Corrected Claims RPA Saves Leading Blues Plan $1 Million
About the Client
- Plan Type: Blue Cross Blue Shield Multi-Line (Commercial, Medicare Advantage, Medicaid, ASO)
- Plan Size: 5M+ members
- Geography: California
Issue
A leading Blue Cross Blue Shield plan required an end-to-end automated solution to streamline operations and achieve substantial cost reductions. The payer required a partner that could bring technical and human expertise to the project to ensure a fast rollout and long-term success.
The payer explained that the organization had significant difficulty managing the volume and workflow of its corrected claims process, which pertains to a resubmitted insurance claim addressing errors or omissions in a previously submitted claim. The corrected claims segment represented a considerable portion of the payer’s operational workload and suffered from challenges that caused inefficiencies and inaccuracies. In addition, the Blues plan wanted claims staff to focus on more complex tasks that could drive revenue, reduce provider abrasion, and improve member satisfaction.
Finally, although the Blues plan wanted to implement technology solutions, the organization’s team lacked the internal expertise and infrastructure to do so.
Action
Sagility partnered with the Blues plan to conduct a comprehensive analysis of the payer’s claims processes. The assessment revealed that the corrected claims area represented a significant opportunity for technological transformation.
Using advanced technology and process innovation, Sagility designed and implemented a robotic process automation (RPA)-driven solution tailored to improve the end-to-end corrected claims segment.
Claims Troubleshooting
A 22-bot solution, with plans to increase that number to 50, effectively addresses both medical and hospital claims that require corrections to the original submissions. The automation validates the information in the claims by accessing the Clinical Information System (CIS) and the CIS Patient-Reported Outcome to determine if any further actions are needed based on the original payment, including adjusting the amount paid out. This approach ensures enhanced precision and consistency in claims handling, significantly reducing errors traditionally associated with manual processes, such as incorrect patient details, missing or incomplete documentation, and inaccurate coding.
End-to-End Process Improvement
The solution eliminates manual interventions for in-scope corrected claims, enabling complete automation using RPA. The automated process entails a detailed comparison of original and corrected claims, identifying discrepancies or changes, and integrating them seamlessly into the claims lifecycle. This end-to-end processing capability enhances operational efficiency, reduces processing time, and ensures compliance with the required standards.
Impact
By implementing Sagility’s end-to-end RPA solution, the Blues plan realized significant improvements in operational efficiency and accuracy.
Automation enabled 50% of the overall corrected claims volumes to be processed entirely by bots, eliminating the need for manual intervention and allowing staff to focus on more complicated issues. The solution was meticulously developed to guarantee operational excellence, achieving an unprecedented 100% accuracy rate.
With the implementation of Sagility’s end-to-end RPA solution, corrected claims processing could operate at scale, positioning the plan at the forefront of technological adoption, with these key results:
- 100% Accuracy: Claims processing handled by bots exhibited flawless precision, effectively eliminating errors and ensuring compliance with regulatory and process standards.
- 50% Completion Rate: With automation effectively streamlining the entire process, the plan completed an impressive 50% of claims using RPA, setting an efficiency benchmark for Blues plans.
- Annual Cost Savings of $1 Million: By minimizing manual intervention and optimizing resource allocation, the initiative is expected to yield substantial financial benefits, translating to $1 million in annual savings.
- 3.5 Million Claims Processed Annually: With the enhanced automation capacity, the Blues’ system can handle a staggering 3.5 million claims annually.
Sagility’s RPA solution represents a transformative step forward in claims management, showcasing the power of automation in delivering scalable, accurate, and efficient processes that meet and exceed client expectations.
These accomplishments reflect how human expertise supported by the strategic implementation of automation technologies can revolutionize claims processing. By embedding precision, efficiency, and scalability into operations, Blues plans can unlock new levels of productivity while delivering unparalleled accuracy.
bot-enabled accuracy, eliminating errors and ensuring regulatory compliance
completion rate with the help of automation to streamline the entire process, setting an efficiency benchmark
annual cost savings by minimizing manual intervention and optimizing resource allocation
claims processed annually with enbanced automation
