Automating payer audit tracking helped a US Health Plan auto-fix 50% of claims errors

Background

Our client, a Fortune 500 managed healthcare company based out of Minnesota, was losing close to $15 million annually due to mispaid claims. At the time, the client was processing approximately 283,000 claims annually. 24% of these claims were routed to an internal adjustment team, resulting in higher turnaround time and additional costs.

The Health Plan’s strategic initiative was to reduce claims expense. Firstsource’s robotic process automation solution helped prevent claims leakage while nurturing a deeper customer relationship.

Business challenge

The client’s complex manual adjustment process led to increased time to pay and poor payment accuracies, in turn leading to over/under payments to members.

In addition, the healthcare company used a reactive checking and monitoring process. The errors were identified and fixed only after claims were finalized and the checks were cut.

Firstsource solution

To tackle the fraudulent claims and identify erroneous claims, Firstsource designed an intuitive robotic process automation (RPA) powered Virtual Auditor solution that helps validate 100% of the claims. The automation solution helps in scrutinizing 74 different potential error opportunities and validating suspects in real-time.

Firstsource’s Virtual Auditor solution helped automate core processes, identifying, analyzing claims and maximizing recoveries. It helped the client analyze an average of 12000 global error databases on a monthly basis.

We were also able to help in identifying potential auto-correct logic for 50% of these global errors. Our solution completely transformed the claims audit process, proactively identifying errors, auto fixing, improving productivity and efficiency, while also reducing cost.

Firstsource has been providing claims adjudication services to the managed health care company, over the past several years, building a flawless claim processing environment, leveraging innovation, automation and process excellence.

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Connect with our team to understand how automation and analytics-led transformation can reduce costs and manual errors – all while improving efficiency and the overall Member and Provider experience.

Business impact

Our solution delivered impressive results including:

  • Improved overall quality and TAT
  • Seamless claims tracking of  with a single click while eliminating unnecessary claim routings
  • Improved OAR (Overall Accuracy Ratio) Quality from 99.32% to 99.82%
  • DPMO (Defects Per Million Opportunities) reduced from 5689 to 1839

40%

of adjustment team’s effort automated


50%

of errors auto identified and auto fixed by Virtual Auditor


66%

Volume reduction in internal adjustment


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