Why Current Claims Processes Are Unsustainable

April 11, 2022
Image of man looking frustrated, rubbing his temples.

It doesn’t matter if you’re an insurance executive, healthcare provider, medical claims staff member or patient – the idea of “medical claims'' has a traditionally negative connotation. It elicits an image of inefficiency, complexity, errors, and high costs. The current landscape in the industry is not making things better, with new regulations that require participants in the system to work within tight frames, increasing downward cost pressure from all parties, a labor shortage, and an overwhelming and growing volume of data.

According to a claims-related survey conducted by Accenture, “the two most important factors that influence customer satisfaction—aside from the perceived fairness of the settlement itself—are the speed and transparency of the claims process.” To leave this area unaddressed results in lower satisfaction scores and loss of customers to competitive firms.

Existing Solutions Limited

The common ways that insurance companies are trying to solve this problem are simply unsustainable for the long-term.

Many businesses try to deal with the labor shortage and increased demand by adding to the workload of current staff members, which is fueling burnout and attrition. It exhibits a lack of attunement to the daily lives of those who process claims for a living. The work itself is low-paying, soul-crushing, and often holds no hope of career advancement. To increase the amount of mundane work while attempting to hold down labor costs is a recipe for continued exodus from the field.

Other organizations may attempt to shuffle claims processing tasks overseas to countries that have lower standards of living and, therefore, lower wages. Business process outsourcing (BPO) providers are struggling with similar training, retention, and wage demand problems, requiring them to increase rates as well. This means that overall costs for insurance companies using BPOs will soon reach unprecedented and unsustainable levels.

Most existing automations solutions are limited as well, often requiring a great deal of human intervention to verify data, correct errors, and deal with special circumstances. Technologies such as optical character recognition (OCR) require a high level of accuracy in the placement and format of data to work effectively. Since healthcare related forms are frequently unstandardized, many automated systems are extremely limited in the benefits they provide.

Document Vision Promises Sustainable Claims Solution

The medical industry has established some standard forms such as the CMS-1500 and the UB-04 that are now widely used throughout the United States, in an attempt to collect all necessary information to process medical claims more efficiently. However, problems arise with illegible or difficult to read handwriting, missing data, or information that is placed in an incorrect box. Human manual entry is slow and error-prone; many current automation solutions are also unable to effectively deal with these problems.

As artificial intelligence technology has grown more sophisticated, solutions such as Roots Automation Document Vision promise relief from these common and challenging problems. This cutting-edge technology allows digital coworkers to infer which boxes are checked even if they are not exactly marked, work with blurry or skewed scans, deal with incomplete forms, and recognize a wide range of common documents such as medical or pharmacy ID cards, policy documents, claims forms, and more to extract needed data.

Current customers have experienced significant returns on investment in brief periods of time. For example, a healthcare and insurance clearinghouse that had a growing volume of medical claims due to expansion and simply couldn’t keep up. By using Roots Automation, this organization saw an 80 percent reduction in manual efforts pertaining to processing claims and was now able to automatically scale up the size of the virtual team as needed based on incoming volume.

Read more about how our Document Vision solution can improve your document processing cycle time, reduce cost and free your people from mundane work.

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