AI, RPA Improves Dental Appeals, Boosting Efficiency by 30%, Accuracy by 50%
About the Client
- Plan Type: Dental
- Plan Size: 5M+ members
- Geography: National
Issue
A top 5 national dental plan sought to improve accuracy and reduce costs in its appeals intake process. But the plan faced major hurdles.
Manual reviews of grievances, complaints, and appeals were labor-intensive and error-prone, leading to frequent misclassifications, misrouting, and processing delays. The high volume of auto-forwards further strained operations.
Variability in data formats and case complexities made standardization difficult, resulting in inaccurate classification and routing. This inconsistency weakened the efficiency and reliability of the appeals intake process, negatively impacting member and provider experiences.
Delays from manual processing fueled dissatisfaction, escalated grievances, and drove up operational costs, ultimately harming the payer’s financials and reputation.
Action
Sagility proposed a phased approach to overhaul the grievance and appeals intake process by streamlining procedures and deploying automation.
- In phase one, Sagility conducted audits to understand the root causes of the misclassifications and inefficiencies in the intake process. We identified patterns and common errors in the manual intake process that can be rectified by process redesign and automation.
- In phase two, Sagility presented a proposal to expand the project scope to include processes before classification. Sagility introduced an integrated AI and RPA solution with a natural language processing (NLP) engine.
This AI-driven RPA solution analyzed keywords and context within client grievances and appeals cases, enabling accurate classification and routing of cases. The NLP engine also helped differentiate between expedited and non-expedited cases.
Impact
The RPA solution executed the necessary process steps for intake and routing, reducing average handling time and manual interventions while improving accuracy by minimizing human errors.
This led to lower operational costs, enhanced member/provider experience, and helped the dental plan exceed quality service level agreements in the appeals processing operations.
- ~50% increase in accuracy by reducing misclassification and improving routing.
- ~30% boost in efficiency, resulting in faster resolution of grievances and appeals.
- Enhanced provider and member experiences by improving accuracy and reducing processing time.
By addressing the dental plan’s foundational issues, Sagility reduced misclassifications, the number of auto-forwards and improved the overall accuracy of the intake process while enhancing efficiency and overall member/provider satisfaction.
increase in accuracy
boost in efficiency
