Digitally minded managed care organisation taps Protiviti to lead RPA implementation in its claims audit department

Digitally minded managed care organisation taps Protiviti to lead RPA implementation in its claims audit department

digital organization taps Protiviti to lead RPA implementation

Change Requested: 
Adopt robotic process automation innovations to boost operational efficiency and agility, furthering broad-based growth initiatives.
Change Envisioned : 
Automate the claims audit process to verify accuracy of payments, make adjustments and detect adverse trends.
Change Delivered: 
Thoughtfully executed RPA solution adaptable to state laws, reducing audit time from four minutes to 22 seconds on average (91-percent improvement).

Healthcare organisations around the globe are confronting an aging population, complex care regimens, fragmented payment systems and outdated infrastructure in an environment already marked by rising costs and increasing regulation. One fast-growing and diversified multinational managed care organisation knew that overcoming those challenges and staying ahead of its rivals hinged on a well-defined, innovation-based strategy. The organisation made digital transformation the driver of innovation, starting with a plan to implement robotic process automation (RPA) to take on manual, repetitive and time-consuming internal audit tasks.

The organisation recognised that RPA would not only enable the business to scale for growth, but that it would also free staffers to perform activities that have a higher impact on the bottom line — an important advantage, considering the challenging and competitive market for labour. To kickstart the initiative, the firm ran a competitive selection process, ultimately choosing Protiviti as its RPA partner. Protiviti’s RPA expertise, along with our history of delivering value to the company in other areas of the business, paved the way for this engagement. For its first RPA project,
the company selected the claims audit process.

Building the Automated Process “Bot”

The claims audit function scrutinises processed claims to ensure that amounts paid to healthcare organisations are accurate and correctly based on state requirements, the time of service and other inputs. The claims audit department works directly with claims-processing units across several states in the U.S. to make any needed adjustments and remedy underlying problems or policies causing errors.

The organisation and Protiviti agreed that putting an automated process “bot” in charge of routine, low-impact claims would boost the company’s operational efficiencies by increasing the number of claims audits performed in a day, reducing corrections and adjustments, mitigating compliance and regulatory risk, and cultivating the digital technology skill set of auditors. It would also allow human auditors to focus on claims of a significant dollar amount — or those considered high-impact — and troubleshoot more complex, subjective circumstances that a bot would be unable to resolve. Supervising the automation software conducting the audits would be a new responsibility of the audit employees.

Given the extraordinary volume of data and complexity of the process, Protiviti provided the company with several bot product options for a pilot project that ultimately covered claims from four states and Medicare. Working closely with the senior vice president and senior manager of the claims audit function, as well as IT security and quality analysts, Protiviti led an effort to select the best option for the company, coordinate IT security assessments, configure and install the software, and build, test and deploy the automated claims process.

The fact that the company operates claims-processing centers in multiple states presented a challenge early on because of each state’s own set of complex laws and rules surrounding health insurance claims and payments. In response, Protiviti and the organisation first designed the bot to handle claims within a state that had a relatively simple regulatory regime. The team was then able to leverage that already created digital capital for other states by adding additional rules to the bot’s established foundation of core logic and workflow capabilities, rather than starting the process from scratch.

The team then launched an incremental pilot project focused heavily on verifying the accuracy of the bot’s output. At each step, the team assessed performance and adjusted the business requirements or the bot, as needed, to remedy any unexpected results. Protiviti also designed and deployed a customised visualisation dashboard in Microsoft Power BI. This customised dashboard provides a visual overview of the bot’s processing results and overall health.

Sample Dashboard: Claims Audit Results and Automated Process Performance

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With the pilot project well underway, it is clear that RPA promises to enhance significantly the organisation’s claims audit effectiveness. Prior to the bot’s implementation, an individual would spend four minutes on average on each audit. RPA can complete the task in as little as 22 seconds.

A Thoughtful Method Recommended

As demonstrated by this global healthcare organisation’s vision, RPA can be harnessed to drive digital transformation initiatives to boost efficiency and competitiveness. In this case, it was an everyday internal audit process that proved the best candidate for initiating automation with the most value delivered. However, companies can apply bots to any number of other routine functions or tasks that sap valuable worker hours. The key to success is to take a deliberate and disciplined approach to the effort and work with the right partner, from evaluation and identification of the eligible tasks and processes, to thoughtful implementation and performance verification.