RPA Healthcare Eligibility

    US Healthcare Billing Process Challenges

    The US healthcare billing system needs digital transformation to meet the increasing workload and to cut down the operating costs. According to a report 22%* of the claims submitted are rejected out of which 40%* are never ever resubmitted. 65%* of claim component denials are never contended for. Moreover above 10%* of the claims are never paid correctly. To prevent all this from happening, checking medical insurance and plan benefit eligibility is utmost important. The first step in processing the entire medical billing is to perform medical insurance checks and eligibility for a patient.

    For a clinic or healthcare provider any error in insurance eligibility verification can result in costly treatment and denied claims. Normally health insurance validity checks are based on coverage, diagnosis and treatment needed. The checks include payable benefits, type of plan and coverage details, plan exclusions, referrals and pre-authorizations. All these checks are performed manually most of the time and are pretty inefficient, manual and error prone.

    RPA & AI for Health Insurance Eligibility Checks

    Robotic Process Automation RPA can help automate health insurance eligibility checks and make pre-authorizations for the patients that are scheduled for appointments. RPA robots help in fast and error-free medical insurance checks and eligibility validations. The patient insurance eligibility verification is delivered through the RPA automation that results in:

    1. Decreased time & effort: All the manual work is taken up by the RPA robots to go into the payer websites and search and check for patient’s eligibility.
    2. Increased approvals & authorization: Since the clinics and health providers are sure of the medical insurance of the patient then claim approval and authorization rate increases substantially.
    3. Decreased billing cycles: If the gatekeeper to the whole medical billing process is strong the billing cycle definitely decreases and approvals happen quicker. The gatekeeping is done by automated insurance checks by RPA bots.
    4. Increased staff productivity: The staff can focus more on productive work and contingency issues rather than just trying to get hold of the medical insurance data for the patient.

    Overall the operational costs come down drastically by automating the critical medical insurance verification process.

    Apart from automating eligibility checks from different payer websites RPA can also apply Artificial Intelligence to extract data from verification forms to accurately check the insurance benefits and send data to the medical billing systems. The handwritten eligibility forms can be converted to structured data using OCR and AI and then this data can be used to verify a patient’s eligibility. This eligibility status can then be ingested into the medical billing systems to further process the other billing steps like patient demographic entry, CPT & ICD coding, ChargeEntry, claims submission and payment posting.

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