OVERVIEW

Hospitals and physicians handle numerous claims every day and depend on Revenue Cycle Management (RCM ) providers to consistently follow up and secure accurate and timely payments from insurance companies. This process often requires detailed documentation and continuous communication among Healthcare Providers, legal counsel, and insurers to ensure accurate and timely reimbursement.

CLIENT

A US-based Healthcare RCM Firm needed a critical operational pipeline to improve every stage of its Motor Vehicle Accident Claim Processing, involving multiple workflows and stakeholders. They partnered with Quantrium to streamline their claim-related data and documentation using advanced NLP techniques which delivered greater efficiency, enhanced accuracy, faster claim resolution, and customer satisfaction.

THE QUANTRIUM LEAP FORWARD

Quantrium developed a scalable AI-powered Claims Management Pipeline that facilitated:

• Document Submission through multiple channels.
• Data Retrieval using NLP to read, comprehend the documents, and extract key details like the policyholder’s name, claim amount, and damage type to save time and reduce human errors.
• Identification of the right patient account and matching it with the right bill.
• Recognition and analysis of the Explanation of Benefits (EOB) from the payment documents to reconcile the amount due appropriately.
• Identification of potential litigation issues and risk classification through contextual data insights.
• Calculation of payouts based on historical trends.
• Approval of claims and automatic payment reconciliation.
• Management of rejection and redressal where necessary.

IMPACT

The Client successfully processed over $70 million in insurance claims and 35,000 documents monthly, with 65% achieving fully touchless processing at 100% accuracy. The solution also enabled the client to scale exponentially without additional resource overhead.

TECHNOLOGY STACK

NLP (SpaCy, Scikit-learn)

Text Extraction (AWS Textract)