RPA – Managed HealthCare


In a mainframe claims processing platform, programing intricate processes that are required to automate complicated and dynamic claims, is too slow and expensive. Since most of the decisions necessary to automate a MHC claim are rules based, use structured data, and relate to relatively stable processes, RPA’s non-code invasive nature makes the SDLC process unnecessary. This greatly enhances the speed at which RPA developers can create claim bots, far less expensively than any other automation method.

Claim related Grievance and Appeals (G&A) cannot be denial without a review by appropriately trained and licensed reviewer. RPA can be use to review and reject for appropriate documentation and to allow the Grievance or Appeal by simple review of basic information with Cognitive technologies like NLP. Down coded claims like emergency room E&M procedure or units of occurrence are some examples.


The client presented an opportunity to deliver a proof of concept if RPA can be adopted in customer service department:

  • Determine if Grievance and Appeal type handled by RPA
  • Develop a RPA Process – Check for Appropriate Documentation and Reject if not present
  • RPA process must Adjust Related Claim (s) and determine if Grievance or Appeal allowed
  • Automate the process to generate response letter, update and close Grievance and Appeal tracking


The Results

  • Implemented RPA in 8 Weeks
    Based on the complexity of the process, it took us 8 weeks to automate. Quick & Efficient
  • 100 % Accuracy
    Robotic decision making and outcomes were predictable, consistent, and 100 percent accurate.
  • 80% Increase in Productivity
    A process that takes 15-20 mins to complete was completed under 1 minute using RPA
  • 100% Compliance
    Robots were programmed for compliance issues and alerted employees on compliance issues every time so decisions can be made safely
  • 40% Labor Reduction
    RPA implementation lead to reduction in work force by 40%.