At a glance

Automation streamlines claims processes

The following processes were automated with robots developed specifically for Community Health Choice:  

Prior authorization/referral matching (Edit 205)

QNXT generates an edit when a claim is received for a service that requires prior authorization, but it wasn’t issued or automatically applied through QNXT. When done manually, our client's employees checked the claim for specific data points, including providers, dates and services. With an average monthly volume of approximately 7,500 claims, this process created a significant strain on processors and put the health plan at risk for a costly backlog. Without automation, the health plan would have needed to pay overtime for manual processing or borrow from other departments to get the claims processed on time. Fortunately, our robots quickly searched QNXT for an authorization that matches the claim data, eliminating the time-consuming, manual process that had an average handling time of six minutes per claim. Robotic automation allowed the health plan to save more than 750 full-time employee (FTE) hours and roughly nine FTEs monthly. This translates to a cost savings of 83% and $3.6 million saved since 2016.

Provider matching (Edit 101)

Providers must be referenced on all claims, but when a provider is missing from a claim, the claim pends until a record is created and/or attached. This interruption in the claim cycle put the health plan at risk of significant backlog and required time-consuming, manual intervention. Cognizant deployed a robot to research and reconcile claims with missing provider information within QNXT. The robot finds a provider match in the QNXT system and attaches it to the claim. If no provider match is found in the QNXT system, the robot flags the claim for further investigation. By automating this high-volume process—more than 9,200 claims each month—Community Health Choice has saved more than 480 FTE hours per month and $839,000 since 2016, an overall 51% cost savings.

Call tracking

Health plans typically log calls to and from members for plan-related changes or performance and for accurately tracking questions. For instance, Community Health Choice keeps call logs when members need to change their primary care physicians (PCPs). A Cognizant robot monitors the QNXT database for specific verbiage. When it detects that verbiage, the robot opens the record, grabs the new provider information and logs the call in QNXT, noting the call and the PCP change. Automating this process helped prevent employees from duplicating work by re-entering comments in QNXT. With an average monthly volume of nearly 7,100 calls, automating this process has saved Community Health Choice more than $306,000 in operational costs since 2016, the approximate equivalent of two FTEs per month.

Duplicate claim process (Edits 532, 533)

QNXT recognizes when multiple claims are submitted with similar data, such as provider, date of service or services rendered. For these claims, an examiner must validate whether the claim is indeed a duplicate, which is time-consuming and involves considerable risk for human error due to complex exceptions. With an average monthly volume of 6,500 duplicate claims, the manual process put Community Health Choice at risk for low accuracy ratings, a metric that could lead to a financial penalty and jeopardize eligibility for their Medicaid line of business. Our robotic automation solution diminishes the risk by quickly and thoroughly checking data points to compare the claims. Automating this process saved Community Health Choice 672 FTE hours per month, a total labor savings of more than $1.4 million since 2016.

Timely filing (Edit 311)

Every payer has timely filing requirements that vary by state, product and contract. Every incoming claim is reviewed for timely filing and is denied or reimbursed according to payer-specific rules. Without automation, our client's examiners had to manually review each claim, at an average of over three minutes per claim. With nearly 5,000 claims monthly, the process was a significant drain on resources, costing the health plan hundreds of additional FTE hours. Since implementing a Cognizant Robotic Automation Services robot, Community Health Choice has saved 300 FTE hours per month and more than $704,000 in labor costs since 2016, the equivalent of roughly 0.4 FTEs saved per month.

Penalties and interest robot

The Texas Prompt Payment of Claims Act requires insurance companies, including healthcare insurers, to pay or deny a claim within 30 days electronically or 45 days non-electronically. If claims are paid late or underpaid, penalties and interest accrue. Since early 2020, many healthcare insurers have been overwhelmed with priority changes due to COVID-19 which created a large backlog of claims. When Community Health Choice implemented one of our robots, it processed 14,000 backlogged claims in just two weeks, saving the health plan 1,167 FTE hours and preventing significant potential penalties. 

Jiva authorization updates

In early 2020, many elective procedures were limited due to COVID-19, which created a backlog. Authorization end dates were extended due to the stress COVID-19 had on the healthcare system. To ensure that Community Health Choice's members were informed of their authorization status and end dates, the Cognizant Robotic Automation Services team created a robot specific to the web-based platform, Jiva, to update the plan's 8,000 backlogged authorizations and send authorization letters to members.

Coordination of benefits (Edit 216)

Coordination of benefits (COB) allows health plans to determine who is responsible for payment when a member is covered by two different plans and ensure that a member’s benefits and reimbursement rate does not exceed 100% of allowed medical expenses. COB claims are also paid or denied based on the Medicare plan, benefit plan, type of claim and location of services rendered. Since beginning to leverage a Cognizant robot in April 2018 to automate this process, Community Health Choice has saved over 9,700 manual hours and $210,000.

Harris Health indigent (HHI) enrollment

The Harris Health System's financial assistance program is focused on healthcare access for low-income Harris County residents who don't qualify for other state or federal healthcare programs. While this is a low-volume process with an average monthly volume of 900, the value of automation comes from ensuring the latest benefits are applied to member claims processing. Since deploying a Cognizant robot in June 2019 to automatically add and update enrollment for Harris Health's financial assistance subscribers, Community Health Choice has saved over 2,800 manual hours and $70,000.

Special investigation unit (SIU) recoupment

Some U.S. states require insurance companies to maintain an SIU—which investigates and recovers funds from suspected insurance fraud or malpractice—to conduct business in those states. Community Health Choice deployed a robot to reverse and adjust claims based on upcode billing. Although this is a low-volume process—with an average monthly volume of 900—this robot ensures that Community Health Choice is processing claims accurately and that members and providers receive their full benefits and compensation. To date, this robot has saved over 1,700 manual hours and $47,000.