Top-Line Benefits of Robotic Process Automation for Claims Management

June 6, 2020


Claims management requires substantial data entry, evaluation and appeals and is time and labor intensive. The 2021 CAQH Index identifies it as the most time-consuming transaction for providers using manual processes. Not surprisingly, 43% of health systems that leverage robotic process automation (RPA) use it for claims management, according to new Becker’s Healthcare research.

With the fiscal pressure of ongoing staffing shortages and significant patient insurance coverage changes, it makes sense to explore how to optimize the end-to-end process of managing insurance claims.

Top 5 RPA use cases

  • Eligibility: 59%
  • Authorization: 57%
  • Claims/follow up: 43%
  • Charge capture: 39%
  • Payments/collections: 39%

Why today’s claims management is so complex

Insurance claims management organizes, bills, files, updates and processes medical claims related to patient diagnoses, treatments and medications. It directly affects accounts receivable, reimbursement and cash flow. It has also become increasingly complex. Stringent contract rules and frequent authorization and eligibility changes make payer requirements a moving target. This places a tremendous administrative burden on the revenue cycle team and results in ample opportunity for errors and delays.

RPA streamlines and speeds claims management

RPA is software technology that replicates many actions of a staff member to complete routine administrative and clerical tasks without user intervention. Programmed software robots (bots) run continuously in the background, ensuring that predictable, repetitive tasks are performed without the need for human intervention. Automation works around the clock, executing tasks in a fraction of the time it would take a human. RPA improves staff productivity and frees time for higher-value work, helping to accelerate cash, reduce accounts receivable days and proactively intervene on denials.

Overcoming costly claims-management challenges with RPA

Optimizing claims management is vital to a healthcare organization’s financial health. Here are four top-line-boosting benefits of automation for claims management:

1.) Improve first-pass clean claim rate.

Clean claims, free of errors and expected to be ready for processing and payment without needing additional input, are often viewed as a key revenue cycle management performance metric by hospitals and health systems. Submitting first-pass clean claims means fewer denials, less time in accounts receivable and faster payment to your healthcare organization. RPA bots can take over critical tasks for clean claims, such as copying and entering data from one system to another, reconciling and verifying claims data, and opening and gathering data from emails. While time-consuming and error-prone when done manually, automation eliminates human error and processes data exponentially faster.

2.) Accelerate claim status follow-up.

Eliminating the need to manually check claim status frees up 25 minutes per inquiry that your team could be spending on other revenue-generating activities. RPA bots go directly to a payer’s website and curate enriched claim status information beyond a standard 277 response. Claim status details can then be prioritized and integrated into your electronic health record (EHR) system, driving a more efficient workflow. This helps reduce accounts receivable days and improves staff utilization by allowing more timely intervention on any claim follow-up and potential denials.

3.) Streamline denials and appeals management.

RPA brings much-needed process efficiency to denials and appeals management. RPA can be leveraged to prevent front-end denials by automating eligibility and prior authorizations. It can also accelerate appeals processing by pulling medical records from your EHR into a templated appeal letter as soon as a denial is posted. Automating denials and appeals management eliminates human error, optimizes staff productivity and expedites the overturning of denials into recovered payments.

4.) Enhance employee satisfaction and utilization.

A 2022 Data Brief from the American Hospital Association makes clear that workforce-related challenges are still among the most critical financial and operational pressures facing hospitals and health systems. Additionally, recruitment expenses are up. Revenue cycle leaders face the dual challenge of doing “more with less” while also ensuring retention. RPA improves staff productivity and satisfaction by eliminating the mundane, manual tasks of claims management and improving access to meaningful data. RPA empowers teams to focus on high-value, strategic work that drives financial health and sustainable workforce wellbeing.

Expected outcomes of RPA adoption for claims management

Robotic process automation delivers productivity, accuracy, and process efficiency benefits to multiple claims management processes while helping healthcare organizations lower costs, submit clean claims, and speed up revenue collection. Here are a few useful resources with more information about automating the healthcare revenue cycle:

Discover how R1’s Best in KLAS automation solutions can help your healthcare organization simplify complex, labor-intensive workflows to maximize revenue recovery and boost efficiency.

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