Automating Claims Management for a Health Insurance Company

No health insurance policyholder likes to wait for longer than necessary to get reimbursed for health insurance payments. During end-of-year holidays, many policyholders have the time to solve issues with their health insurance policies, such as sorting payment receipts and preparing their applications to be freed from additional contributions. This creates a massive workload for the health insurance company at the beginning of the year.
Insurance companies sometimes hire temporary seasonal workers to help manage the influx of inbound customer contact and increased internal operations. However, these staff are usually inexperienced, unqualified, inefficient, and a poor investment as a result. Therefore, insurance companies are required to investigate more intelligent solutions.

Robots replacing humans

Robotics software (or RPA) can provide a real alternative. Time and effort spent by humans processing invoices can be significantly shortened with tested quality assurance using robotics software, which helps to regulate the level of human interaction needed during peak periods.
In order to process claims, first-step applications, and all related documents such as proof of income and payments must be digitized. A complex evaluation must take place, which requires a lot of time if it is processed manually. The total income of all family members has to be summed up in order to decide the individual limit of payment. For example, if the customer suffers from a chronic disease, only 1% of the entire income has to be spent for medical purposes, otherwise, 2% must be covered by the insured.
After calculating the limit of payment, all proof of payments must be checked in order to decide whether they are correct and if the amount specified can be approved. If the sum of all payments is higher than the individual limit, the difference is reimbursed. It takes quite some time to handle such claims. Short-term seasonal workers lack the necessary qualifications and experience to significantly support the team in this process.
Additionally, the risk of errors is increased when people who lack business experience are involved. A risky game in the insurance industry as a reputation is imperative. As a result, it has so far been necessary to put a lot of time, effort, and money into training and quality assurance in the past. And there is no guarantee that that temporary employee will provide more than even one season of value to that company.

Health insurance claims automation

Many policyholders choose to reduce their payment contributions throughout the year. No matter which time of year an insurance company experiences surges in customer contact, there is a high potential to streamline the process by automating reimbursements using robotics. Scalable robotic process automation programs are highly qualified and available 24/7 all year round.
In this instance, to digitize a document management process for a health insurance company, optical character recognition (OCR) would be used by SPS as the first step. OCR software captures unstructured data from documents and provides them to a robot in a structured format. If all required data is available, the robot would start processing the data according to strictly defined business rules.
Rule-based checking by RPA software can occur internally or externally at one of SPS’s secure data processing locations, and the data would then be transferred back to the health insurance system. All processing is documented and the customer service employee would receive a report with suggestions in order to finalize the transaction.

Intelligent Automation (IA) is the future for health insurers

Complex cases with very different business requirements would be processed by the robot first. Besides the recognition of various income types, the robot would read very different proofs of payment and recognize the relevant data before the evaluation, in order to ensure that only approved data is transferred into the health insurance system. Duplicate payment documents would be detected by the robotics software.
The robotic solution by SPS is not only convincing businesswise. An automated document management solution can reduce manual processing by up to 50%, which reduces processing times and increases customer response times. Using automation software rather than manual processing, policyholders would receive their reimbursement faster, leading to higher customer satisfaction with fewer additional resources required.
Single steps such as handling OCR results, processing of erroneous or incomplete applications, quality assurance, or payment through the health system software would still be handled by a human. A robot shortens the transaction time, ensuring higher accuracy and reduced process costs, just through the validation of data delivered by OCR.
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