Streamlining Health Claims: Embrace Automation with These 5 Effective Methods

11th September 2023

In the aftermath of the COVID-19 pandemic, the highly underpenetrated health insurance industry has reported stellar growth of 23% in 2022-23, according to the RBI’s latest Financial Stability Report. And yet, only 35% of the non-life players have posted underwriting profits in FY19-FY22.

Struggling with the pitfalls of traditional claims processing methods, which involve serious delays, errors, and leakages, harming insurer profitability and consumer interest in the long run, health insurers must take action to automate their medical claims processes.

The IRDAI’s recent mandate to cap all expenses at 35% of the gross premium will further squeeze the fortunes of health insurers, leaving them no choice other than to streamline their operations. In this article, we will outline how Indian insurers can automate their health claims processing systems.

Effective Ways to Deploy Claims Processing Automation

Enabling the end-to-end digital processing of health claims is far from easy, as it involves a myriad of steps, from health information extraction and verification to claim payouts.

The presence of multiple stakeholders that maintain their data in different formats, the subpar scalability of OCR solutions to consolidate digital data, and poor data integration and sharing practices present critical challenges to automating claims processing.

However, it is precisely these areas that present the scope for automation.

1. Data Standardization: Given the involvement of several hospitals, medical clinics, pharmacies, and labs that follow their own reporting rules and data storage formats, centralizing and standardizing their unstructured and disparate data is one of the easiest ways to automate medical claim processing.

2. Workflow Streamlining: Insurers can streamline their workflow by eliminating routine, repetitive tasks and automating them using Robotic Process Automation (RPA) tools. RPA automates data extraction from claims documents, helps prioritize tasks requiring human touch, analyzes processes for efficiency, and improves service delivery levels.

3. Claims Prioritization: By deploying rules-driven Intelligent process automation (IPA) tools, insurers can classify and prioritize the health claims made based on insights gleaned from previously submitted documents. This helps determine the policies that require specialized resources, subsequently reducing operating costs and hastening the claim payout.

4. System Integration: Instead of toggling between diverse systems to homogenize submissions by various claimants and process medical claims, insurers can unify their platforms by ensuring seamless integration with their underwriting and accounting cores.

5. Fraud, Waste, and Abuse (FWA) Minimization: Claims processing automation can yield the highest benefits by eliminating FWA, which annually totals Rs. 600-800 crore. Using AI and ML technologies, as employed by Perfios Health Claims Automation Solution, to extract and analyze the data for suspicious activity and fraudulent claims, insurers can save costs, bringing down premium prices in the long run.

Automating Claims Processing Using Perfios Health Claims Automation Solution

While automating multiple aspects of the claims processing system in chunks is one way to improve financial health and reputation, health insurance firms can benefit even more by using Perfios Health Claims Automation Solution.

Supporting a robust data framework, capable of reading and analyzing various data formats spanning medical, financial, claim forms, invoices, and more without data loss, Perfios Health Claims Automation Solution is the true game-changer in the claims payout business. Its unique features include:

Straight-Through Processing: Perfios Health Claims Automation Solution ensures end-to-end digital transformation of claims processes, starting from the identification of fraudulent, wasteful, and abusive activities and ending at health claims payout, driving down claims processing times by 3x.

Superior FWA Detection: Perfios Health Claims Automation Solution leverages its proprietary data standardization libraries driven by policy-specific deterministic rules and ML algorithms to automate suspicious claim detection, thereby resulting in better auto-adjudication.

Quick implementation: Insurers can frictionlessly integrate Perfios Health Claims Automation Solution into their systems in fewer than three months, eliminating the need to develop their own automated models that require vast troves of data for training.

To summarize, health insurance firms can greatly benefit from automating their claims processing systems, as it will bring down costs, minimize FWA, and improve service delivery and customer satisfaction levels. Perfios Health Claims Automation Solution helps deal with automation challenges by standardizing data consolidation and improving the recognition of fraudulent medical claims, resulting in cost savings.

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About Perfios: Perfios Software Solutions is India’s largest SaaS-based B2B fintech software company enabling 900+ FIs to take informed decisions in real-time. Headquartered in mumbai, India, Perfios specializes in real-time credit decisioning, analytics, onboarding automation, due diligence, monitoring, litigation automation, and more.

Perfios’ core data platform has been built to aggregate and analyze both structured and unstructured data and provide vertical solutions combining both consented and public data for the BFSI space catering to their stringent Scale Performance, Security, and other SLA requirements.

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