The RPA solution was robots with automation scripts based on the same business rules used by the claims group to manually corrected the errors. Both the manual and the automation solutions were imperfect - the claim was still pending and still being touched for resolution. However, robots removed 25 FTEs from this manual process, which the customer considered significant saving, and bottlenecks of two and three-day durations were reduced to same-day resolution.
Now, the claims are pulled into work queues based on their hold codes and robots programmed to automate specific edit changes are assigned to the queues. The robots navigate to the claims system screens; collect the data needed to edit the claim; make the edit changes and resubmit the edited claim back into the claims systems.
Manually processing the edit changes took ten to fifteen minutes, whereas robots can do the tasks in one to two minutes or less. The RPA solution completely removed the claims team from this edit work, replacing approximately ten to twelve FTEs with robots. It also provided the ability to handle sudden increases in claims volume with more robots, instead of reassigning claims agents to low-value work.
However, the claims agent must look up information in many documents to properly process this claim: at a minimum, the attached explanation of benefits (EOB); the summary of benefits (SOB); and the benefits grid. Plus, any other attachments to the claim file.
The RPA solution put these claims in a work queue for robots to assemble all the necessary documents, then placed everything in the claims agent’s folder. Taking this assembly work away from the agents and allowing them to focus exclusively on adjudication decisions, shifted about two hours a day from low-level documentation tasks to high-value claims processing work—for each agent.