Managed care company doubles down on automation, unlocking exponential value and transformation potential

Organizations in the managed healthcare sector contend with ongoing claims payment challenges, among many others. Fragmented systems, manual claim auditing, payment errors and tedious reporting drain countless employee hours, and relentless regulatory demands bring pressures daily. As a result, managed care companies are understandably thirsty for ways to relieve the claims audit burden, even as many of them are not sure where or how to obtain that relief.

A First Step

In 2018, a publicly traded managed care company in the U.S. took a first step toward relief. The organization partnered with Protiviti to implement a pilot robotic process automation (RPA) program to increase the efficiency and coverage of its claims audit process. In just a couple of years, what started out as a small trial engagement with five bots has blossomed into a collaborative relationship that uncovered a goldmine of efficiency and cost reduction.

After experiencing rapid efficiency with the bots’ pilot implementation — reduction in claim audit time from 6 minutes to 22 seconds, on average — the managed care company saw the value of scaling the project across additional states and services. They chose Protiviti as a forward-thinking provider with deep industry expertise who propels the company’s big ideas and assists with their realization. They leaned on the proven success of the pilot and wanted to replicate it in a vaster way.

Unlocking Opportunities

In addition to expanding the geography and increasing the number of claims audited, the client wanted to use data analytics to move from sampling to full population audits, to identify outliers and high-risk claims and to identify and remedy the root causes of errors. They also wanted to enhance the PowerBI reporting instituted during the original pilot and add screen capture for audit evidence. What started as one pilot project ballooned into many due to earlier successes. The company looked to Protiviti for a long-term collaboration that delved deeper into automation.

Automation progression

Year One Implementation:

  • Pilot — Five bots

Year Two Implementations:

  • Scaled the RPA program by adding 11 additional bots across multiple products
  • Power BI reporting — Combined nearly 50 reports into three Power BI files to increase efficiency and effectiveness of reporting

Year Three Implementations:

  • Expanded depth of existing bot implementation
  • Built additional bots to address specific areas of concern identified through design thinking sessions
  • Audit evidence screen capture bot - reduced time to audit claims by 15 minutes/sample (thousands of samples)
  • Data analytics - piloted advanced analytics to provide insights over large claims populations and outliers/trends for investigation

Year Four Implementations:

  • Expansion of bots to additional locations, benefits, products and fee schedules
  • Expansion of screen capture bots
  • Sample selection bot
  • Expanded data analytics

Exponential Value

With each phase of the project, the company added greater and deeper automation and intelligent technology, seeing value skyrocket. Efficiency and coverage increased year-over-year. Employees were enabled to review claims faster and take on more value-added tasks. Back-end interfaces were used to streamline processes and expand bots to additional states. Protiviti engaged the company in multiple design thinking sessions to determine how the current bot implementations could be applied to more use cases.

Claim auditors had been using tedious Excel spreadsheets and ineffective PowerPoint slides to track and report errors, whereas today, Power BI is used to weigh, score and evaluate errors.

While efficiency increased exponentially, the company also gained agility and flexibility among its employees. As monotonous tasks were automated, employees are able to take on value-add activities, diversify their skills and perform higher-level, more interesting responsibilities.

Visibility was heightened — instead of testing samples of data, the company is leveraging its new technology to evaluate full populations of data sets to uncover all errors rather than only the outliers in a sample population.

The company was running dozens of manual claim reports. We were able to take those reports and consolidate them down into three Power BI dashboards. Once awareness about the capability of Power BI spread throughout business departments outside of claims audit, it created a buzz of innovation throughout the organization.
Lindsay Gleeson

A Fully Transformed Claims Audit Function

Starting with a small RPA pilot — but dreaming big — the claims audit function has transformed itself into a deeply automated and highly efficient function which engages daily with bots, dashboards and weighted analyses of claims, seeding benefits across other departments, from operations to finance and internal audit. The substantial benefits include:

  • Reduction in manual effort
  • Significant increase in claims audited per year
  • Decrease in audit time from ten minutes to six seconds per claim
  • Higher rate of error identification due to increased coverage and root cause remediation
  • Reduction in adjustments due to errors identified for larger populations
We promote and support connected communications. We tell clients, ‘Here’s what your other functions are doing — have you communicated with them? We think we can pull their data and tie it together to streamline the process.’ Being a multi-service firm with deep industry knowledge and a history of providing value across a variety of services allows us to deliver that kind of broad, cross-functional value.
Lauren Lang

Teamwork Brings Success

The company banked on Protiviti’s deep expertise in the managed care sector and the success that came from the initial five-bot implementation. Thanks to a deep understanding of the company’s environment, its processes and its people, Protiviti and the company were able to scale the automation initiative to other areas of the organization - from audit and operations to compliance and HR. Design thinking exercises facilitated by Protiviti helped the client see the possibilities and connect their organizational dots. More than a single function success, the organization has seen its own significant potential for transformation with automation and data analytics.