Automated health claims processing – case study

Health insurer achieves same day processing of medical gap and extras claims, while reducing claims resources by 30 percent.

Situation

Our client is an Australian not-for-profit health fund operating for more than 80 years. They wanted to enhance their service delivery processes to provide faster member reimbursements for a better member experience and reduce member churn.

In the first instance, extras claims made by a member are automated through EFTPOS processing solutions. In some circumstances, health providers are unable to process transactions electronically and the member is required to submit a manual claim by completing a form or uploading a copy of the tax invoice/receipt via a mobile/web application.

Medical gap claims are also made through physical forms by doctors, which require the health fund to process through to Medicare for payment processing.

Currently, this takes the client up to 10 days to process the claims due to the complexity of the forms and the differing data sets required to be captured against each extras modality and medical claim type. The client required 10 FTE resources to capture, input and assess the claims to ensure they are processed within the regulated timelines.

Solution 

The client required a solution whereby their extras and medical gap claims are classified by the type of tax invoice and health care service. This improves data captured for each type, and will achieve the following:

1. Improved data capture accuracy, leading to a reduction in over/under payments with Medicare.

2. Faster payment cycles to members.

3. Improved audit scrutiny over claims, by maintaining current data capture from forms or by increasing data capture required for validation.

By working closely with Computershare, the client expects to achieve automation and straight through processing of up to 85% of its medical gap claims and a minimum of 50% for extras claims. 

Where Computershare are unable to capture 100% of the required data, our automated workflow process presents the claim via an exception portal for the client’s claims team to complete, ensuring accuracy of claim data. This allows same-day processing by Computershare and the minimal data entry for the claims team to complete a claim. 

The new solution will allow the client to reallocate 30% of its claims processing resources to other areas of the business and increase customer satisfaction with faster reimbursements​.

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