Five results that might just make robotic process automation worth your while

So how can RPA be applied in healthcare? Here’s a real-world example.
09:12 AM

There’s no shortage of industry buzz surrounding robotics, artificial intelligence, machine learning and other next-generation technologies. While some of these are still coming into their own where healthcare is concerned, others are well proven to help automate and streamline processes that traditionally have required manual intervention.

Take robotic process automation (RPA), for example. RPA is not an android or robot, but rather a computer program operating as a recording of human interaction. It records activities like typing, checking for errors, and cutting and pasting between applications. Once the recording is created, logic can also be added as needed. The technology then can be strategically implemented to streamline the administrative process by enabling the computer to execute basic tasks that then can free resources, time and capital. 

While some may write off the technology as old-school “screen scraping” or macros, new robotic automation capabilities extend well beyond those offered by older solutions.

So how can RPA be applied in healthcare? Here’s a real-world example of its use by a health plan (“the Plan”) – with some impressive metrics.

Like many payers in today’s market, the Plan faced cost restrictions and limited resources. However, the business still needed to focus on growth, so its leaders set a significant goal to triple the size of enrollment over a five-year period. The Plan had two priorities:

1) Achieve its growth goal with little to no increase in administrative costs, and

2) Maintain claims-processing quality and timelines.

The Plan decided to use RPA based on studies showing that the right technology can automate an estimated 70 percent - 80 percent of typical rules-based processes.1 They researched and selected a new front-end, electronic claims-processing tool that included robotic automation support.

After a two-month implementation cycle, the solution was up and running. Although the build-out continued over time, the five robotic claims processors helped the organization successfully achieve its growth potential with extraordinary outcomes over the five-year period. The results speak for themselves:2

  1. Membership tripled – Membership went from 35,000 to 100,000
  2. Clean claims processing reduced by 90 percent – All clean claims were processed within five business days, reduced from 30 days. Additionally, all claims were processed in 30 days, down from 45.
  3. Claims processing audit errors went down by 1.5 percent – The initial error rate was at 2 percent, and after implementation, the error rate dropped to less than 0.5 percent.
  4. Claims backlog was eliminated – Claims that didn’t initially match to a provider record were automatically recycled. After the RPA made an initial match with a single claim, they were processed without further manual intervention. Over time, this eliminated claims backlog, which also increased provider and member satisfaction.
  5. Auto-adjudication rate jumped to 98 percent – After implementation, the organization set out to use the solution to eliminate every repeatable manual claims processing step, which led to a 98-percent auto-adjudication rate.

The success didn’t stop there.

Once the initial set-up was complete, it quickly became apparent that the technology could be used in other areas to replace wasteful manual processes.

After just a few hours of programming, the solution updated more than 3,000 provider data records in less than four hours. On another project, it took about a day and half of programming to enable the re-adjudication of more than 68,000 claim lines, a project that would have taken the claims staff at least two weeks to complete. With the use of the automated solution, all 68,000 adjustments were successfully processed in less than three days with 100-percent accuracy and no resulting processing backlog.

HEDIS quality scores climbed above the statewide average.

Another opportunity presented itself when the Plan discovered that many of its providers were incorrectly coding adolescent well-child visits as sick visits. The result was a significant drop on that measure in the Plan’s HEDIS quality scores. Fixing the issue required provider outreach and resubmission, including the submission of a reversal record and a replacement record for each claim that had been billed in error. Using the automated robotic solution, the Plan enabled the reversal/correction process, which led to more than 7,000 claim lines being resubmitted with the appropriate diagnosis coding. The result pushed the adolescent well-child quality score above the statewide average.

It’s clear the success of RPA on the organization was expansive. However, the success went beyond the technology. The Plan worked with a team of experts that understood the business needs and helped translate those needs into projects that could properly leverage the robust capabilities of the solution. Implementing the right technology is vital, but having a great partner to help support, enable and execute the project to drive the best results is an important piece of the puzzle.

Today more than 30 percent of organizations rely on manual steps in more than half of their business practices, with 22 percent of employee time spent on menial labor.1 Unlike other IT- focused initiatives, RPA carries less risk and greater reward with rapid, low-cost deployment opportunities. RPA solutions can help your organization save time and money as well as boost employee morale by removing tedious tasks from their day-to-day operations. In addition, they can help you reduce error and improve quality.


  1. The Raconteur, Robotics & Automation Special Report, June 28, 2017.
  2. All results in the real-world example represent the client’s unique experience based on customization efforts and product usage. Change Healthcare does not guarantee every organization will have the same results or experience.

About the Author: 

Toni Bonde, Healthcare Consultant, Change Healthcare 


© 2017 Change Healthcare LLC and/or one of its subsidiaries.

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