Medical insurance payers are a key part of the healthcare value chain across the United States and beyond. For doctors and hospitals to get paid, patients to get reimbursed, and companies to get billed for premiums, millions of transactions funnel through the back-end systems of health insurance companies every month. Those transactions happen largely on IBM i/zSystems applications, built and refined over decades to address the business processes of that particular company. They are the core operational system in any insurance provider. Insurers process hundreds of thousands, or even millions, of claims per year. The goal of the Vice President of Claims Operations is to maximize auto-adjudicated claims— claims that require no human intervention and are thus managed exclusively by the software. Typically, insurance companies have autoadjudication rates of about 75%, meaning 25% of claims require human intervention
Manual claims often exit the automated system for trivial reasons, chief among them mismatches in provider data or pricing, relative to Medicare and Medicaid tables. Human intervention takes time, slowing the claims process down, and introduces more opportunity for new errors. Customer satisfaction and doctor/hospital satisfaction drops as claims take longer to be paid. And, in some instances, compliance regulations can be violated when a delay exceeds a set limit. In addition, even for straightforward claims operations, the cost of manual intervention on 1% of claims can be upwards of $1M/annually. For leaders in Claims Operations, maximizing auto-adjudication rates means faster, cheaper, more accurate, and more compliant claims processing. Just a few percentage points improvement on the auto adjudicated rate can dramatically lower costs for insurers.
For many health insurance companies, Robotic Process Automation, or RPA, is a rapid, flexible and extremely effective solution. While integrated into other parts of the infrastructure, standard RPA offerings are unable to work with legacy-based applications to efficiently automate their functions. With Rocket® Process Automation, health insurance companies can tackle inefficient processes they were unable to automate before.