The challenge: Manual processes plus labor shortage equal massive work backlog
Monitoring the status of claims submitted to health insurers is critical so that providers can take appropriate actions depending on whether a claim will be paid, suspended or denied. Our client, a large regional hospital in the southern US, had a slow and complex manual process for claims verification and validation and posting crossover claims (MESA). The hospital’s revenue cycle management professionals had to toggle between different internal systems to identify outstanding claims, then either login to payer web portals or call payers directly to look up a claim’s status.
This time-consuming, inefficient process had resulted in a backlog of more than 7,000 claims requiring status checks. The claims represented more than $5 million in revenue, so it was vital to understand their status. Yet the hospital estimated it would take months and months to accomplish that task, a project for which it didn’t have the necessary resources.
The solution: Automating manual process delivers quick return
We collaborated with our client to identify the claims status checks as an excellent candidate for a first automation project. Deploying an RPA solution, or software bot, would net a relatively quick return for the hospital. It would also solve an ongoing problem and create a foundation for additional automated solutions.
We built the bot to automate six critical processes across multiple payers. The bots emulate all the steps the provider’s staff were taking to toggle among internal and payer systems to request the status data and update the relevant systems. The Firstsource team delivered the software bot in about 75% of the time it typically takes to develop these solutions because our team already understood our client’s systems, applications, and workflows. That knowledge also helped us structure the bot so it could be deployed with the minimum possible disruption to our client’s processes.
The results: Returning time, money and satisfaction to the provider
We deployed the bot on a weekend. When our client’s revenue staff reported to work on Monday, the bot had checked and updated the status of all 7,000 backlogged claims. That enabled our client’s revenue management staff to realize potentially more than $5 million in revenue.
The bot continues to roll. It carries out the entire claims status process without requiring human intervention and at several times the speed humans can achieve. That’s enabled our client to redirect its revenue staff away from mundane tasks to higher value, revenue-generating strategic activities. These include tasks requiring human expertise and decision-making skills, including following up on claim denials. The automation solution has also enabled our client to avoid hiring and training additional staff.
As a major healthcare vendor, Firstsource monitors payers’ updates and changes to their process and data requirements; and automatically adjust our software bots as necessary to ensure uninterrupted optimal performance.
A foundation for additional automation
The client realized a return on its investment within a few months. The bot’s performance led the hospital CIO to recommend robotic process automation to the organization’s human resources department to streamline its many rote, manual processes.
In addition to implementing the software bot, we offered our client education about how to identify processes suitable for bots. The bot’s architectural framework will enable the client to extend its capabilities to other functions with minimal programming.  Automating simple repetitive processes builds a solid foundation for more sophisticated levels of automation to complement the bots, such as generative AI features. These can identify underpayments by analyzing payment data and comparing it to contracted rates; reduce eligibility-related denials; and assist in medical coding for greater accuracy.
Our client estimates it is now saving more than $600,000 annually by using the bot to check claims status. Work is current and sustainable without adding more staff. Without the bot, the hospital would need approximately 40-plus FTEs to carry out the tasks the bot can accomplish on its own. Productivity has increased and accuracy is at 100%. The client’s revenue professionals are more satisfied doing high value work that requires their full expertise vs. carrying out rote, repetitive claims checks.
