Case Study
UST SmartOps AI-powered automation solution helped a U.S. insurance company accelerate claims data approvals by 67%
OUR CLIENT
This insurance association, which aims to provide affordable healthcare, is a federation of many independent companies that collectively insure more than 100 million people in the U.S. The organization operates across the country, several U.S. territories, and many additional countries. It also administers Medicare insurance plans in several regions across the U.S.
THE CHALLENGE
Cumbersome, error-prone, manual claims audit processes slowed productivity and efficiency
The company struggled to manage and validate the large volume of claims reports submitted by its affiliated companies for audits. A small 5-person review team manually audited several thousand records each month—a process that consumed over 500 hours each month. This tedious process was prone to human errors, causing inaccuracies in report validations. These errors, combined with the time-intensive process, led to frequent escalations from stakeholders and consistent breaches of service level agreements (SLAs). The validation delays negatively impacted operational efficiency and compliance. To compound the situation, the existing portal used for validating claims reports was inefficient, with slow loading times further hindering the review team’s productivity. The sluggish system exacerbated the already time-consuming, tedious, manual audit process.
Because of these issues, the company could not easily scale its audit processes to accommodate a workload increase and more stringent compliance requirements. As a result, the company struggled to maintain consistency and accuracy in its claims audit process, negatively affecting both internal operations and external relationships with affiliate companies. The company needed an automation solution to accelerate processes, reduce human errors, and improve audit accuracy.
THE TRANSFORMATION
UST’s automation solution replaced manual processes and accelerated claims validations
UST delivered an automated solution, using UST SmartOps intelligent automation platform, to streamline claims report validations. UST SmartOps automated workflows using a rules engine to fetch data from the data warehouse, generate reports, validate the data against predefined criteria, and generate validation scores. UST developed a custom UI portal, enabling users to see the validation reports and make approval or rejection decisions quickly. Users can also review audit results at a granular level to understand validation criteria. These automated processes significantly reduced manual effort and minimized errors.
The UST SmartOps claims report validation solution continuously monitors incoming reports by regularly querying the data warehouse. As new reports are detected, the solution triggers automated workflows to generate the associated reports, ensuring timely report creation without manual intervention. The rules engine validates report data against set criteria, automatically flagging any failed validations for further review. In cases where the rules engine detects issues, the solution sends automated emails to the appropriate team, ensuring swift issue resolution and operational efficiency. After each workflow is complete, validated report data is stored in a standardized format in a database, making downstream data retrieval easier and more consistent.
The health insurance company now has an AI-powered automation solution to audit large volumes of claims reports in real time, reducing manual workloads, enhancing speed and accuracy in claims report validations, and improving SLA compliance and operational performance.
THE IMPACT
Massive productivity gains reduce processing cycles and speed decisions
The company achieved these remarkable improvements in operational efficiency after the UST SmartOps AI-powered process automation solution was implemented:
- 75% reduction in processing effort for report generation and validation—by eliminating manual interventions, increasing productivity, and allowing the team to focus on more strategic tasks
- 66.6% acceleration in approval or rejection decision-making process—thanks to the user-friendly portal, automated validation scores, and granular view of validation results, providing critical information to enhance business decisions
- 100% SLA compliance—because the automated process ensured that all tasks related to report validations were completed on time, reducing operational costs and enhancing the company’s reputation for reliability and timeliness in its claims audit processes
In addition, the automated solution helped prevent errors and escalations, improve accuracy and data quality, reduce rework, and increase visibility and control over the entire operation. The solution also positioned the company to scale its operations to handle increasing report volumes without adding extra resources.
If your company wants to automate manual processes, accelerate decision-making, and increase operational efficiency, sign up for a complimentary business process automation assessment.
RESOURCES
https://www.ust.com/en/industries/healthcare