Health Plan Operations
Health plan operations are complicated; increasing volume coupled with the demand for qualified claims professionals has made claims management in today’s world, difficult.
Even beyond the demands of day-to-day production, claims operations leaders must stay abreast of constantly changing regulations and ensure that their business processes are efficient and up-to-date.
Much of a claims examiner’s day is filled with manual repetitive tasks that while vital to operations, are tedious and can leave room for human error.
Faced with these common challenges, many payers are looking to try something new to help improve their processes. For some, this leads them to leverage automation to help meet these demands.
In this case study we will examine how SymKey helped one health plan streamline its claims reprocessing strategies and do the work of ten claims processors with minimal effort.
About UPHP
Based in Marquette, MI, Upper Peninsula Health Plan (UPHP) is a managed care and provider service organization that has been serving residents of the Upper Peninsula for more than twenty years.
Total Membership: 58k
They provide health coverage for individuals enrolled in Medicaid, the Healthy Michigan Plan, MIChild, Children’s Special Health Care Services, and MI Health Link.
UPHP is an organization that is committed to advancing the health and well-being of the communities they serve. Because of the unique needs of their community, they are an organization that thinks outside the box to find solutions that deliver value to their members.
With over 58,000 Medicare and Medicaid members and over 75,000 claims per month, one thing is certain: they process and reprocess a lot of claims.
The Challenge
Health plans that focus primarily on government programs are accustomed to frequent changes such as provider billing requirements, fee schedule changes, and eligibility updates. UPHP was facing the all-too-common scenario of managing daily production volume while tackling special reprocessing projects.
To keep up with demand, they may have been forced to hire additional claims processors or they may have needed to ask more of their examiners who were already working at capacity. The team was looking to work smarter, not harder and they knew they needed to find the right solution to help.
For health plans, there can often be administrative burdens and challenges when it comes to implementing new technologies. With a clear understanding of the obstacles they may face, UPHP knew they needed a solution that was fully customizable and built specifically for organizations like theirs. Choosing the right partner helps streamline the implementation process and avoid any curve balls.
This is when they discovered SymKey.
What is SymKey?
SymKey is a robotic process automation solution that takes care of tedious claims processing tasks. It isn’t artificial intelligence, it is IntelliRPA® automation. This means that SymKey is fully customizable to meet the needs of the health plan and will not deviate from the rules that are set for it.
UPHP was able to implement SymKey in just three days, much faster than any other solution on the market. Within a matter of days, SymKey was up and running helping alleviate repetitive tasks so UPHP’s claims examiners could focus on complex tasks that require human intervention.
Robots in Action
When the State of Michigan delayed the release of its January 2021 fee schedule by three months, it could have created a challenge for UPHP. This project would have required an estimated 450 hours, or 67 days, of work for their examiners. However, they were able to avoid any potential delays in production by leveraging their SymKey robot to reprocess over 4,500 claims in just one month.
UPHP examiners would have to manually reprice Medicaid behavioral health claims based on the member’s age and the location of service. With SymKey, UPHP can automate the processing of over 435 claims per week for this scenario.
Sometimes, providers send duplicate claim submissions. When this occurs, even with powerful auto-adjudication tools it sometimes still requires a significant amount of time to comb through pended claims to determine whether they are in fact true duplicates. Using customized SymKey workflows, UPHP’s robot reviews the original claim against duplicate submissions and eliminates the need for the examiner to manually review that claim.
MIHealthLink funnels in rural health center claims which utilize a complex methodology for reimbursement. This creates a significant demand on examiners’ time when they are required to manually review and reprice these claims. Using SymKey, UPHP is able to manage complex Medicare and Medicaid dual repricing to eliminate manual work and reduce the potential for data entry errors. This accounts for roughly 150 claims per week.
Review and Reprocess
SymKey robots are programmed to review the coordination of benefits to determine if that member has active medical coverage on that service date. SymKey can then deny for primary coverage, listing the primary policy information. This is helpful for providers and alleviates the need for an examiner to review. On average, UPHP uses SymKey to process about 175 of these claims per week.
2022 brought a new set of challenges, one of which was a change in attending provider requirements by MDHHS. The new changes did not slow them down; UPHP was able to seamlessly reprocess over 6,800 claims in less than two months by assigning their robotic claims examiners to the project.
5,000 of those claims were processed through the Claim Reprocessing queries that UPHP customized. Another 1,800 were processed through the Claim Reprocessing Reenter Lines Already Negated query.
A Positive Impact
UPHP’s claims examiners were already working at capacity when the team implemented SymKey. Had UPHP held off on adding a robotic process automation solution like SymKey to their team, they may have been forced to require overtime from their staff or potentially hire additional staff so they could tackle the reprocessing projects while keeping up with their normal schedule.
Now, their examiners are able to focus on production inventory, preventing backlog.
"Knowing that we have SymKey for reprocessing projects is a relief because, without SymKey, reprocessing a bulk volume of claims while maintaining a current inventory can feel quite overwhelming."
The sheer amount of time it would have taken to reprocess those claims could have put their production schedule in jeopardy and would have increased the workload for their already busy team.
It’s estimated that the 2021 project would have taken at least three full-time claims examiners to do the same amount of work that SymKey did.
The 2022 project would have needed two full-time examiners to complete.
For UPHP, the easy implementation process, the ability to set their own rules, and the burden taken off their staff make SymKey an invaluable tool that is sure to be a permanent fixture in processing and reprocessing their claims.