To accelerate payments to its health plan clients, this healthcare services provider embraced a highly digitized, automated approach to claims capture and processing, underpinned by Kofax Claims Agility™. Today, the company can process medical claims up to 50 percent faster, while newfound efficiency will allow the company to take on a four- or five-fold increase in workload while keeping headcount flat, supporting profitable growth.

The Challenge

This company helps health plans, including Programs of All-Inclusive Care for the Elderly (PACE) organizations, to efficiently co-ordinate end-to-end operations—from electronic health record (EHR) management to claims adjudication and processing.

Traditionally, the company relied on manual methods to handle claims. Clients submitted claims in paper form, and employees manually keyed the information into the company’s core electronic health record (EHR) solution, which is used to process and adjudicate the claims.

Each claim form may span one to many pages, and each form page comprises 150-250 fields on average, with the most complex forms containing as many as 400 fields. Due to the massive volumes of information involved, the manual entry of data into the EHR system was tedious and time-consuming. What’s more, relying on human input resulted in high error rates, causing costly re-work that only delayed processing further.

A spokesperson explained: “In recent years, our business has grown to serve more clients and process more claims. Because we relied heavily on manual processing, we were struggling to keep up with the soaring workload. As claim volumes grew, backlogs became increasingly common and, during periods of peak demand, there was often a three- to four-week lag time between receiving a claim and submitting it for processing.”

Recognizing that these delays impacted their ability to serve health plans and their beneficiaries well, and also exposed health plans to late payment penalties, the company was keen to find a way to make claims processing more efficient. By enabling its teams to process a greater number of claims, the company would be able to scale up to take on the growing workload. At the same time, the company looked to improve the accuracy of information-capture processes, in order to reduce the risk of errors and cost of associated re-work.


The Solution

The company selected Kofax Claims Agility as the foundation of an automated and digitized approach to claims processing.

“Kofax Claims Agility ticked all the boxes for us,” said the spokesperson. “It offered precisely the capabilities that we were looking for in a single package. We also wanted a solution that we could deploy quickly, then customize to fit the needs of individual clients, and Kofax certainly met that requirement.

”Today, the company takes advantage of Kofax Claims Agility to transform paper claims into a digital format for automated processing. Whenever a new claim arrives, it is scanned, data is automatically captured from the image using optical character recognition (OCR), and then validated for completeness and accuracy within Claims Agility. The relevant data for """"clean claims"""" is then converted to EDI and routed to the EHR solution for processing—eliminating the need for employees to manually key in data and apply business rules.

The company has already rolled out the new solution to one of its health plan clients, and expects to go into full production with up to 12 clients in the coming months.


The Results

The new approach is already delivering positive results—boosting the speed and accuracy with which the company can capture and process claims.

The spokesperson noted: “Preliminary results have shown that Kofax Claims Agility has cut average processing times for claims by 30 to 50 percent. Whereas in the past, it could take up to a month to enter new claims requests into the system, we are on track to cut this timeframe down to less than seven days in the near future—enabling faster reimbursement or a prompt response to the client if the claim is denied.

”With Kofax Claims Agility bringing unprecedented efficiency to information capture, the company can accommodate new customers and rising claim volumes, all while keeping a tight rein on costs.

“We anticipate that Kofax Claims Agility will enable us to process more than 100,000 claims a month in the future—a four-to-five times increase on current volumes,” remarked the spokesperson. “What’s more, we expect to absorb this huge spike in workload while keeping staff levels flat, ensuring that business growth does not come at the cost of profitability.”

Previously, the company had to ensure that the people entering data from claims forms had good knowledge and experience of health insurance claims processes, otherwise data could be submitted incorrectly. By eliminating manual data entry, the company has freed up these skilled resources for higher-value work. And, they are now able to hire less skilled, lower cost resources to process claims, an unexpected benefit.

Increased automation has not just saved time; it has also enhanced the accuracy and integrity of claims-related data. The solution automatically flags discrepancies with captured data through pre-determined business rules, ensuring that only "clean claims" flow into back-end systems and processes.

“With a more rigorous pre-adjudication process, we reduce the risk of errors creeping into downstream workflows where they are more difficult to correct,” explained a spokesperson. “That helps us ensure fast, accurate payments to our health plan clients and deliver a more responsive, reliable service.”The spokesperson concluded: “With Kofax, we have taken claims processing to the next level. Teams are working faster and more efficiently than ever before, and we now have the solid foundation we need to keep growing our business and deliver consistently excellent service to our healthcare partners.”