Claims leakage is a huge issue facing the health insurance sector. Under immense pressure to process claims in a short time frame, claims handlers are forced to accept high levels of leakage to avoid delays.
According to PwC, claims leakage is primarily caused by three factors: human error, sub-optimal processes, and legacy technology. Sprout.ai gives health insurance companies the power to stop claims leakage in its tracks, by supporting claims handlers to process healthcare claims more quickly and accurately.
In this article, we dive into the power of leveraging generative AI in healthcare claims to significantly reduce claims leakage.
Claims processing before Sprout.ai
Without Sprout.ai, health insurers have only two options to process claims.
1. Manual claims processing
Manual claims processing is a slow process. It can minimise leakage, but also risks high operational costs, poor customer experience, and human error.
2. Building DIY rules-based claims processing
Businesses desperate to improve their insurtech capabilities might try to build their own rules-based claims processing software.
However, this is labour-intensive and requires in-house expertise that many insurance providers simply do not have.
DIY rules-based claims processing often results in excessive rules that notify handlers too frequently. This eliminates any potential time or cost-saving benefits.
It also makes achieving sufficient accuracy and effectiveness nearly impossible.
What needs to change
Health insurers face unique challenges, from high volumes of unstandardised documentation to skilled staff shortages.
By bringing in claims automation software that can handle simpler claims in a fraction of the time, claims handlers can dedicate their time and expertise to more complex claims.
However, manufacturing the software necessary in-house is unlikely to yield the desired results.
The insurers who will succeed in a challenging sector are the ones who invest in easy-to-implement, AI-powered software that empowers them to process claims with accuracy and speed.
Read more: Out-of-the-box claims solutions vs. building a bespoke solution
How Sprout.ai can benefit insurers
By implementing AI-powered claims automation, insurers can benefit from a more efficient and accurate claims process flow.
Data-based decision-making
Claims handlers have to review each case with care and attention to detail. This requires a lot of time and puts significant pressure on handlers.
From claims filing at the FNOL stage to policy checking and intake processing, the volume and variety of relevant information means that claims handlers are quickly consumed by administrative tasks rather than dedicating their time to complex cases that require human empathy and nuanced decision-making.
Sprout.ai leverages automation to review all available data across documentation. It can recognise over 450 different document types, automatically extract the relevant information and validate it against policy documents, notifying claims handlers of any inconsistencies quickly and accurately.
This supports claims handlers to make a more informed decision while expediting the claims process.
Faster claims processing
It takes time to process each claim manually and accurately. For some health insurers, it can take up to 2 months to resolve claims, potentially leaving customers out of pocket or without the medical treatment they need.
Claims handlers are often stuck in an impossible situation, trying to expedite the claims process, without sacrificing accuracy. The reality is that attempting to balance both objectives within a manual claims process leads to increased leakage, claims delays, dissatisfied customers and burnt-out claims handlers.
Sprout.ai uses Natural Language Processing (NLP) to contextualise relevant data and validate it against the customer’s claim. It also automatically calculates limits, excesses, inclusions, and exclusions.
This doesn’t just make claims processing faster but reduces leakage in the process.
The average claims processing time with Sprout.ai is 20 seconds, and remains under 1 minute 95% of the time.
Higher staff retention rates
This can lead to workforce attrition, with staff feeling overworked and finding themselves unable to focus on the parts of their job they enjoy the most.
The insurance sector is facing a shortage of skilled claims handlers. Insurers can’t afford to let capable talent go.
Sprout.ai handles the manual aspects of the role that staff find most frustrating, from document reviews to data analysis. It even provides staff with predicted outcomes.
It can also handle simpler claims that can be resolved in seconds, freeing staff up to support claims that require a human touch.
Increased customer satisfaction
The customer landscape has changed dramatically since the pandemic. From e-commerce to dining out, consumers have come to expect instant service that’s hassle-free.
The insurance sector is no different. While customers deal with a health crisis, they want their healthcare interactions to be quick and seamless.
Customers being made to wait days or weeks for claims to be resolved has a big impact on their relationship with their insurer. Choosing between improving this relationship and reducing claims leakage can feel impossible for insurance providers.
Sprout.ai helps speed up the claims process from weeks down to seconds, without sacrificing accuracy. This eliminates the need to choose between speed and attention to detail for insurers.
Read our report: Customer Experience | The Claim Handler’s Perspective
Automation holds the key to the future of healthcare claims
For health insurers, looking to minimise claims leakage, while keeping customers happy, adopting claims automation is a clear solution.
By leveraging automated tools such as Sprout.ai, insurers can significantly reduce their leakage, minimise human error and provide claims handlers with the data and bandwidth they need to effectively assess claims.
