For competitive reasons, the client has decided to participate anonymously in this story.
US health insurance administrator increases claim auto adjudication rate (CAAR) to reduce risk and costs while improving market competitiveness, with multiple robotic process automation (RPA) solutions driven by Leapwork.
Before adopting Leapwork’s codeless automation solution, this health insurance administrator manually processed close to one million claims per year. Because of this, the team regularly experienced data entry errors.
“For tax purposes, we must enter accurate W9 data to be used for the creation of IRS 1099 forms at year-end. Historically, this has been a manual process which took resources and ran the risk of data entry errors.”
Because manual processing is such a time-consuming activity, a growing backlog of claims spilled over to the service department. The customer service desk was swamped by calls chasing claims status, whilst the claims processing teams had a growing backlog of claims.
With a low claims auto adjudication rate (CAAR) of 20%, this became the perfect candidate for automation and reducing costs.
To compete as a third-party administrator, having a high CAAR is essential. It also acts as a metric that the company is assessed on.
If the business were to continue processing the majority of their claims manually, they could be at risk of losing customers. In turn, this would make it challenging to continue to grow the business. This can put the business at risk of losing discounts from providers, and in the worst case, lose a relationship with a network provider.
By introducing a more efficient way to process claims automatically, without human intervention, the business could avoid financial penalties from not meeting provider network turnaround times. They could revamp their customer services and reduce the need to rely on the service desk to chase claims progress.
In the past, this health insurance administrator used Selenium for automation. Selenium is a framework for automating web applications and requires the ability to write code. This made business users reliant on IT to build automation.
For a process to be automated, business users would send a screenshot to the IT department. This led to gaps in communication, because business users couldn’t review whether the automation was accurate.
“A typical business user will glaze over if you put Selenium in front of them”. - John Wood, Business Solutions Architect
Because it is an open-source tool, it is also limited in functionality. They needed a ticketing system and scheduler to auto-adjudicate. Without this function, they were still reliant on human action.
To achieve agile and smarter workarounds for their claims processing, and increase their CAAR, they had to find a solution that was easy to understand. Any business user had to be able to understand how the automation functioned.
By adopting Leapwork’s codeless automation platform, the health insurance administrator is able to seamlessly automate a number of processes, including patient not found, provider cleanup, system workarounds, carry-over accumulators, 1099 entity entry, and work item transfers.
“Leapwork put automation back in the hands of the business. Business users can now understand it.”
Because of the intuitive and visual language, teams across the business can reach out to the automation team and get same day solutions. A video log of the automation flow means that business users can check the solution is working.
“What business users look at the output, they know exactly what the flow is doing - they can immediately spot when something is wrong.”
With Leapwork, the speed and accuracy of claims processing increased from 20% to approximately 67%, elevating them to a competitive platform amongst leadingU.S health insurance administrators.
In the past, they faced large volumes of claims that needed to be moved from one work item queue to another. With their previous system, this wasn’t possible.
With the introduction of Leapwork, the company was able to move over 11k records. Because the process was no longer manual, the team saved approximately $100,000 in postage costs that previously arose from member errors.
The increased CAAR resulted in 22,000 fewer calls being directed to the service desk. This enabled them to eliminate the need for entry-level admin staff.
With the freed resources, the health insurance administrator could upskill and relocate employees to value creasing tasks that require human intervention. They could reintegrate staff without needing to hire new resources. In turn, this saved the team between $60-90K in hiring costs within the first year.
The CEO is “delighted” with the results and the automation team is routinely asked to solve business problems using Leapwork.
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