Planning and execution
HGS’s team of 10 design and development resources identified and validated processes and supported both pre-work and pend code architecture design, development, implementation, testing, and documentation. The scope of RPA, leveraging 25 bots, addressed both medical and hospital claims at pre-work, with initial steps for solving an edit in manual adjudication to validate provider, subscriber, member, billing, coordination of benefits, and determination of content cleanliness. All steps were rule-based.
For the pend codes process, inefficiencies in payment were identified without referral authorization, for a downstream impact on rework and calls. By bucketing the claims and automating validation, duplicate logic/follow-up logics could be avoided and more accurate, quicker identification of claims for payment were released, for significant end-to-end process improvements on client payments.