Use cases

Member Enrollment

Paper Enrollment forms received via fax, email or scanned paper which are entered manually in the enrollment system, OCR is also used. RPA can be used to automate the membership enrollments

  • Custom file formats – > Employer groups send membership data in custom format, or through their own membership system, which have to be translated into the payer enrollment system. RPA can automate the process of parsing the custom formats files and entering the data in the member enrollment systems

Claims Processing

  • Claims Processing: Paper claims received via fax or mail or scanned claim images in email can be automated and fed to the Claims adjudication system using RPA bots.
  • Claims received as Non-standard EDI or other custom file feeds from providers or members can be automated and fed to the Claims adjudication system using RPA bots.
  • Claims received from third part provider systems may not have a seamless integration into payer Claims system, which can be processed using an RPA bot.
  • Claim Processing Errors occurs due to incorrect information related to member, billing, coding, or eligibility data. A robotic process can look up the error code, and either edit the claim or suggest an edit eliminating the manual intervention.
    • A bot can be developed to validate member information,
    • A bot to validate benefit information.
    • A bot to validate the Accums
    • A bot to verify COB.
  • Claim Denials because of incorrect data results in payment delays or delays receiving follow up Care for members. Bot can be developed to look up the claim denial codes and act for Eg: A bot can suggest correct PDM credentials based on provider table or internet search
  • Claim Audit & reporting is very structured process, but human intensive. Many of the process steps can be automated using bots

Payment Processing

  • End to End payment processing involves transactions to Payers from providers, clearing houses systems in different formats, any fragment workflows can contribute to inefficiencies and delays in payment processing. Robotic bots can streamline end to end payment process, eliminating all the manual handshakes
  • Provider data Management: PDM errors is one of major issues encountered by Payers and Members alike, when an incorrect provider data is encountered a bot can look up provider network data or intelligent search on provider address and details to correct or suggest corrections to provider data.
  • Likewise, many other process within sales, quoting, billing, reporting & analytics that have scope for process improvements and cost savings using Bots

Pharmacy Benefit Management

  • MailOrder Rx: Orders are received from members in various formats and channels which need to be run against the benefits of the member, after claim processing is done medication needs to be filled and mailed to the member. This complete process involves lot of manual intervention and opportunity to optimize the process and eliminate manual touch points
  • Fraud & Abuse: Fraud and abuse detection and prevention needs continuous monitoring of the claims emerging from certain member, demography or address, ML and AI can be leveraged to alert any trends that can be a potential fraud of abuse scenario. RPA leveraging ML and AI can be used to prevent and early detection of fraud and abuse.
  • Paper Enrollment; Enrollment forms received via fax, email or scanned paper which are entered manually in the enrollment system, RPA can be used to automate the membership enrollments
  • Custom file formats – > Employer groups send membership data in custom format, or through their own membership system, which have to be translated into the Pharmacy enrollment system. RPA can automate the process of parsing the custom formats files and entering the data in the member enrollment systems.
  • Benefit Plan design often involves good amount of data analytics around, how existing plan performed, cost savings for members, cost savings to the plan, demographic info, drug utilization trends. Some PBMs have mature systems and some PBMs have disparate system where the data is aggregated and benefit plan is coded from documents. RPA leveraging ML and AI can be used to improve the plan design process.
  • Follow ups to the claim rejection process can be automated using Bots.
  • Claims received as Non-standard EDI or other custom file feeds from providers or members can be automated and fed to the Claims adjudication system using RPA bots.
  • Drug Utilization Analysis: This process involves intense analytics around the claims per drugs, distribution by plans and demography so strategic decisions can be made on plan design for upcoming years.