High attrition of medical allied professionals
Most healthcare insurers employ allied health professionals for back office functions such as claim pre-authorization and adjudication. However, staffing is problematic as these professionals’ first preference would be to work in a clinical setting, as these provide stepping-stones for overseas career opportunities. Not surprisingly, healthcare back office operations often struggle with high employee turnover, and the corresponding productivity loss, processing delays, and customer service issues.
Challenges : Improve the turnaround time of claims processing to realize prompt-payment discounts.
High attrition of medical allied professionals
Delayed claims processing
Prompt-payment discounts offered by service providers are forfeited
Solution : Auto-adjudicate claims with machine-learning algorithms
MediLink enhanced business rules with machine learning algorithms to auto-adjudicate claims based on consistency of patterns recognized from past experience.
Incorporated statistical rules and limits to flag suspected fraud;
Employed supervised learning from three years of data to label incoming claims as “Approved” or “Referred” for human verification;
Continually improved machine learning performance by incrementing training data with correct labels.
Impact : Significantly shortened turnaround time, big savings in processing cost and increase in realized discount
55-60% of claims are auto-approved in the initial trial with 95% precision rate
Millions realized in discounts for timely payment of claims
Case Study