AI and RPA Transform Appeals, Reducing Cost by 30%
About the Client
- Plan Type: Medicare Advantage
- Plan Size: 10M+ members
- Geography: National
Issue
A national health plan struggled to process Medicare Advantage appeals, facing excessive costs, low accuracy, and lengthy turnaround times.
The complex appeals process stemmed from vast unstructured medical documents requiring meticulous review. The manual approach necessitated a large team, causing inefficiencies, delays, and frequent errors.
These inaccuracies had serious consequences:
- Poor Star Ratings led to financial penalties, diminished reimbursement rates, and lower member enrollment.
- Dissatisfied members complained to Medicare and left negative survey feedback.
- Providers frustrated by delays and inaccurate appeal resolutions faced operational challenges and increasing dissatisfaction.
The insurer struggled to balance appeal processing while ensuring accuracy and efficiency. The manual workload hindered streamlining, while ineffective automation caused delays, high costs, and regulatory exposure.
Action
Sagility reviewed the appeals process, identifying inefficiencies and automation opportunities. Our team implemented a re-engineered, automated solution, streamlining intake through final decision-making.
The transformation involved three key steps:
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Impact
The automated process enhanced operations, financial performance, and member, provider satisfaction.
Key impacts included:
- ~30% decrease in appeals processing time, allowing higher volume handling, lowering costs and enhancing service levels.
- ~4% boost in Star Ratings through improved accuracy and faster processing, driving financial performance by attracting more enrollments and reducing CMS penalties.
- ~75% reduction in Medicare complaints thanks to improved accuracy in appeals processing, minimizing financial penalties and enhancing reputation.
- Streamlined processes improved satisfaction for members and providers, with faster appeal resolutions and quicker reimbursements, leading to higher retention and positive referrals.
- AI and RPA automation eliminated data entry and other manual errors.
- Appeals were quickly directed to the right personnel, reducing classification time.
decrease in appeals processing time
boost in Star Ratings, attracting more enrollments and reducing CMS penalties
reduction in Medicare complaints due to improved appeals processing accuracy
