How a Healthcare Insurance Company is Bringing RPA and AI into Business Operations


At HfS, we hear quite a bit about the challenges of incorporating RPA and AI into business operations, so when I spoke with a healthcare operations leader about his experience at a U.S. healthcare payer recently, I wanted to share it… but can only do so anonymously. Here’s how RPA first – and AI down the road – is being incorporated into the business operations, by defining appropriate scenarios, thinking outside the box, managing proactive communications with staff, and looking to get people excited about the positive impact on jobs, relationships between payers, providers, and patients and healthcare consumers and on health, medical, and financial outcomes.

What is the use of Intelligent Automation in your organization today?

We are building momentum from our business case into implementation with robotic process automation (RPA) and defining a conceptual “bridge” to get into artificial intelligence (AI) – what is the use case and how to use to impact financial and medical outcomes.

Where and how did you get started?

Started by looking at RPA to drive additional efficiencies from labor and financial perspective and then realized that the organization needed to be considering a broader strategy. It isn’t just about the technology but how does it change the experience of the internal employees and the health plan members directly? We have a plan that we are iterating as we go… as we learn more about the capability and the potential impact. Using RPA and AI can change our internal processes and free up talented staff. We can change the way our employees interact with members, providers, and patients in a way that changes their experience and medical and financial outcomes.

How will employee roles change when RPA is introduced?  

RPA – and eventually AI too — will free up our employees to engage more directly and interactively with our stakeholders such as healthcare consumers and clinicians. For example, today, the provider office has to fax authorization and wait for response. How can we use RPA and AI to ingest the form on a front end web site, have an algorithm that runs to identify “we always provide authorization for this service” and flip it back in seconds; or if not, route it for the appropriate review. This kind of intelligent automation frees up the care management team to do something more important; and hopefully, that translates into relationship and outcome uplift for the provider, member, or both.

Employees who are processing claims and reviewing authorizations, for example, have interactions and engagement with members, providers, and patients that are reactive and responsive. We could get in front of these same people more proactively if those processes and reviews were automated and only potential denials or exceptions were flagged. These employees could be reaching out, instead, to discuss a pended claim or questions about authorization. Our hope is that “in a year or two, we can shake our heads and say, wow, we used to have hundreds of people who are now creating personal interactions instead of processing behind the scenes.”

Who in the organization do you need to work with and how does that play out?

First, we had to go through a process with the enterprise architecture team and get approval to proceed. We are working with a service provider who helped define the scenarios and evaluate the technology. We then moved forward with a proof of concept that showed what we could deploy around claims payment and pended claims, the business story for our business unit colleagues. Then we laid out what is RPA and AI and demonstrated how it works—how you could address a claim that 15 people used to work on full time just for one fall out. It resonated. Over the years, I have had to advocate for software that we were excited about – rarely have had to sell a product or idea where the senior level is buying into it before the grassroots technical effort. That was the case here. The executive team could see the opportunity and get enthused about it.

How is the move to intelligent automation and “digital labor” impacting your workforce?

From a technical perspective, our CIO team is working through the details.  As the senior leaders get excited and then go into the team to talk to subject matter experts to codify RPA based solutions, the employees are concerned that their job is going to be automated and eliminated. You have to be able to tell the story to help employees understand that what is being automated is this routine action you do in the back shop today – that here is an opportunity to parlay your experience into interaction and impact with the members, providers, and patients. It’s a dialogue that is playing out pretty well.

We believe that as we move services people to working more directly with the providers and members, they will be performing work they will find more enriching. We also realize that we need to understand what skills and capabilities are needed for this. We are building out a robotic operating committee and working with business leaders to talk about – as we deploy these solutions and staff becomes available for different roles, what are those roles and what capabilities do people need for them. And we don’t want to move them into doing work that will be automated “next.” We are in early stages here. So far our efforts with intelligent automation have been grassroots with excited senior executives how have said, go into my organization and show me how it works. As we get scale, we will work through retooling.

Tell me about how the funding and business case development is coming along.

Our organization is quite rigorous around investment. When we talk about RPA and provide evidence of 4:1 and 5:1 return on investment the story becomes easier. We are always focused on continuous improvement and how that parlays into impact. Again, the story of using automation to free up skilled staff is powerful. For instance, in finance, changing manual reconciliation at the close of month with large team to be automated and the more complicated work being the focus of the human effort, the logic becomes more apparent and the investment, obvious.

From these “early stages” of about 12 months in, the momentum and excitement is gaining, and I anticipate that we will pick up speed with RPA and into AI over the next year with top down sponsorship.  What excites me most is the possibilities of what we can do to free up our own employees and at provider offices to anticipate and be more proactive about issues and concerns and eliminate bottlenecks and slow downs for higher quality service and interactions.

Bottom line: While this interview is a bit like the old dating game where one person asked questions and the other sat behind a black curtain, it helps shed light on how enterprises that have been working one way for so long are making progress in moving forward with RPA and AI, considering talent and technology and how it changes the way we need to work going forward in healthcare operations.

Posted in : Healthcare and Outsourcing, Robotic Process Automation


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