Auto adjudication is the process of swiftly processing insurance and public benefit claims, without the need for manual intervention or decision-making for each claim. In essence, it’s about harnessing the potential of technology and smart system configuration to handle claims automatically.
It’s often misconstrued as a straightforward process. Configure certain rules and parameters, set up your system, claims are paid in full, pay a partial amount, or deny the claim all together. Voilà! You’re done! In reality, it’s a nuanced and complex endeavor. The industry standard benchmark for auto adjudication hovers around 80% and while organizations may aim for that auto adjudication rate, many fall short, with first pass rates ranging from 10% to 70%.
Achieving a high auto adjudication rate is often seen as a sign of a well-optimized claims department but it’s not the whole story. Here’s the twist: auto adjudication isn’t just about numbers. It’s about efficiency, accuracy, and ensuring that your claims department is working smarter, not harder. The real question to ask is: “Where are my examiners spending their time?” Identifying those specific scenarios and workflows that genuinely require human decision-making and striking the right balance between timeliness and precision is key.
The Role of System Configuration
System configuration plays a pivotal role in the auto adjudication process, potentially boosting rates by 15-25%. But there’s an art to it. A well-defined set of rules is the backbone of efficient auto adjudication but too much automation can lead to an excess of pended claims, defeating the purpose. System configuration must be optimized to ensure that claims requiring manual processing are the exception, not the rule.
Introducing SymKey: Beyond Auto Adjudication
SymKey isn’t just auto adjudication. It’s a game-changing solution that not only complements system capabilities, but it can also help address system functionality challenges. SymKey goes beyond system auto adjudication by mimicking the work of a claims examiner. Unlike traditional auto adjudication, which relies on system rules, SymKey’s approach is backed by real-world claims operations expertise. Those complex scenarios that usually require the touch of an experienced claims examiner… SymKey can handle them painlessly.
Edit Any
Field
SymKey can touch and edit virtually any claim header or detail line field
Automate Manual Tasks
SymKey can touch and edit virtually any claim header or detail line field
Improve Accuracy
SymKey automates the process of applying all note types
The SymKey Advantage
- Increased Efficiency: By automating complex scenarios, SymKey reduces the workload of claims examiners, allowing them to focus on critical decisions rather than repetitive tasks.
- Accuracy and Timeliness: SymKey ensures that claims are processed accurately and promptly, striking the right balance between system efficiency and human expertise.
- Optimized Configuration: Our real-world experience guides the fine-tuning of system rules to prevent unnecessary pending of claims, making your claims department more efficient and effective.
- Beyond Mere Auto Adjudication: Our software works like a claims examiner, interacting with the claims system as if it were human. SymKey robots have the ability to touch and edit virtually any claim header or detail field, all via the user interface, without the need for back-end database alteration.
- Payment Stage: SymKey can move claims to the beginning stage of the Check Payment process. This action is beyond standard system capabilities.
Don’t limit yourself to the restrictions of system auto adjudication. Take your claims processing to the next level with SymKey and experience a newfound level of efficiency and accuracy. Our team can help with process design and help automate claims adjudication. Contact us today to learn more.