Re-engineer, automate to avoid claims errors

By Manjunath; Practice Lead, Claims Adjudication; Sagility

Healthcare claims management is a focal point of potential transformation for payers and providers alike. The global healthcare claims management market is expected to reach $13.93 billion by 2023, up from a valuation of $10.16 billion in 2017, according to MarketsandMarkets. According to the Council for Affordable Quality Healthcare, manual claims processes can cost up to $4 more than equivalent electronic transactions. And aside from the significant cost savings, efficient and accurate claims management has a uniquely front-line impact of enhanced member/patient engagement and Star ratings.

The healthcare industry has made advancements in automating claims-related business processes, with today’s tools and process innovation bringing breakthrough results. Here are three ways claims automation and workflow reengineering can address errors for significant business impact:

• Data quality, though an elementary task in nature, is one of the key drivers for mispayments. While optical character recognition (OCR) addresses much of the data capture process, the need for manual intervention cannot be ruled out completely. Any data quality inaccuracies upstream can compound for mispayments that cause significant downstream effort, increased costs, and provider dissatisfaction. Automation and reengineering can drive data integrity to reduce this effort.
• The benefits that process reengineering can bring to claims operations include knowledge sharing between geos and provider payer. As an example, Sagility provides claims reengineering process improvements (such as education and training via a shared drive integration with our Manila team), for one of our payer clients. For example, Sagility provides claims reengineering process improvements (such as education and training via a shared drive integration with our Manila team) for one of our payer clients. Per the process improvement, Sagility stores Bangalore-originated customer service notes on claims correspondence to providers.  This information makes our Manila contact center professionals better educated and equipped to handle escalated cases. The projected end result will be:
  • A better provider experience, with reps more informed and educated on how to handle escalated cases
  • Improved first call resolution
  •  Fewer escalations
  • Reduced transfer rate
  •  Improved provider education to identify trends that can improve claims cycle times

• Rework on the rework. If a claim is resubmitted for rework, for example, for a grievance or compliant, sometimes a miskey or mistake is made. This is when a customer complaint may occur and negatively impact their relationship with the payer or provider..  The first-time-right approach avoids this scenario.  Sagility has completed retro system updates for a major healthcare payer, and additional information/balance billing contributes to approximately 2.8% of the overall reworks (enterprise level reworks hover around 4 to 5%), there are simple ways to address these claims in the first instance. Automation could help reduce the claims that fall for rework, with reduced provider interactions and faster claims resolution.

Ultimately, all of these claims initiatives go a long way toward improving accuracy, reducing turnaround time, and cost-containment. Looking ahead, there will be even more technology innovation to map and improve ecosystem challenges in the process.