The 5 Technology Components You’re Missing to Automate Your Complex Claims

Posted February 11, 2021 by Kevin Hulvey

In our December blog, we discussed how health systems are turning to outsourcing for their complex claims. In this month’s blog, we look at how outsourcing is giving hospitals access to IT services required for complex claims processing.

Does your hospital have the latest technology to make your revenue cycle successful? One of the issues hospitals and health systems are dealing with is a lack of IT resources required to automate processes and streamline administrative functions. This is especially true of the revenue cycle process where hospitals communicate with dozens of vendors, manage contracts for hundreds of payers and process thousands of claims as quickly and efficiently as possible.

Unfortunately, healthcare systems don’t always have the resources to replace manual processes, and in cases where they have invested in technology, the systems are often antiquated or don’t integrate or communicate well with third parties, such as payers. Working around the limitations of these systems often involves FTEs making phone calls to payers or performing other time-wasting activities.

The good news is that today’s innovative technology can help solve many of these issues. In the past, healthcare IT systems often replicated a paper-based, manual process into a computer-based, manual process – essentially replacing a cheap paper process with a very expensive computer system that did the same thing the same way. For many healthcare companies, it would have been cheaper and easier to continue using the paper process than some of the electronic systems that are unfortunately still being used today.

The recent big leap forward in the IT industry is the growing use of artificial intelligence (AI). It’s become a buzzword in our industry, but despite all the hype, the fact is that true AI – computers that can make independent decisions not based on their programming – doesn’t exist yet. However, there are more limited forms of AI that do exist and are already in use today such as machine learning, speech recognition, decision management and robot process automation (RPA). These are all valuable tools, especially in the healthcare industry where so many processes are extremely people intensive. Unfortunately, these high-tech solutions are often out of reach for hospitals due to budgetary constraints or a lack of internal IT resources.

It’s not surprising that hospitals are seeking vendors who can provide services that are built on the most innovative technology. In the revenue cycle area, as reported by RevCycle Intelligence in the article 30% of Hospitals Use Two or More Revenue Cycle Management Vendors, healthcare organizations are looking for vendors who can provide automation solutions to improve their revenue cycle performance:

“Technology has the potential to boost waning margins after the devastating impact COVID-19 had on revenues the past year, according to some healthcare finance leaders. Meanwhile, revenue cycle automation has also been linked to faster patient collections, less administrative burden and cost, and better claims management.”

Our proprietary Enforcer System utilizes several technologies to entirely automate various portions of the human process by using the following components:

  1. Machine learning automates some of the initial portions of the claims process for certain groups of claims so that human intervention is no longer required to do these otherwise very manual tasks.
  2. RPA technology completely automates many of the processes in the latter portions of the claims process, by integrating with multiple disparate systems so that we can efficiently communicate with third parties like payers. 
  3. An advanced, automated rules engine captures the highly specialized experience of certain staff members and spread that knowledge across the entire team.  This is accomplished by codifying what needs to be done and how into a complex set of rules and data.
  4. Decision management is used across the entire claims lifecycle process taking inputs from machine learning and RPA so that human intervention is only used where their intellect, capabilities, and experience is truly needed.  The result is that claims are only introduced into the human workflow at the right time, and not before or after.
  5. Data analytics is also used throughout the claims lifecycle to analyze trends and other data to gain insights that are typically only available by sifting through large amounts of historical data.

For the last 20 years, EnableComp has invested in creating proprietary technology solutions from day one.  We didn’t want to rely on off-the-shelf technology, because they were simply inadequate to meet the needs of complex claims processing. Instead, we built innovative and specialized solutions based on what we knew our clients needed for Workers’ Comp, Veterans Administration and Motor Vehicle claims.  Our cutting-edge technology is one of the underlying reasons that EnableComp can process claims faster and more efficiently than internal revenue cycle teams and consistently exceed our client’s expectations.