ISG Momentum® Strategic Perspectives - Intelligent Claims in Healthcare – Navigating COVID -19 and Beyond
Health insurers have less control than many other businesses over the factors that are fundamental to their operations and profitability. Regulatory changes, peaks and valleys in claims volume, and medical innovations that create questions about coverage all have an outsize influence on the industry. Work processes that may have been considered efficient or even industry-leading now may represent a competitive disadvantage. In the face of these challenges, health insurers need to optimize where they can.
These industry fundamentals were well established even before current events provided a stark reminder. COVID-19 is being disruptive in both predictable and unexpected ways. For example, the U.S. government has promised that patients will not need to pay for coronavirus testing. However, the status of treatment coverage is currently uncertain, a situation that will cause confusion over how claims will be coded, billed and adjudicated. The rapid response to containing the virus led authorities to lift licensing and interstate treatment restrictions on the use of telehealth, which helped lead to an unprecedented surge in telehealth consults, with billing questions in their wake. Amid the coronavirus crisis, the Centers for Medicare & Medicaid Services issued its Interoperability and Patient Access final rule. It requires health insurers to have processes in place for standardized payer-to-payer data exchange by 2022, and to have APIs for patient data sharing by the start of 20211.
These developments reinforce the imperative for health insurers to control and improve the variables that they can. Extending automation into claims processing represents one of their best current opportunities. It costs health insurers approximately $4 to manually process a claim that requires human intervention, whereas an automated claim costs only $1.252.
Intelligent automation – the combination of robotic process automation (RPA) and artificial intelligence (AI) – has opened opportunities for payers to achieve unprecedented levels of efficiency while improving customer engagement. Applying intelligent automation to claims processing currently represents one of the strongest levers that payers can pull to take costs out of their operations.
This white paper identifies why claims processing is a good process to target, how RPA and AI create sustainable value, and how insurers and service providers can take advantage of the opportunity.
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