Digital case study claims processing

​​​​​​Client profile

The client is an Australian not-for-profit health fund. Operating for more than 80 years, it focuses its business strategy on offering affordable, personalised and holistic products and services to its 230,000 customers.

Situation

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 claim 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 these 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 currently receives more than 100 manual claims per day, requiring 10 FTE resources to capture, input and assess the claims to ensure they are processed within the regulated timelines. The client wanted to enhance its service delivery processes to make it faster for their members to receive their reimbursements, leading to a better experience and less member churn.

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 leads to improved data capture for each type, and will achieve the following:

• ​Improved data capture accuracy, leading to a reduction in over/under payments with Medicare
  
• Faster payment cycles to members
  
• Improved​ Audit scrutiny over claims, by maintaining current data capture from forms or by increasing data capture required for validation
  

Computershare's experience and continuous investment in the private health insurance industry, will provide the client with access to best practise business rules and enabling Straight Through Processing (STP) for complex claim types. The client expects to offer multiple complex data capture scenarios using one software solution, by integrating data capture, workflow and the claims processing system. This will enable the client to only intervene on the exception. ​​

Results

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 up to 50% of its Extras Claims. Where Computershare are unable to capture 100% of the required data, the claim will be presented in an Exception Portal for the client's claims team to complete and send through to the relevant Claims Processing system, ensuring 100% accuracy of claim data.

This will further enable same-day processing by Computershare and enables the claims team to perform minimal entry to complete a claim. In addition, the new solution will allow the client to reallocate 30% of its claims processing resources to other areas of the business by improving efficiency in its business processes. ​