AI for Claims Reconciliation: 600% Increase in the Volume of Claims Expion Health Handles Daily

For more than 30 years, Expion Health (formerly Exponent Health), has developed cost-control tools for its customers in the healthcare industry, including large national insurance organizations such as Blue Cross/Blue Shield, self-insured employer groups, third-party administrators (TPAs), and pharmacy benefit management (PBM) companies. Its solutions include the ExpionIQ™ platform, which provides predictive intelligence for healthcare cost management and revenue optimization.

The healthcare industry is immense—and immensely complex. D.S. Suresh Kumar, Chief Transformation Officer for Expion Health, says the company’s clients need fast, reliable information that will help them calculate costs for medical services and products that are fair for both end user customers as well as the organizations serving them.

“Healthcare is a $5.1 trillion industry, but it has a long way to go in terms of transparency and bringing down costs,” Kumar says. “For example, an MRI might cost $375 in one facility and $5,000 in another. Who knows what is a fair price? We help our customers come up with a fair price so no one is getting dinged.”

Historically, Expion Health dealt with claims through time-consuming processes that included manually keying in claims data from unstructured documents. In a typical scenario, an insurer submits a claim to Expion Health, sometimes via EDI but often using paper forms.

“We did manual data entry by logging into the claims systems on the payer side, then pulling the claim down, and then logging it into our pricing system before sending the recommended price back to the client,” says Kumar. “Our old process took a lot of time because we had to match it against market and historical data. We were limited to processing about 75 claims a day.”

UiPath helps streamline claims processing

Senior management within Expion Health challenged Kumar and his team to find a faster and more efficient way to work.

“We knew about UiPath, and contacted one of their partners, qBotica, which had experience with UiPath Document Understanding and other UiPath tools, including UiPath AI Center and UiPath Action Center,” Kumar says.

The qBotica and Expion Health teams deployed a solution that dramatically streamlined the old data-gathering process using four steps:

• A UiPath robot downloads claims in PDF format from the payer.

• UiPath Document Understanding processes the claims, most of them unstructured documents, extracting required data points.

• An Expion Health employee reviews any claims with extraction problems and corrects the errors using UiPath Action Center and UiPath AI Center.

• The extracted data is sent to the Expio Platform for final processing and claims pricing.

“With qBotica’s help we are using Computer Vision to extract claims data from the claims processing system and then using Document Understanding to classify and validate the claims, and extract the data needed for reconciliation” says Kumar.

By leveraging Document Understanding, AI Center, Action Center, and other advanced components in UiPath such as Computer Vision, there's been a tremendous amount of effort saved in building the necessary features from scratch to help enable intelligent document processing and seamless human-robot collaboration.

D.S. Suresh Kumar, Chief Transformation Officer, Expion Health

Up to 600% increase in processing speed

Kumar says speed has been a hallmark of the UiPath solution. In a sample one-month period following deployment of the solution, Exponent successfully processed 4,132 claims, averaging 148 claims per day and achieving a peak of 710 in a single day. The solution uses five robots that are helping the company achieve a 99% success rate on claims processing and an overall 97% increase in productivity.

We have gone from processing about 75 claims a day in the past to now frequently processing as many as 500 claims or more in a day. That’s almost a 600% increase in the volume of claims we can handle.

D.S. Suresh Kumar, Chief Transformation Officer, Expion Health

He adds that speed to market is also a benefit.

“We can get our professional and institutional claims loaded much faster than in the past,” Kumar says. “Also, once our employees are acclimated to Action Center, it inspires a lot of confidence in their ability to supervise the process.”