RPA in Healthcare: How reimbursement process works

Some providers—mostly independent physicians—avoid the complex maze of healthcare reimbursement altogether by simply choosing not to accept insurance. Instead, they bill patients directly and avoid the administrative burden of submitting claims and appealing denials. Still, many providers can’t afford to do this. Participating on multiple insurance panels means providers have access to a wider pool of potential patients, many of whom benefit from low-cost healthcare coverage under the Affordable Care Act. More potential patients = more potential healthcare reimbursement.

By embracing RPA, healthcare providers can improve the patient experience while reducing costs and improving efficiency. Increased automation combined with more efficient processes will make the day-to-day easier for staff as they’ll spend less time on tedious manual work, and more time on patient wellness. 

When billing insurance, consider the following five steps that providers must take to receive and retain healthcare reimbursement:

  • Step 1. Document the details necessary for payment. Providers log into the electronic health record (EHR) and document important details regarding a patient’s history and presenting problem. They also document information about the exam and their thought process in terms of establishing a diagnosis and treatment plan. 
  • Step 2. Assign medical codes. Providers or certified medical coders assign medical codes in the electronic health record (EHR), or the EHR may suggest codes through automation. These codes translate narrative documentation into concise terms that payers use to understand what services physicians or other healthcare professionals perform and why. This includes International Classification of Diseases (ICD)-10 codes that capture diagnoses as well as Current Procedural Terminology (CPT) codes that denote procedures and services. 
  • Step 3. Submit the claim electronically. Providers may submit claims directly to payers, or they may choose to submit electronically and use a clearing house that serves as an intermediary, reviewing claims to identify potential errors. In many instances, when errors occur, the clearing house rejects the claim allowing providers to make corrections and submit a ‘clean claim’ to the payer. 
  • Step 4. Interpret the payer’s response. After a claim passes successfully through the clearing house, a payer reviews the claim and either adjudicates fully towards the allowable amount or rejects all or a portion of the claim. Payers communicate healthcare reimbursement rejections to providers using remittance advice codes that include brief explanations. 
  • Step 5. Prepare for post-payment audits. Although providers can take steps to identify and prevent errors on the front end, they still need to contend with post-payment audits during which payers request documentation to ensure they’ve paid claims correctly. If documentation doesn’t support the services billed, providers may need to repay the healthcare reimbursement they received.

Each of these steps takes time and resources, two of the most limited commodities in today’s provider settings. As the industry continues to pivot toward value-based payments, health information technology will play a critical role in streamlining processes and increasing efficiencies related to healthcare reimbursement.

How IntelliBuddies® helps
IntelliBuddies® - Buddies operates and executes the processes at a much greater speed than humans. It is bundled with essential intelligent automation tools and technologies, that helps the organization to streamline the following reimbursement processes—inputting data into EHR system, generating medical codes, submitting the claims through emails, interpret payers response, and preparing post-audit report operations without any human interaction seamlessly with the AI automations which includes concepts such as NLP, OCR, ML, speech and visual recognition bundled in the tool.

The Process Designer IDE tool provides large set of activity libraries, and an intuitive drag and drop interface to define the workflow so that anyone with minimal coding knowledge can easily start automating the processes by connecting individual activities to build a sequence.

Source: Continuum
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