims.

Over a year, the team developed and implemented over 40 RPA tasks, centralising control over thousands of daily file transfers and improving data consistency and timeliness. The new solution saved the team about 10 hours a week in manual work and 5-10 hours weekly in centralising FTP processes and using RPA’s email capabilities for auditing and notifications.

Full case study can be found here

Many businesses have a strategic advantage in claims processing due to robotic process automation, which improves efficiency and accuracy.

 

Contact SmartTechNXT for a free consultation on how RPA can transform your claims workflows.