Top Three Focus Areas for Automation for Healthcare Payers for 2022

Top Three Focus Areas for Automation for Healthcare Payers for 2022

  • Grishma Valliyod
  • February 9, 2022
Category: Intelligent Automation, Healthcare, AI

Today, healthcare companies are investing heavily in making the patient care experience as smooth as possible. This is true especially because of digital transformation driven by the pandemic as well as service offerings driven by technological advancements.

A survey by Statista shows that 90% of large healthcare organizations have adopted Artificial Intelligence (AI) and automation strategy for some of their processes and at least 66% of them are familiar with Robotic Process Automation (RPA).


In this article, let us talk about three focus areas for automation that can be most impactful for healthcare companies. These areas can accelerate business process efficiency and deliver value to customers.

1) Claims Automation

Claims processing is the most widely automated process by healthcare payers. Leading surveys show that as of 2018, over 95% of insurance executives have adopted claims automation in some form. Bots that support the claims process can be trained to read documents of various formats using the latest Optical Character Recognition (OCR) technologies.

usecases-3 The Artificial Intelligence (AI) powered engine can interface with various channels like emails, physical mail, etc. to accept the claims forms. These digitized forms can then be processed using the applicable business rules defined by the healthcare payer, and the claims can be automatically adjudicated without any human intervention.

If required they can be routed to relevant departments for further processing. The solution can be scaled to process varying volumes of claims solving the challenges of staffing and seasonality.

Payers also see an increase in claims processing speed and reduction in loss adjustment expenses.

2) Member Services

usecases-3 Claims processing status and updates contribute to a large percentage of customer calls to the contact center. Consumer behavior studies show that customers would prefer to help themselves if they could. For this reason, empowering the contact center with self-service capabilities is a relevant investment for customer experience management and to reduce overheads and expenses.

Contact Center AI makes life easier for customers as well as for the agents servicing them. The AI bot services the requests without human intervention. In scenarios that require additional checks or analyses, the bot intelligently brings in a live agent into the loop.

The bots can gather all relevant information about the caller and provide a single-pane dashboard to the agent, making it much easier for the agents to complete the service quickly instead of toggling between multiple screens to fetch the necessary data. This means that a live agent is only introduced into the contact center service loop in cases where advanced requirements need to be met.

AI can also be trained to gather sentiment analysis of the caller and detect potential issues before they actually surface. This capability empowers contact center managers to keep the number of incidents and escalations low.

Enrollments can also be carried out through self-service using Contact Center AI.

AI can be integrated into the customer portal in the form of predictive inputs in search tabs, intelligent recommendations for services and product offerings and in general to create a personalized experience for each customer.

3) Provider and Network Operations

usecases-3 The third area of focus for healthcare payers is to automate their provider and network operations. A review by the Centers for Medicare & Medicaid Services (CMS) showed that 52.20% of providers had inaccurate information like wrong location, incorrect phone number or the provider currently doesn’t accept new patients when the directory indicates that they do.

The review also showed that these discrepancies increased frustration for members. For example, a member trying to find a provider within the network is unable to locate the facility because of the incorrect address.

Automation technologies can effortlessly handle end-to-end member services and provide accurate provider data. Optical Character Recognition (OCR) with Artificial Intelligence(AI) can be used in data extraction and processing of medical records to automate Pre-authorization processes. This also ensures a smooth and seamless member experience.

Vendor payment processes are also ripe for automation. Automation solutions are scalable and hence handle fluctuating volumes of requests from members. It is also scalable and can accomplish autonomous data entry in processes.

Strategic implementation of Intelligent Automation (IA) into healthcare processes can help improve the patient experience significantly through efficient claims processes, personalized member services and accurate billing.