Role of RPA in Making Medical Claims Processing Efficient and Accurate

Published Date

November 20, 2018


4 minutes

Written By

ACL Digital

Robotic Process Automation (RPA) involves application of the concepts of artificial intelligence (AI) and the capabilities of machine learning to automate a business process end-to-end. Use of appropriate programming, software and digital frameworks is inherent to the application of RPA solutions to business. Medical Claims is one such business process where RPA can play a key role and automate the process end-to-end, right from the stage the insured patient receives treatment to the stage where the hospital raises the bill with the insurer.

Medical claims processing is a huge industry and RPA services hold promise in taking it to the next level. In fact, many robotic process automation use cases apply to and are relevant for the medical claims processing or the medical coding industry. Here’s a stage-wise analysis of how Robotic Process Automation services enhance medical claims processing across its life-cycle:

1. Pre-registration : In this introductory step, the medical coder feeds the patient’s insurance information into the database and creates a copy of the patient’s insurance proof. This step can be automated through RPA by automatic medical coding that maps the patient’s insurance information with the hospital records.

2. Verification of insurance information : In case of a new patient or a new insurance policy, the health claims expert interacts with the patient or family member to be sure the medical procedure covers the insurance, and that the patient understands his or her coverage. RPA can map and automate the nature the treatment required with what is covered in the insurance policy.

3. Recording of the services received by the patient : The healthcare provider or the doctor checks the patient, curates a diagnosis, and administers the necessary treatment. She or he then records this information in the patient’s Electronic Health Record (HER). RPA, in conjunction with the mapping performed in the last step, feeds this data automatically in to the EHR and even creates one in case it is not present hitherto.

4. Collection of applicable payment from the patient : During check-in or check-out, the patient might need to pay certain expenses not covered as a part of the insurance, depending on the insurer’s policy. This payment goes to the medical service provider. RPA has capabilities to segregate covered expenses from the uncovered ones and highlight the same in a pro-active manner, for the benefit of healthcare provider, patient as well as insurance provider.

5. Assignment of medical codes : The medical coder checks the patient’s Electronic Health Record and assigns diagnosis codes from an applicable classification of ailments. In case any procedures were performed, the coder assigns procedure codes from an applicable list of terminology of procedures. This task needs to be done in an accurate manner to ensure the provider is paid correctly and that’s where RPA comes in more than handy. Through RPA, the medical coding is both quick and accurate, which is leverage-worthy, especially in case of large hospitals with high patient turn-around 24*7.

6. Claim submission : Upon a satisfactory documentation of both the medical codes as well as the patient payments, the medical coder generates the insurance claim. This document is submitted to the concerned insurance company, with the exact procedure depending on how the patient is covered and the claim application process of the company. RPA can automate this entire process in a multi-pronged manner, keeping the interests of all the 3 parties – patient, healthcare provider and insurance company in to ample and prior consideration.

7. Receipt and posting of the payment : Once the claim has been submitted in an appropriate and compliant manner, the payer or the insurer sends payment to the medical service provider, and the medical coder posts the payment to the healthcare provider’s account. Medical coders are also sometimes responsible for tracking payments that are late and also checking and fixing claims that may have been submitted with errors. Needless to say, RPA is a natural answer to these potentially loss-inducing business developments.

One of the primary priorities of the medical coder is process accuracy and the one immediately following it is process efficiency. Inaccurate coding could often lead to non-payment of claims and also delay in revenue collection for the medical service provider. Medical coders, therefore, need to be organized, detail-oriented, and analytical. This lets them lend a critical eye toward the procedures, diagnoses, coding, and insurance claims.

And RPA forms the best automated medical coding solution across a vast gamut of medical claims processing software available in the market. To ensure establishment of an accurate and efficient medical coding system, the only effort required is to get connected with the right robotic process automation vendor or RPA service provider.

About the Author

ACL Digital

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