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Bot vs. Bot: Using Technology to Combat Increasing Denial Rates

Amanda Parada
August 30, 2023
Future of RPA in healthcare

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Technology advances have benefited numerous industries in a multitude of ways. Most often, these technologies make an employee’s job easier or help make arduous processes more efficient. That’s exactly what robotic process automation (RPA) has done for revenue cycle management (RCM) organizations within the healthcare industry.

But more than just making processes and employees more efficient, automation can help RCM organizations battle one of the most problematic aspects of the entire process – claim denials. Insurance companies are already using automation to streamline the process of reviewing, and denying, claims. So, RCM organizations need to combat this automation with automation of their own.

Denials and automation

The numbers are staggering. According to two separate surveys, 89% of all hospitals and health systems saw a rise in denials during the past three years, with half of the participants describing the increase as “significant.” Another study revealed that 30% of healthcare leaders reported claims denials increasing at a rate between 10 to 15%.

Some claims are being denied even when patients receive care from in-network physicians. One Kaiser Family Foundation study revealed that in 2021, on average, 17% of claims were denied, with one insurer denying 49% of claims. In 2020, one insurer denied 80% of claims.

And nearly 65% of denied claims are never refiled, leaving healthcare organizations missing out on much-needed payments.

A claim can be denied for several reasons, including incorrect or missing information or the need for additional information. And this is one area where insurance providers are using automation. Automated systems can validate claims against policy terms and conditions. If the submitted claim doesn’t meet certain criteria, it is often automatically denied.

Insurance providers are also using automation for other tasks, including:

  • Pre-authorization
  • Medical necessity review
  • Fraud detection

Since insurance providers are taking advantage of automation, RCM organizations must answer by automating many of their own processes.

RPA to the rescue

For RCM departments, the answer is RPA. The industry saw a huge jump as the use of automation in revenue cycle operations grew from 66% in 2020 to 78% in 2021. Another 2021 study revealed that 82% of RCM organizations were adopting automation.

RCM organizations have adopted RPA to help with a host of simple tasks, including: ​

  • Patient scheduling
  • Claims management
  • Regulatory compliance
  • Data entry/migration/extraction
  • Denial management

RCM organizations turned to RPA to increase department efficiency, reduce operational costs, improve accuracy, and re-allocate staff for tasks that require critical thinking and decision-making.

When it comes to denial management, if a claim is denied, a representative has to manually gather all the necessary information, quite often from multiple systems, to analyze why the claim was denied. Then, those employees must scour those same systems to gather all the necessary information before resubmitting the claim. This is a long, arduous process, but not when automated with RPA.

With RPA, the denial process can become more efficient, saving valuable time for your staff as well as your patients. Here’s how:

  • Incorrect/Missing Information: The bot can be directed to log into various systems and look through each system for incorrect and missing data. If any information is found, the bot automatically updates the account.
  • Invalid Coordination of Benefits/No Coverage: A bot can be directed to conduct an eligibility check. It can check various systems to search for coverage options and make appropriate updates based on provider guidelines.
  • Additional Documentation Required: The bot can be directed to gather all necessary material as directed by the insurance company, such as medical records, pre-authorization details, clinical notes, and more. The bot then creates a PDF of the required documentation and submits it to the insurer.
  • Adjustment Postings: The bot can log into the system of record, then create an adjustment transaction.

The role of AI in RCM

RPA has proven to be a valuable tool for RCM organizations. But there is another tool garnering a lot of attention lately – artificial intelligence (AI)

Within the realm of RCM, AI has successfully aided in identifying patterns and preferences among patients. For example, AI can help identify each patient’s preferred method of communication. AI can also determine the level of patient engagement, which drives better health outcomes and overall patient satisfaction. AI has also been highly effective in creating propensity to pay (P2P) scoring models by leveraging advanced data analysis techniques to predict a consumer’s likelihood or propensity to fulfill their financial obligations.

So, can AI’s analytical capacity, or “brains,” be used to bolster RPA? What if RPA had the “brains” to handle more-complex tasks instead of merely the simple ones? That’s exactly where this technology is headed. AI can be used to do the necessary “thinking”. Then it can direct RPA to execute the task. In short, the artificial brain (AI) makes the decisions that activate the hands (RPA).

The use of AI in RCM is in its infancy. But as this technology continues to develop, the potential for how it can be used in RCM is nearly unlimited. Ultimately, the more tasks that can be automated, the better it is for RCM organizations, their employees, and patients. Employees can be freed from mundane tasks to focus on those requiring a human touch, specifically when connecting and reaching out to patients.

RPA and AI: A better future

“Alone we can do so little; together we can do so much.”

This quote from Helen Keller sums up what many see as the future of AI and RPA within RCM operations. On their own, each of these technologies can provide some benefit. But, when used together, the technologies can provide immense benefits. Organizations will become more efficient. Employees will discover more job satisfaction, and patients will have a better overall experience.

That sounds like a win-win for everyone!

Contact a Finvi solution specialist if that sounds like a win-win to you as well.

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