Claims Processing

Introduction: Healthcare organizations face significant challenges in managing complex claim processes, where slow and inaccurate billing result in increased workloads, delayed payments, and, in the worst cases, timely filing denials. A low speed and high cost to collect can cripple healthcare providers financially, compromising the quality of care. This case study explores how Robotic Process Automation (RPA) was implemented to revolutionize the claims scrubbing process, achieving improved accuracy, efficiency, and ensuring clean, timely claims.

Challenge: A leading national healthcare provider, processing 50,000 insurance claims per month, grappled with inefficiencies rooted deep within their manual claims generation process. Billers, constrained by their limited permissions compared to the Intake team, found themselves repeatedly correcting the same issues in the master patient index for each claim and future claims for a given patient. This workaround, although deemed the path of least resistance in the short term, was highly inefficient and unbeknownst to the RCM director. Furthermore, the variability in the payor mix led to scalability issues, with some billers becoming overburdened and others underutilized, depending on their payor-specific expertise.

Solution: Simple Fractal's in-house subject matter experts were deployed to engage with the client and design a solution to encompass business rules for their provider specialties, payor contracts and local rules and regulations. Starting with a subset of high-volume payors with less complex rules, we employed an informed iterative approach to gradually extend bot coverage, prioritizing risk management and economic feasibility. This solution looked at every data point of the claim (rendering, referring, authorization, insurance eligibility, diagnosis, CPT combinations/same day procedures, etc.) and supporting documentation across 57 payor plans to ensure a clean claim was going out on the first pass.

Impact: The implementation of our digital labor solution led to a 90% reduction in FTE requirements and demonstrated scalability, processing 520,000 claims in the current year — a 30% growth without increased overhead costs. The detailed bot reporting not only identified upstream process issues but also helped preempt denials by early identification of patterns in claim scrubbing issues, significantly reducing errors and increasing claims accuracy.

Conclusion: The successful deployment of RPA for generating clean and compliant claims has resulted in reduced staff turnover, lower hiring needs, and accurate clean claims paid on the first pass, alongside a comprehensive audit versus manual auditing, achieving a 10X ROI. With plans to expand the set of payors and customize our secondary billing solutions further, the healthcare provider is also advancing the automation of the prior authorizations function (already 80% automated) and refining payment posting automation. These initiatives are set to work synergistically, positioning the organization to manage increased claims volumes more efficiently and maintain a higher standard of service for patients. This case study underscores the transformative potential of RPA in overcoming healthcare industry challenges, serving as a model for other organizations seeking to enhance their claims processing capabilities.