Conquering the Costliness of Complex Medical Claim Queries

Posted by Susan Berndt on April 29th, 2021
Susan Berndt
Susan is a creative marketing professional with a demonstrated history of working in the hospital & health care industry. Susan joined Smart Data Solutions in 2016 focusing on marketing strategy, campaign execution and creating an inbound marketing funnel. She has over 10 years of marketing/advertising experience and over 12 years of customer service experience.

Workflow costs reduced by 68%, improved quality and reduction in turnaround time by 72%.

Medical claim queries are highly complex workflows that are often free form, without clear or simple structure. These queries may be initiated by multiple parties such as patients, providers and lawyers. Documents are as large as 100 pages with dense, complicated medical claim and diagnostic information. Medical claim queries are also subject to a wide range of regulations from patient privacy to requirements for accuracy and turnaround time.

The Client Challenge

Smart Data Solutions stepped in to help a client get control of an internal and manual medical claims processing workflow that was both problematic and costly. The workflow output included indexing, categorization and identification of tonality. The manual workflow was problematic for three main reasons:

The SDS Solution

Smart Data Solutions gave the client’s complex workflow a better than human brain solution by leveraging proprietary AI and machine learning capabilities to automate the majority of the workflow. The agility, speed and self-learning qualities of the SDS system resulted in improved automation and quality over time.

The Results

Conquering the Costliness of Complex Medical Claim Queries 1

The client’s overall workflow costs were reduced by 68% while quality improved. An important objective also was achieved in terms of regulatory compliance. Turnaround time for processing of medical claims queries was reduced by 72%.
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