Many Revenue Cycle Management (RCM) teams deploy staff to look up the status of outstanding claims via phone or website inquiry. In many cases, these status checks only yield that a claim is still pending processing. This post is part of a multipart blog titled Optimizing the Revenue Cycle Management Value Equation with Intelligent Automation. Here, we explore how employing Intelligent Automation tools like RPA (Robotic Process Automation) to proactively check the status of claims can eliminate this time-consuming manual process from your Accounts Receivable (A/R) representatives’ workday while still retaining the operational and financial benefit of advanced routing of claims that require additional follow-up.
Revenue teams in hospitals and healthcare systems frequently set goals to lower overall days that claims sit in Accounts Receivable. Every day that a claim sits unpaid by a payer, and hence in a provider’s A/R queue, is another day that the provider doesn’t get paid. With growing and aging populations, and complexity introduced by prior authorization and ICD-10 causing increased claims submission errors, unpaid account queues are on the rise. This makes meeting goals to lower days in A/R more and more challenging.
To lower the number of days that accounts sit in A/R, providers focus on portions of the process in their control. Many improvements can be gained before claims are submitted, such as ensuring accuracy of insurance and eligibility information, as well as improving the accuracy of coding and claims submissions. Once claims are sitting with a payer, providers frequently employ staff to follow up on outstanding accounts and claims by making phone or website inquiries with payers. This allows the provider to gain insight into claims that may be denied or otherwise not paid prior to the claim being electronically interfaced into the provider’s systems, which in turn allows for earlier correction of the issue, reduces overall time in A/R, and results in the potential for improved cash flow. As account follow-up queues grow, hospitals that don’t have a method to automate the claims status check process often see their staff committing more and more time to following up on unpaid claims. In many cases, the claims will simply be awaiting action from payer personnel or have been paid but not yet electronically returned to the provider. This means much of the time spent by A/R staff on follow-up is wasted effort.
As an example of the cost of performing payer status checks at a typical provider, we can do a quick calculation. For this example, we’ll use the following metrics:
Given the above metrics, performing payer status checks would cost the provider $468,000 per year on average.
RPA allows software robots to be created that mimic the activity of human staff performing a repetitive business process. The software robots interact with electronic systems in the same way that humans do. They can interact with desktop, thin client, and web-based applications; read and send email; extract information from text or handwritten documents; and much more. This means that existing electronic systems do not have to change to automate processes with RPA, and that complex programmatic systems integration can oftentimes be avoided.
In the case of payer status checks, A/R staff performing the process manually typically work from a queue of unpaid accounts in a provider’s electronic systems. For each unpaid account, they visit the appropriate payer’s website to check the status of the claim, then update this status in the provider’s system. These updates are then fed into various follow-up queues depending on the status.
The repetitive nature of payer status checks is a straightforward use case to automate with RPA. In fact, we often see status checks as a great way for a provider to get started in automation of revenue cycle processes. RPA robots can work from existing A/R work queues, look up claims status with payers through their websites, and update data into provider systems without involvement from RCM staff. This means that the status checks can be performed more frequently, and with fewer errors than human staff who are tasked with a repetitive process like this. Critically, it also means that the staff time that was lost to checking on a claim’s status can now be spent on higher value tasks or accomplish work that the provider was previously unable to complete without increasing staffing levels.
In the example from the section above, the provider was spending over $450,000 per year in performing status checks, while not being able to use that portion of their staff’s time for other more complicated claims response activity. Besides being able to reclaim this $450,000 worth of staff time for higher value work, the combination of freed staff time as well as accelerated and accurate claims status updates improve claims filing timeliness, which in turn accelerates overall cash flow into a provider. In fact, mid-size providers have seen over $20 million in accelerated cash flow as a result of the impact of automating claims status checks alone!
pureIntegration has been partnering with our customers to automate their most challenging business and technical processes for over 15 years. We offer flexible engagement models and a factory approach to automation development—from building and maintaining automation long term as a managed service, or by building internal development expertise and an operations model (Center of Excellence) to drive automation initiatives, our team can get you off the ground quickly. Engage with us today to find out how to put 80,000 hours of automation experience to work for you!