Claims Status Success: Automation and Segmented Workflow

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According to the 2020 CAQH Index, claim status inquiries have the highest savings opportunity per transaction of any revenue cycle task that the index tracks. While electronic claim status inquiries are at about 72% nationally, there is still an incredible amount of room for improvement. Claims management platforms allow for manual creation of a 276 inquiry and receipt of the 277 response, but it isn’t automated and many rev cycle teams don’t even utilize that capability at all, relying on historical processes.

Staff are still picking up the phone, emailing or sending a fax (good heavens!!!) to check claim status. This is an incredibly tedious and costly task. In 2020, there were 238 million manual claim status inquiries. EACH inquiry takes approximately 20 minutes and costs the health care organization or provider $9.37. Even accessing a payer portal, there are keying errors and a need to again manually update the practice management or hospital information system. As health care organizations face staffing shortages and have a definite need for accuracy and efficiency, continuing manual operations is simply not feasible.


Automating claim status inquiry is the first step. The generally accepted industry average is that a typical rev cycle employee can work about 400 accounts per week. There is good precendent that claim status inquiries are well suited for bots. Digital workers handle the mundane and repetitive tasks more accurately and efficiently, allowing humans to focus on the high-value exceptions/tasks that require judgement. The bot can work approximately 4,740 accounts per week at an average cost of $2.40 per account. That is 1100% increase in efficiency combined with a 75% reduction in cost plus the added bonus of improved employee satisfaction.


The second step is prioritizing the work queues. Staff having to guess which accounts to work without any particular order, leads to missed opportunities and lower collections. Crowd sourced data prioritization based on years of experience and the ability to collect brings additional efficiency to the process. It creates intelligent segmentation of all accounts in the inventory based on 5,000+ business rules and historical perspective. Then it produces recommended actions driven by machine learning technology in a consumer-like experience familiar to users, which speeds adoption and employee satisfaction. This ensures 100% accountability for the entire portfolio of accounts while providing management immediate and direct access to productivity reporting.

Interested in learning more? The team at VisiQuate is focusing on how we can help hospitals optimize their revenue cycle management. Visit our Revenue Cycle Playbook for step-by-step plays to help you stay on top of the ever-changing landscape of healthcare revenue cycle, or contact us to schedule a demo.

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