Healthcare Payers and COVID-19: Unlocking Value With Intelligent Automation

Health insurers have less control than many other businesses over the factors that are fundamental to their operations and profitability. Regulatory changes, peaks and valleys in claims volume and medical innovations that create questions about coverage all have a significant influence on the industry. Work processes that may have been considered efficient or even industry-leading now may represent a competitive disadvantage. In the face of these challenges, health insurers need to optimize where they can.

These industry fundamentals were well established even before the current crisis provided a stark reminder. COVID-19 is disrupting the Healthcare industry in both expected and unexpected ways. For example, U.S. Healthcare payers have promised that patients will not need to pay for coronavirus testing and treatment. However, the process of managing treatment coverage is uncertain, leading to confusion over how claims are coded, billed and adjudicated. The rapid response to containing the virus led authorities to lift licensing and interstate treatment restrictions on the use of telehealth, which helped lead to an unprecedented surge in telehealth consults but left billing questions in their wake. Amid the coronavirus crisis, the Centers for Medicare & Medicaid Services issued its Interoperability and Patient Access final rule, which requires health insurers to put in place processes for standardized payer-to-payer data exchange by 2022 and to have APIs for patient-data sharing by the start of 2021.

These developments reinforce the need for health insurers to control and improve the variables they can control. Extending automation into claims processing represents one of their best opportunities. It costs health insurers approximately $4 to manually process a claim that requires human intervention, whereas an automated claim costs only $1.25. 

Intelligent automation — the combination of robotic process automation (RPA) and artificial intelligence (AI) — has created opportunities for payers to achieve unprecedented levels of efficiency while improving customer engagement. Applying intelligent automation to claims processing currently represents one of the strongest levers that payers can pull to take costs out of their operations.

This ISG white paper identifies why claims processing is a good process to target, how RPA and AI create sustainable value and how insurers can take advantage of the opportunity.

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About the authors

Robert “Bob” Krohn is a Partner and Healthcare Practice Lead at ISG. He has an extensive background in business process optimization, organizational design and execution including the direct oversight of numerous outsourcing contract negotiations. Bob is an ISG Digital Expert and a speaker/ blogger on emerging trends in Healthcare.

Sakshi is a lead analyst with ISG Provider Services. She assesses the impact of emerging technology across Finance & Accounting and the Healthcare vertical. She also tracks market movements and key trends that influence the global sourcing industry. Prior to ISG, Sakshi has had stints with Accenture and Automation Anywhere.