Reimagining healthcare payer operations: the power of process intelligence

Vinay Mummigatti, EVP of Strategy at Skan

The healthcare industry is a complex ecosystem where efficiency is vital, especially for payers. They are the financial backbone of the system and reimburse providers for covered medical services, but the medical billing process is a delicate dance. As claims processors, payers strive for lightning-fast and accurate request processing, ensuring providers receive timely payments and patients aren't burdened with unexpected bills. Yet, they must also be fiscally responsible, controlling costs to ensure the sustainability of the entire system. Member satisfaction adds another layer of complexity, as payers want to ensure a smooth and positive experience for the individuals they serve. When this complex external landscape combines with their system's current internal difficulties, payers have found achieving this balance challenging.

Rising Health Care Costs: Pointing the Finger at Administrative Waste

Healthcare payers navigate a landscape riddled with challenges, and most obstacles stem from a lack of innovative administrative workflows and an overreliance on manual administrative tasks. Administrative spending covers the non-clinical costs of running the health care system. It includes tasks like billing, insurance processing, and general business operations. Although some administrative expenditures are necessary for a functioning system, they become wasteful when they exceed what's truly needed.

Studies have found that administrative costs eat up 15% to 30% of all medical spending in the US. Traditional methods often lack transparency, hindering the identification and rectification of inefficiencies in crucial areas like billing, enrollment, and contract management. This translates to a significant amount of money diverted away from direct patient care.

Here's why administrative waste is a major concern:

• High Costs: The sheer amount of money spent on administrative tasks could be better directed towards patient care and preventative measures.
  
• Inefficiencies: Complex billing practices, prior authorization processes, and many payers create unnecessary hurdles, wasting time and resources.
  
  

By streamlining administrative processes, reducing paperwork, and promoting greater standardization, wasteful spending in health care can be significantly reduced. This can lead to a more efficient system that prioritizes patient care and affordability, but this process starts with leveraging the right technology.

This combination of pressure and opportunity compels payers to embrace innovative solutions. Process intelligence acts as a beacon, illuminating every step within the claims processing journey. Analyzing vast amounts of data pinpoints bottlenecks, wasted time, and opportunities for automation, paving the way for a more streamlined operation.

Process Intelligence: A Data-Driven Revolution

Process intelligence leverages the power of AI to monitor and analyze operational workflows continuously. Imagine a digital microscope that provides a granular view of an organization's internal processes. Process intelligence equips payers with an unparalleled understanding of their operations by capturing and measuring real-time data on workflows.

This technology unlocks a domino effect of positive outcomes. Here's a closer look at how process intelligence fuels significant change within healthcare payer productivity:

• Accelerate Claims Processing: Enhancing workflows is essential for speeding up claims turnaround. Process intelligence highlights areas for standardization and automation, minimizing variability and processing time. Identifying and eliminating unnecessary steps and redundancies ensures quicker payouts for providers and boosts overall system efficiency.
  
  
• Streamline and Save: Repetitive tasks and unnecessary steps drain resources. Automating these activities frees up staff and eliminates waste, delivering tangible cost savings for payers. But process intelligence goes beyond. It lets users analyze precisely how much it costs to process each claim, eliminating unnecessary variations and optimizing the workflow by pinpointing areas that consume excessive time, effort, and money. This translates to significant cost reductions across the board.
  
  
• Improve Member Satisfaction: Streamlined claims processing creates a seamless experience for members. Prompt reimbursements to providers facilitate timely care, boosting member satisfaction and loyalty. Evaluating workforce productivity, process cycle times, and application usage can reduce turnaround times and minimize errors and rework, contributing to a more positive member experience.

• Refine Complex Health Care Payments: Many healthcare payer processes are full of hidden inefficiencies, making it hard to identify areas for improvement. Process intelligence can be a powerful tool to uncover these bottlenecks and ensure compliance, allowing for targeted automation.
  
  

Unveiling the Full Potential of Process Intelligence

Although streamlining workflows is undeniably valuable, process intelligence unlocks a trove of benefits that extend far beyond mere efficiency. Real-time data analysis allows healthcare payers to become proactive guardians of compliance. This translates to identifying and mitigating potential risks before they snowball into costly penalties. Process intelligence doesn't stop there; it is a powerful information engine that generates data-driven insights that fuel informed decision-making. With this intelligence, payers can strategically optimize processes, allocate resources effectively, and elevate operational efficiency.

Process intelligence equips healthcare payer operations with the tools to navigate the complexities of claims processing with unparalleled efficiency and control. By leveraging the power of AI and data-driven insights, payers can achieve significant cost reductions. Imagine faster turnaround times, leading to improved member experiences. Additionally, process intelligence ensures robust regulatory compliance, taking the worry out of navigating the ever-changing healthcare landscape.

This isn't just a technological advancement; it's a paradigm shift. The adoption of process intelligence positions payers at the forefront of innovation. It paves the way for a future characterized by streamlined operations, optimized workflows, and a commitment to delivering exceptional value to all stakeholders within the healthcare network.

About the Author
Vinay Mummigatti is the Executive Vice President of Strategy and Customer Transformation at Skan, a process intelligence solution that uses the power of AI to continuously deliver actionable insights into how work is done. Previously, Vinay worked as Chief Automation Officer at LexisNexis, where he was responsible for global intelligent automation, process excellence and continuous improvement organization. Vinay also previously worked for Bank of America and UnitedHealthcare where he led digital transformation, establishing a global Center of Excellence for automation and process excellence.