Simplifying Healthcare Claims Processing through Document Process Automation

Over the last 9 months, there has been a drastic shift in the way businesses function and this phenomenon is seen across the globe. Insurance companies are no exception, in fact enterprises that were performers over the last few years are now looking at digital adoption and solutions to transform their business, including efficiency, optimising resources, and enhanced customer experience.

The one functionality that plays a crucial role in the insurance business is “claims”. This is the one that can make or break a business. Across insurance companies, claims management is a sensitive area that companies are hoping to streamline and ease up. There are instances of undue delay in verification of the claims request, authentication of the supporting documents provided, and other elements that lead to losing customers, subsequently leading to loss of business as well.

The one objective that insurers across the spectrum have today is to increase efficiency, boost the speed of claims processes, and heightened customer satisfaction levels, which will lead to business growth. The need of the hour, therefore, is seamless claims processing which addresses all the challenges mentioned above. We have done a few blog posts earlier on automating the document process flow, Intelligent Document Processing [IDP], and why insurance enterprises need to adopt IDP. In this post, we shall focus on the healthcare space, with specific focus on claims.

Considering the volatile scenario looming large, Healthcare organizations are prioritizing digital transformation initiatives. Insurers are dealing with pressure from competition and the growing demands of customers. One of the main reasons why insurers are facing these challenges is the limitations within the core systems that causes delay in launching new products, innovation and offering advanced technological capabilities. Similarly, the need for automation is quite high, as it will help speed up the customer onboarding process, reduce time and cost in claims management and open doors to new up-selling opportunities.

It is vital to deploy automation into the processes as it is the only way to achieve speed to market, constant innovation, accuracy in data, gaining insight into customer’s profiles and ease up the claims process. Let us look at the four elements involved in offering a seamless claims process to customers are,

Understanding the current claims business process:

Delivering an exceptional experience at the moment of truth is the most important objective of the claims process, as that is a critical factor in customer retention. However, insurers are challenged to reduce costs — and for claims organizations — that means optimizing processes is also a top priority. Superior claims management demands speed and accuracy, but claims operations teams are often challenged with juggling multiple systems that contain customer and claims data, slowing the claims process and increasing the possibility for inaccurate decision making, potential fraud or litigation, or losing a customer by not meeting their service expectations.

The broad steps in the current claims process flow are:

1. Documentation — Customer provides all supporting documents [hard copy or via email] for the claim — Hospital bills, prescriptions, test reports, discharge summary and other relevant documents
2. Data Capture — The data is captured from the documents and manually fed into the system. In the case of electronic systems, the data is provided to the system directly
3. Review & Verification — Upon the initial review, the verification process is also completed [if the policyholder carries the relevant policy/coverage]
4. In-network Review — A necessary step where an insurer needs to verify if the doctor and/or facility are in-network based on the policyholder’s insurance plan
5. Policy Coverage — What are the elements covered in the insurance policy held by the policyholder [for the particular case]
6. Medical Assistance — Confirmation on whether a procedure is required or not plays an important role in determining the eligibility for an insurance coverage.
7. Evaluate Claim Risk — What is the claims settlement amount? Is there any indication of fraud?
8. Settlement — Once cleared, the provider/doctor gets paid. A detailed explanation of benefits (EOB) is shared with the policyholder [clarification on what is covered and excluded in their policy and what they can expect to pay]
9. Final Clearance — The policyholder is billed for the amount not covered in their policy.

IDP Solution — Transforming Claims

The process mentioned above is quite detailed, and most of the steps involved a paper trail and therefore the entire claims management process takes time and is quite cumbersome. With an IDP solution, the entire process is redefined.

Capture: Instead of submitting the paper documents physically or via mail, the customer can scan the relevant documents through a mobile app which can include a variety of document formats — ID cards, lab forms or medical records, claim forms, invoices, discharge summaries, etc.

Recognition & Classification: Being an AI-driven solution, IDP automatically recognises the different document types and classifies them into various categories like forms, KYC documents, hospital records, etc. Further, the ingested documents use an image pre-processing engine to enhance the quality of the documents and make them ready for data extraction.

Extraction: Based on the document classification, the solution uses an OCR engine to digitise the documents and built-in pre-trained modules to extract specific and relevant data points from the documents such as policy number, claimed amount, underlying condition, discharged date, etc.

Validation: The extracted data goes through a series of complex validation rules and AI-driven business rules engine to rule out the possibility of a fraudulent claim and prevent claims leakage. This includes checks such as:

• Checking for duplicate policies
• ICD (International Classification of Diseases) derivation of elements from the invoice to verify it against the policy coverage
• Eliminating charges applied for pre-existing conditions
• Fuzzy logic — transforming the prescription data into actual medical coded terms

Verification: Based on the confidence threshold limit set by the user, it flags specific documents and data points with irregularities. It escalates and triggers a BPM process to notify the authorised human in the loop for further investigation and reviews and notifies the customer for additional documents for verification.

Integration: Once the data is thoroughly checked and verified at various stages it can be further ingested into an organisation’s core system or other line-of-business systems. Using integration connectors, claim details are further sent to the finance & accounting department for payment processing, and the customer is automatically notified through an email.

Benefits of automating health insurance claims:

For organizations that rely on manual processes, managing medical claim documents and data is labour-intensive and error-prone. With automation and IDP, medical claims processing for organization can increase efficiency and accuracy, minimise touch points, and eliminate process bottlenecks. Some of the key benefits of implementing IDP in health insurance claims are,

• Capture medical claims data without any dependency on any custom software coding — by using our low-code platform to build powerful customized applications
• Route Data & Documents automatically to the right claim examiner based on the predefined business rules by seamlessly integrating your existing business workflows with our IDP solution.
• Configure complex benefits and reimbursement rules to streamline claims processing and reduce payment delays
• Respond quickly to changes in government regulations and support data, document, and process compliance.

Digitizing the entire claims processing and settlement will enable faster reimbursement and greater customer satisfaction. This will also provide a competitive edge for the company and subsequently facilitate business growth as well.