Amerigroup Achieves 100% Claims Accuracy With Intelligent Automated Queuing
50%
turnaround time
100%
accuracy
80%
THE CHALLENGE
Disparate systems, myriad data sources
The company processes between 70,000-80,000 insurance claims every day, of which 1,000-3,000 claims get rejected by the system due to Optical Character Recognition (OCR), data errors, or missing information. Providers often remain unaware of these rejections, totaling 528,000 claims annually and significant revenue loss.
As part of its process, Amerigroup used a “business rules engine” to validate basic claim information. However, the system frequently produced “non-matches,” necessitating manual efforts from the claims team to reconcile approximately 15,000 physicians daily. Plus, the system failed to account for diverse state requirements regarding National Provider Identifiers (NPIs), National Drug Codes (NDCs), and other essential data, resulting in costly errors.
FEATURED SERVICES:
“We were excited to partner with OZ when we learned of their extensive expertise in healthcare industry software development as well as in streamlining business processes.”
– J. Anderson, Director of Claims Department
BUSINESS NEED
An intelligent automated system to reduce claims inaccuracies and revenue loss
Amerigroup recognized the need for automated processes that could substantially reduce the errors caused by their current manual claims processes.
HOW OZ HELPED
OZ develops an intelligent queuing system and comprehensive reporting to reverse claims errors
OZ conducted an in-depth analysis of the current system and developed an intelligent queuing system by leveraging the latest Microsoft technologies. An Intelligent Automation (IA) framework, integrating Robotic Process Automation (RPA) for seamless communication and data analytics for comprehensive reporting across claims processing systems and ancillary platforms, was deployed. OZ created an on-demand rejected claims report with links to review individual claims, allowing processors to reverse claims errors and reprocess them immediately.
To increase the accuracy of data selections, upgrades were made to the intelligent automation business rules engine with new rules added to optimize physician, NPI, and NDC validations, as well as variations in state requirements.
IMPACT
50% increase in turnaround time, 100% claims accuracy
After the new intelligent queuing solution was implemented, the turnaround time increased by 50% with 100% accuracy. 80% of manual processes were automated. The new solution has become a useful tool to complete daily routine tasks and quickly process and adjudicate claims
- With rejected claims enhancements in place, Amerigroup can now reprocess an average of 800 claims, reducing provider follow-up for more than 200,000 claims
- Eliminated hundreds of thousands of follow-up calls from providers with automated rejection letters sent within 10 days of submissions
- Faster claims processing with a high-quality RPA selection process raised the provider matchup rate to 90%; 10% more than the old process’ rate
- Achieved higher match rates by optimizing the intelligent automation business rules engine for the selection of required data such as NPIs and NDCs by state with 100% accuracy
