Medical bill review is a critical but complex process in the insurance industry, requiring compliance with varying state regulations while ensuring accuracy and efficiency. Manual entry and legacy systems often slow down adjudication, increase error risk, and reduce overall productivity. To meet the demand for scalable, accurate, and client-specific bill review, the company turned to automation with Decisions.
Challenge
Before implementing Decisions, the company faced several challenges:
- Manual bill entry and adjudication created delays and increased the likelihood of human error.
- Managing state-specific compliance rules was difficult and required extensive oversight.
- Reviewers lacked productivity tools to track progress and manage workloads effectively.
- Quality assurance required labor-intensive sampling and re-checking.
- Customers had limited visibility into bill status and resolution.
Solution
The company developed its flagship bill review application on Decisions, embedding automation and rules-driven workflows into the process. Key solution components included:
- Automated Adjudication: A rules engine applied state-specific regulations to ensure compliance and accuracy.
- Configurable Work Queues: IT defined end-to-end bill workflows that could be tailored for each client.
- Productivity Tools: Dashboards showed bills worked by reviewer and enabled search across multiple fields for quick resolution of pended items.
- Quality Assurance Sampling: Management could automate random QA checks, with workflows routing bills for review by a second reviewer.