Optimizing health insurance claims processing through data analytics

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Traditionally, the claims processing center is an insurance payer’s largest administrative expense. Often, it’s also the most procedurally and technologically encumbered functional area. With economic and regulatory pressures escalating, insurers need solutions that drive the time and cost out of claims processing. Leading payers know they cannot wait for years-long IT projects to deliver the dramatic quality and cost-cutting results they need today.

Undeniably, great strides have been made toward claims auto-adjudication, yet many payers are still processing upto 50 percent of their claims manually. The perennial challenge is to improve operational efficiency when faced with disparate core applications and data repositories, aging adjudication systems, updated contracts, changing government regulations, plan mergers and other factors that result in convoluted procedures and manual steps.

Pended claims are a painful reality leaving payers with the ongoing struggle of growing claims backlogs, dissatisfied providers and potential regulatory non-compliance. For many payers, the only option for mitigation is to rely on manual processes which are both inefficient and costly.

Background

Our client is a US based non-profit health insurance corporation which insures more than 2 million people in four states. The entity processes a Daily volume of around 85,000 Pended claims, 29,000 Fully Insured Pended claims, around 1,900 claims Aged Inventory greater than 30 days.

They faced lot of hurdles in their claims processing center due to scattered data and lack of centralized system. Prompt payment on insurance claims is required by regulatory authority with penalties if delay exceeds a threshold. Manual claims processing workflow can be complex, with multiple departments/agents involved. Existing systems could supply the data required to track claims, but the data was difficult to interpret and take any actions.

The customer wanted a system that could act as an easy means of acting to expedite processing of a claim. They wanted to optimize the Pended claims Workflow Process to reduce the number of claims that age past the limit at which a Prompt Payment Penalty is assessed. To achieve this goal, better visibility into the ongoing progress on Aged Inventory of claims was the need of the hour.

Solution

CloudMoyo is the partner for streamlining claims processing operations for the insurance company. We developed integrated dashboards & views for executive and process owners to track the ongoing status for Aged Inventory of claims with automated heat maps. This was done using SharePoint & Tableau views for the executive and process owners’ dashboards, and a SQL Server data store to track and manage the daily loads of Pended claims.

The new solution enabled the client to present data with an executive view of interactive charts and KPIs in clearly-structured and interactive form and also provided a drill-down capability to allow senior staff to locate claims that require attention to avoid penalty. Once claims are identified for action, the solution helped create a workflow for immediate action (e.g., send an email to an agent with claim details and requested next step).

Value delivered

CloudMoyo helped deliver a simple yet functionally superior solution to automate the claims processing workflow to deliver benefits such as-

  • Increased visibility into pending claims that require attention
  • Reduced average processing time, open claims inventory
  • Centralized view for 1000 odd users for quick, easy action
  • Increased accuracy, productivity, compliance
  • Ultimately, cost savings to the tune of $500,000 annually in reduced penalties

This article also appeared on Datafloq which is a one-stop-shop for Big Data. Read the published post here.