RPA in Medical billing

24 January, 2020


Today Healthcare systems changing fast, not just about patient needs but also in the area of Medical Billing and Medical Coding. Most Healthcare services performed between patient and doctor but much is left to be done when the patient leaves the doctor's office or Hospital. The medical Billing process is essential to healthcare providers as it allows them to receive reimbursement from an insurance company for the services which they have provided to a patient and thus keep their doors open for business always.

What is Medical Billing Process?

The medical billing process is not performed by a single individual. Medical Biller and Medical coder involve in front desk administration and back-office management as well. Unlike everyday transactions where we receive service or product and quickly pay the bill, whereas medical billing is a complex transaction. Communicating with the healthcare insurance company is a key role in the medical billing process.

The medical billing process starts right from the preregistration process where the Patient schedule an appointment with practice or facility or provider through an online portal, call or office visit. Patient information and health care insurance details asked for appointment registration that helps to establish financial responsibility. Based on the Patient insurance plan, the medical biller will determine which services to be covered and how much co-pay, Co-Insurance or OOP will be responsible. The Insurance Eligibility verifies coverage for the specific treatment that the patient is going to get. As per the appointment schedule, the patient visits the provider for treatment. After the patient has checked out, on every patient's chart the healthcare provider documents the procedure were performed and provides a diagnosis. That medical record then translated into codes by a medical coder, each code indicates what was done and why it was done or used by the physician. Next, a medical biller uses those code and include the cost of each service and prepare bill which called it as Superbill, to comprise a claim that would be sent to a patient insurance company for reimbursement against service or treatment has been given. The medical biller must ensure that the claim is "clean" before sending it to an insurance company.

Some facilities or practices decide to use clearinghouse for scrubbing and to format claims according to the specification of an insurance company and HIPAA compliance. HL7 standard with the help of mirth integration claims data can be transfer to a clearinghouse.

When the claim is approved, the provider or practice will receive reimbursement against the treatment or services provided. If the claim gets denied or rejected as per that medical record or claim get updated and send it back to the insurance company for reimbursement. Once the claim gets approved, the medical biller will attempt to recover patient responsibility expenses from the patient to settle down claim. This is done by sending a statement or invoices through the mail and calling the patient for reminding them to pay their bill. The analysis reveals that patients experienced annual increases of up to 12% in their out-of-pocket responsibilities for inpatient, outpatient and emergency department care in 2018. [1]

How to reduce costs?

The healthcare billing system is a financial process that utilizes medical billing software to track patient care experience from appointment scheduling, registration, coding, billing to the final payment of balances. Providers are depending on the payer and plan more than ever for reimbursement which is increasing the impact on clinical and financial performance. Nine percentage of healthcare claim gets denied initially, putting 3.3 percentage of provider revenue at risk according to a recent study. It cost providers $118 per claim, or a total of $8.6 billion in administrative costs each year, according to the same study. Industry experts estimate that approximately 90 percent of claim denials are preventable.[2] For example, absent or incorrect patient demographic information is one of the top reasons why payers deny claims.[3] Providers can prevent common claim issues like this by automating front-end workflows.

Typically, provider practices have difficulty to understand their cost to collect and understand numbers and translating them into action. The average claim denial rate is less than 5 percentage depends on practices according to the Medical Group Management Association (MGMA). If the practice denial rate is more than 5 percentages, then the provider has to dig in and try to understand the cause of it which will help providers to diagnose scope where improvement is needed and prescribe the right solution to protect revenue.

Keep less percentage of A/R greater than 120 days this would help to protect the practice financial health. Avoid delayed completion of the document which can have an impact on claim management that leads to revenue of the practice.

How to Improve Efficiency?

Automation is key to streamlining the healthcare billing system and to increase overall productivity and efficiency. Revenue cycle automation will reduce the administrative burden on healthcare professionals, streamline revenue cycle processes, and decrease human error and labor costs. However, practices should be implementing the right technologies to achieve efficiency. Provider practices must invest in healthcare billing system technologies that integrate into established workflows and legacy systems. To bring the revenue cycle up to speed can help providers adapt to the evolving industry by using technology.

Medical/Hospital Billing software

It would be hard to find a healthcare institution or non-institution without medical billing software. The use of software or solution for Patient Schedule, Appointment, to verify patient insurance eligibility, documenting medical or clinical records, medical coding, medical billing, and claim to the insurance company with just a click. Coding of a medical record, generating superbill and sending claims to Medicare, Medicaid or other insurance companies through this software.

Medical billing software helps to identify the key factors that have the greatest scope for improvement for practice to reduce cost. More sophisticated billing software can recall all diagnoses, HCPCS and procedure codes available. Such software can recall provider, patient, insurance, medical record information based on the previous office visit and previous claims to reduce duplicity and to reduce the time which allows the user to update the bill by adding or deleting items to the claim. To sum up, Automation is key to streamlining the healthcare billing system and to increase overall productivity and efficiency.

RPA in Revenue Cycle

The American Medical Association estimates that some payers suffer rework on over 20% of claims due to human data entry errors. Human data entry is a slow process and they do mistakes. The error rate for human data entry is 0.5%.[4] Human data entry error results in reprocessing a claim. Re-processing a claim costs up to four times higher than that makes it in the first place.

Payers ensure the accuracy of each claim at the onset. The Healthcare Billing and Management Association (HBMA) found that the frequency of overpayments, rejections, and denials of health insurance claims reaches 50%, mainly due to manual data entry errors and the high complexity of claims.

Solutions for Data Entry Errors:

A computer has relied on human operator manual efforts as the first step in performing their functions. But in the 21st century, such a manual process is being automated to reduce error to zero and speed up data-related tasks. In this context, automation is the linking of various systems, software, and applications so that they become self-dependent, self-acting and self-regulating. Today’s high requirement is data entry and data maintenance must be automated in the IT functions. In healthcare Member Enrollment, effective charge capturing, medical claims reprocessing, health plan updates, collection/Account Receivable, and more can be completed automatically and accurately. According to the Healthcare Financial Management Association (HFMA), a large chunk of net charges are lost because of charge capture leakage.  Robotic process automation helps to improve the pace of medical billing with precision and performance.[5] RPA Solution can be able to automatically perform repetitive and time-consuming data-related tasks faster than human operators with 100% accuracy. RPA Automation helps to gain in productivity, efficiency, cost-saving and provide data with quality.

The two keys factors for RPA making automation of data entry and related tasks in practical required are (1) software that allows the application to perform the data-related tasks now done by human operators and (2) the supervision where the supervisor can teach the software to do their job correctly.

RPA is a low-risk and fast-win business solution. RPA performs the data-driven task longer and faster than a human employee can enable the work to get done in time. Providers and payers with RPA programs are achieving significant benefits in an overall increase in net collection, overall gross revenue capture and reduction in claims denial.

Watch the video about RPA in Medical Billing

About Pronix

Pronix, the trusted global standard for solution development, process management and automation to enables both IT and BDMs to more quickly and easily create and manage simple and sophisticated business processes from back to front-end. We have the fastest way to build applications with the lowest cost and the highest satisfaction among our peers. We welcome the opportunity to discuss your business requirements and demonstrate our unique approach to workflow automation.

Pronix has developed a software solution which has been proven to improve the business operations, business performance, ROI, data accuracy and speed of data-related task performance for healthcare payers and plans which can intelligently automate the routine and repetitive tasks of data entry, data maintenance, integration, migration, aggregation, and testing – essentially any manual unstructured data process.

Pronix is experienced in implementing Business/Robotic Process Automation Solutions using various tools such as UIPath, BluePrism, Appian, Automation Anywhere, DELL Boomi.


Nikhil Ramteke
Healthcare Business Analyst, Pronix Inc


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