Healthcare Agency Improves Efficiency with Automated Claims and Inquiry Processes

A provincial healthcare agency sought to modernize their claims and inquiry processes to reduce manual work for medical service providers and improve patient care. Their current processes had several challenges, including a highly manual new doctor registration process, tedious medical claims inquiries, and an arduous claims submission process leading to bottlenecks.

Apps Associates replaced the agency’s aging environment with a BMC Remedy-based solution for eight service centers, featuring electronic eSubmit and Inquiry Management Systems (IMS) for claims submission and inquiries, platform integrations, and workflows for enhanced forms processing.

The eSubmit platform processes over 1500 claim requests per day, while the IMS platform fulfills 60% of 1.1 million annual claim inquiries with automated query response. The new workflow solution manages licensing and onboarding of new providers with full dashboard-based application status monitoring and escalation based on SLOs.

With the new digital processes and platforms in place, the agency plans to expand current functionality with natural language interaction and proactive communications based on intelligent analysis of their systems of record.

• Over 50% reduction in time spent reviewing claims by senior agency resources
• 60% of 1.1 million annual claim inquiries are now electronically fulfilled with automated query response
• Over 1500 claim requests now processed per day