Digital Workers on the Frontline of Healthcare Claims Processing

More than 294 million Americans have healthcare insurance coverage, and just over two-thirds of those people have private coverage. This means that millions of healthcare claims are filed every day, putting a significant strain on healthcare facilities.

Processing healthcare claims has traditionally been a manual process that is fraught with challenges. It’s time-consuming, prone to error, and difficult to scale as patient numbers grow. However, with today’s technology at our disposal, it’s time for a new way to process claims.

Digital workers can significantly cut down on the length of time it takes to process claims, making the process faster and free of error. This results in happier employees and improved customer satisfaction.

What Are Digital Workers?

Digital workers are software bots that are designed to perform specific tasks that are typically repetitive and rules-based. When it comes to healthcare claims processing, these are tasks such as pulling data from multiple systems and sources, auto-filling forms, verifying information, auto-adjudicating claims and flagging complex claims for a human to examine more closely.

These digital workers can perform tasks in seconds, work 24/7 and keep claims processing moving forward at a significantly faster speed than if it was done manually. Plus, each digital worker can be assigned a specific set of tasks related to a particular area of claims processing, further increasing the efficiency of the overall process.

The Benefits of Using Digital Workers to Process Claims

One of the primary misconceptions of the use of digital workers is that they will replace human workers. The reality is that digital workers are designed to work alongside their human counterparts. This allows human workers to focus on more high-value tasks and customer interaction, leaving the digital workers to take care of the tedious tasks that used to take up too much human time and energy.

There are many benefits to using digital workers for healthcare claims processing. These include:

  • Processing claims in a matter of days or weeks, rather than months
  • Eliminating the error that inevitably comes with human data retrieval and form-filling
  • Reduction of processing costs of up to $25 per claim
  • Flagging of complex claims for human processing
  • Making edits to basic claims information, such as age, address, and ID
  • Communicating and updating other systems, including legacy systems
  • Recovery of revenue that may otherwise be lost
  • Increased customer retention
  • Increased satisfaction among employees

Claims Processing Use Cases

There are many ways in which the automation of healthcare claims processing can be used to benefit employees and patients. The following use cases show the power of digital workers and what they can do for you.

Errors associated with missing or incorrect data

It is common for claims to have missing or incorrect information, particularly if the information has been input manually. This may be something as simple as an incorrect address or ID number or the age of the patient being left out. It can take hours for human workers to go through each of these claims manually to find the correct information.

Digital workers can comb through the various claims screens and data sources quickly and efficiently, finding the correct information and editing the claim in seconds. This makes it possible to edit hundreds of claims a day with ease.

Healthcare claim denial

As many as 30% to 40% of healthcare claims are denied because they are not in compliance with regulations. This can amount to a significant loss of revenues for a healthcare facility.

If a patient’s claim is denied, digital workers can go through the data and information associated with the claim, review the claim, identify any issues that are present and identify exceptions related to compliance. This can help avoid non-compliance issues with a claim and allow a healthcare facility to potentially recover millions of dollars in accounts receivable.

Adjudicating complex claims

Many healthcare claims are complicated, particularly in situations where a person is covered by their own insurance plan and that of their spouse. This requires a significant amount of coordination to ensure everything is adequately covered without the payment going over the amount of the claim.

While these complex claims must be overseen by a human, digital workers can go through the claim and its attached files (including the summary of benefits, explanation of benefits and the benefits grid) and put all the required documents in the proper folder. This reduces the amount of time it takes to adjudicate these claims and frees up the time of the human worker to focus on the adjudication decision at hand.

Now is the Time for Healthcare to Embrace Digital Workers

With an aging population and COVID-19 adding to the increase in patient numbers, it is more important than ever for healthcare facilities streamline their claims processing to make it faster, more efficient and more cost-effective. Digital workers have the power to ease the pressure on human workers, so they can put their focus where it belongs—on the patients.

To find out more about how digital workers can make healthcare claims processing easier, faster and more cost efficient, reach out to Ampliforce’s automation team today to get started.