Intelligent Process Automation: Expediting Access to Healthcare Insurance Coverage

Determining and verifying eligibility for social benefits, public services, and professional certifications can be a manually intensive and document centric process. Multiple manual touch points result in delays in processing requests, variances in determination outcomes, inefficient utilization of staff, and frustrated applicants. Considerable manual effort is expended to:

Many states faced this challenge with the implementation and administration of the 2010 Affordable Care Act (ACA). Infocap was awarded a contract to support an Intelligent Process Automation initiative at the largest State Based Exchange (SBE). The SBE is currently serving 1.6 million consumers. 

The Conditional Eligibility Challenge

A critical component of the ACA process is the verification of application data submitted by consumers. Most consumer applications are verified and approved by referencing demographic data from a Data Services Hub. A Data Services Hub combines data on income and employment from IRS records, health and entitlements from HHS records, identity from Social Security, citizenship from Department of Homeland Security records, and residency/income from state records. In many instances, consumers are determined to be conditionally eligible for healthcare insurance coverage when application data doesn’t match data from the Data Hub. This outcome is called a “data matching issue” or DMI. Conditionally eligible consumers are mailed a notice asking them to submit additional documentation to address the DMI. Infocap’s SBE customer had 600,000 DMI tasks in 2020.

Processing of consumer documents and DMI business rules was manually intensive for the SBE. It required staff to execute multi-step workflows, access disparate systems, and manually adjudicate DMI exceptions. Service Center Representatives (SCRs) spent an average of 13.9 minutes processing each DMI task to determine if the conditional eligibility status could be cleared or consumer follow-up was required. The SBE determined they needed to streamline DMI processing and initiated a solicitation for the development and implementation of an automated system. The stated goals of the SBE solicitation were: 

The Solution

Intelligent automation of document intensive workflows is a key offering of Infocap. Infocap determined that the SBE system solicitation was a candidate for Infocap’s Intelligent Process Automation (IPA) solution. IPA is a process automation strategy and solution design approach that streamlines the capture and validation of document centric data to intelligently direct the execution of both human and digital worker executed workflow tasks. 

Infocap first approached ACA stakeholders in 2016 with the IPA message and value proposition. Infocap was an early adopter of emerging technologies such as Robotic Process Automation (RPA), Machine Learning (ML), and dynamic process orchestration. Infocap has been successful in implementing innovative approaches that currently process more than 85% of the DMI responses submitted by ACA applicants nationwide, including both federal and state run exchanges. 

Infocap’s Document Imaging and Verification Solution (DIVS) efforts have focused on three key intelligent automation goals.

Goal #1 – Automate Document Handling. Document automation leverages a unified document processing workflow for submitted documents (mailed, faxed and uploaded documents). The workflow utilizes cognitive document recognition (artificial intelligence/machine learning) to automate document type identification and data extraction. Best practice data validation user interfaces implemented by document type allow staff to quickly correct OCR errors and to flag illegible documents. The ultimate end-goal being the document capture and data validation at the point of submission by consumers using smart devices. A Robotic Process Automation (RPA) enabled search function matches documents to applicants when documents arrive without case information or to verify associations made by document scanning vendors. 

Goal #2 – Automate Eligibility Adjudication. Systematic eligibility adjudication is achieved by dynamically applying business rules based on type of DMI issue, type of documents submitted, and applicant case data. Adjudication outcomes, reason codes, and computed business rule data are recorded in a comprehensive transactional data base. A robust Process Intelligence component supports near-real time dashboards and reports so decision makers, business analysts, and operations staff can monitor and improve system performance. 

Goal #3 – Optimize Exception Processing, Task Routing and Consumer Follow-up. A robust process orchestration platform takes advantage of transaction data to identify and intelligently route complex submissions or submissions that fail business rule requirements. Data driven routing allows the segmentation of staff into work groups by level of training or subject matter experience. Case and document data, meta-tagged document image files, and adjudication outcome data is used to generate actionable mail notices or pre-populate call screens. RPA is used to retrieve additional case data, retrieve previous document submissions, and automate updates to case management systems. 

The Outcome

Intelligent Process Automation has delivered a win-win for all SBE stakeholders by significantly reducing consumer DMI submission processing times, ensuring consistent application of business rules, freeing service center staff to address complex cases, and providing detailed outcome metrics for prioritizing continued system enhancements. The system was critical in reducing the strain of a 65% increase in DMI work volumes in 2020, facilitating a COVID driven transition to remote work in less than 2-weeks, and is currently successfully adjudicating over 70% of DMI tasks. To-date Infocap has achieved the following:

Infocap understands that Intelligent Process Automation is a journey not an immediate technology outcome. This is especially true when implementing systems for determining and verifying eligibility for social benefits, public services, and professional certifications. Capture and assessment of process metrics establishes a common foundation for discussing and prioritizing process improvements and the application of emerging technology. The journey begins when organizations work with a trusted technology partner with the experience and team of experts. We encourage you to reach out and engage Infocap to start your Intelligent Process Automation journey.