How You’re Leaving Money on the Table and What to Do About It

Why Automate?

A large driver for automation comes down to the dollars and cents—finding how automation solutions can make each dollar go farther. But that isn’t to say it’s the only consideration; it also helps an organization put their people to work where they are really needed.

• COST SAVINGS
  The Council for Affordable Quality Healthcare (CAQH) estimates that U.S. Healthcare industry can save an additional $11 billion annually in automating business processes around claims and eligibility data. So much of the effort in claims processing involves repetitive tasks that are a perfect task for a computer. A typical hospital already spends 50-60% of its expenses on salaries and benefits, and three out of four CEOs say reducing costs and creating efficiencies are one of two top financial priorities. A smart and assertive automation plan can reduce the financial burden of administration in your business and allow employees to focus on value-add areas like delivering outstanding care and defining business strategy.
• MAKE THE MOST OF YOUR RESOURCES
  There are some things automation is not great at. Humans remain the best equipped for strategic planning and critical thinking: no one knows your business like you do. But people are also prone to make mistakes. Give the rote, high volume tasks to a computer and let employees focus on service, strategy, and most importantly, patient care. Computers are best when it comes to this transactional kind of work. The more automation that is implemented on transactional work, the more data is available for analysis of your business—giving employees more tools to strategically move the business forward.

What Can Be Automated?

A broad question with a broad answer, in general terms anything involving the transmission, processing, reporting and analysis of data is ripe for automation, and any rote tasks or standard processes can be automated. When it comes to automating financial solutions for hospitals and healthcare organizations, there are a number of specific answers.

• CLAIMS PROCESSING
  One of the biggest areas of impact for automation is simply in claims processing. Payer websites allow for claims data on the payer’s risk to be pulled and stored into your systems. This can be done manually, using multiple FTEs to navigate, pull, save, identify issues, and all the rest, or it can be done automatically, in some cases freeing up full teams of people to be utilized in more valueadd roles. The CAQH estimates the use of online portals to manage the processing of transactions increased 55% in 2017. What’s more, setting up a claims processing automation solution facilitates an improved ability to analyze the claims being processed.
• CLAIMS WORK DISTRIBUTION AND WORKFLOW MANAGEMENT
  What about claims that your staff needs to approve or deny? This can present their own host of challenges. There can be efficiencies in having certain types of claims reviewed by a portion of the larger team. Many claims will be rejected and come back for review again, and for some of these there might be efficiencies in having the same person as before review them. Perhaps some people are specially qualified to review claims with higher dollar amounts. All of these considerations can help reduce errors, improve efficiency, and ultimately reduce interest payments by tightly managing turnaround times on the review of claims.

  In order to realize an efficiency gain on a process like this, you’ll want to consider how to successfully employ technology to manage the flow of claims. The most crucial part of functionality you’ll want is the automated distribution of claims to Managed Care Coordinators (MCCs). A robust solution would also give managers the ability to manage the distribution by editing the members on a given distribution list, reassign claims for unexpected conflicts, and exclude members from receiving claims for certain periods (e.g. for PTO). Additionally, automating this workflow facilitates additional business intelligence on the process: you’ll be able to more closely manage turnaround times, get insight into high or low volume periods, and see how efficiently your team members are reviewing claims. All of these things will help keep claims moving without having to rely on clunky Excel workbooks.

• HEALTHCARE AND MACHINE LEARNING
  Machine learning is a big buzzword that has followed in the tracks of the “big data” phenomenon. It is the discipline of using programmatic solutions to implement statistical models on data. These models seek to deliver information to an organization to help drive decision making. The solution “learns” the dataset and can provide information about how the data points tell a larger story, and how a population might change in the future.

  Machine learning can be used in a number of applications in healthcare administration. On the smaller side, it can be used to perform heuristic checks on third party data. This means an organization can programmatically model the data it receives from a third party, and determine when the integrity of the data might be compromised. A statistical model can give a lot more insight early on as to when you might be looking at bad data and stop it before it flows downstream elsewhere in your systems.

  A larger undertaking could be to set about creating a model to predict if a claim should be considered clean versus rejected and approved versus denied. As the model classifies claims, a prudent organization will still employ a manual review, but maybe certain groups of claims are approved 96% of the time and not worth the effort to review each one manually. Using the model to group claims and determine where there is the biggest ROI for your time investment would be the end goal of such a solution.

• AUDITING CLAIMS PRICING ERRORS
  Pricing errors on claims are a common occurrence. Usually, they are for negligible differences when you consider the effort to having to manually review the claims, request a refund for overpayment, and follow up on the requests that get ignored. Maybe you have some of the domain knowledge you need to effectively review these claims, but the time spent can be cost prohibitive, even if it means leaving money on the table. It doesn’t have to be this way, though. The key is to formalize the domain knowledge into a structured process that can flag claims with potential errors for review. Spending the time to put together a good process can do 90% of the work for you, giving a much higher ROI on the resources utilized.
• OTHER OPPORTUNITIES
  There are a number of other opportunities to streamline processes with automation. Maybe you need to set up a process to attribute members to Primary Care Providers. Maybe you need a comprehensive solution to better manage your providers; maybe you need to take a look at waste and redundancies in the way you’re exchanging data with third parties. These are all good questions to ask as you identify opportunities for improvement.

Machine Learning Tips

If you think it’s time to take a closer look at how automation can streamline your business, it’s a good idea to begin working through your options and what a comprehensive solution might look like. Our company of 30 brilliant and agile developers is here to help you every step of the way. With a proven track record of implementing solutions and a deep knowledge of the healthcare industry, let us guide you on the path to streamlining your business and making each dollar go further.