Automated Claims Transfer and Resubmission System for Healthcare Revenue Cycle Optimization

The client faces a highly complex revenue cycle process involving manual transfer and resubmission of insurance claims, which is time-consuming, error-prone, and inefficient. Currently, employees spend significant manual hours sorting claims, leading to increased labor costs and a high risk of human errors, negatively impacting revenue collection and operational efficiency.

A mid-sized healthcare organization specializing in durable medical equipment distribution, seeking to streamline insurance claims processing and revenue cycle management.

• Reduce the time required to process claims transfer and resubmission by at least 95%.
• Eliminate human errors associated with manual claims processing, achieving near-zero error rates.
• Free up approximately 8 hours of manual labor per week, allowing staff to focus on denial management and other higher-value activities.
• Automate the classification of claims into rejection, resubmission, and exception categories using robotic process automation.
• Improve claim processing accuracy and speed to enhance revenue collection and customer satisfaction.

• Automated claim retrieval from file servers and data management platforms.
• Verification and validation of claim data integrity before processing.
• Classification engine to sort claims into rejected, resubmitted, and exception categories based on predefined criteria.
• Automated handling of claims eligible for transfer or resubmission, reducing processing time dramatically.
• Exception management module to flag claims requiring manual review.
• Logging and audit trail for compliance and process monitoring.

• Data management platform where claims data and spreadsheets are stored.
• Insurance claim processing systems or APIs for claim transfer and resubmission.
• Logging and audit systems for compliance purposes.

• System scalability to handle at least 250 claims per day with room to grow.
• Processing speed to complete claims classification and transfer within 25 minutes weekly post-deployment.
• High availability and minimal downtime to support continuous operation.
• Security measures to protect sensitive patient and insurance data, complying with healthcare regulations.
• Auditing capability for transparency and compliance audits.

By implementing the automated claims transfer and resubmission system, the organization anticipates a 95% reduction in processing time per week, enabling staff to focus on denial management and reducing manual labor costs. The automation aims to achieve a 0% error rate on resubmitted claims, increasing overall revenue collection efficiency and elevating staff satisfaction through reduced repetitive tasks.